Why Don't We Dismiss Residents?

Thearticle “The Hidden Costs of Failing to Fail Residents”1 in the June 2011 issue of the Journal of Graduate Medical Education might be better titled “W hy Don't We Dismiss Residents?” The article by Drs Roberts and Williams is a carefully considered discussion of the problems inherent in dealing with poor resident performance. To assure the public that trainees have acquired the knowledge, skills, and attitudes to independently practice medicine, the Accreditation Council for Graduate Medical Education (ACGME) and its Review Committees have developed more specific requirements and have substantially increased the need for documentation. Increased analysis of resident performance has uncovered more resident performance issues. It is not clear whether we are seeing more unprofessional behavior in physicians2,3 because residents currently in training are different from those from earlier generations, or that as supervisory faculty, we may have missed or overlooked some of these deficiencies in the past. There is some evidence in recent years that we are seeing more unprofessional behavior in physicians.2,3

The concept of failure is extremely important. Residents who do not demonstrate competence to the level of the program's academic and professional standards should not be advanced. There is merit in providing residents the opportunity to remediate. Repetition of clinical rotations for residents with academic difficulty can be beneficial for residents to develop into practicing physicians.

Problems in the area of professionalism are more difficult to remediate. We have found that residents with professionalism challenges are either “socially promoted” as described in the article or are issued notices of nonreappointment. However, for programs to be able to offer remediation for professionalism, there need to be models for remediation. Review of the literature demonstrates a dearth of literature and/or evidence of successful models.4

The ACGME provides residents with a due process that often, as the authors allude to, brings in the legal system, which makes the dismissal process time and labor intensive. Although a program may be maintaining exact, detailed records of the performance issues, residents challenge or appeal their dismissals, which makes programs reticent to pursue this course of action. The fear of litigation should not be an issue if the process has been objectively followed and documented, and the dismissal is not “arbitrary and capricious.” The courts will not intrude on the academic judgment if due process is followed (ie, an individual is notified of the issue, given an opportunity to respond, and offered remediation if possible). Although dismissal is frequently saved for only very egregious performance issues, this should not be the case.

Until program directors and faculty are comfortable with failing residents as well as dismissing them for performance issues, nothing will change except that program directors', designated institutional officials', and general counsels' frustrations will continue to increase.