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Tips to resolve grievances in your residency program

From the February ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

ACGME accreditation requirements

Six steps to take when you have a grievance

Printer not working in the resident lounge? An attending being abusive? Program not fulfilling your educational needs? Or worst of all, have you been asked to leave your program?

Residents' complaints range from simple annoyances to issues that can permanently affect careers. While most complaints can usually be handled by discussing the problem with a chief resident or at a housestaff meeting, serious unresolved educational problems exist.

From January 1998 through September 2000, for example, the Accreditation Council for Graduate Medical Education (ACGME) received 21 complaints from internal medicine programs. The most common complaint? Lack of due process when a resident is in some way penalized.

Some housestaff, for example, said they weren't given enough time to explore other positions when told their contract would not be renewed, said David Leach, MD, executive director of the ACGME. Other frequent complaints focused on work hours, a lack of grievance procedures, lack of evaluation and feedback, discrimination, inadequate or lack of supervision and contract disputes.

ComplaintsAs a result of these complaints, ACGME officials say they have worked to expand complaint procedures for residents who are terminated, whose contracts aren't renewed or whose careers are threatened in any other way.

All accredited residency programs must now notify residents in writing that their contracts will not be renewed at least four months before expiration. (The goal is to give residents time to participate in the Match, as most annual contracts end in June.) And programs that consistently exceed caps on hours or admissions will receive a warning.

While these changes should help housestaff resolve grievances, there is a bigger problem: Many residents don't know how their programs address grievances. Learning that process, experts say, not only will help you resolve issues, but also can help preserve your professional reputation.

Low-level problems

The good news is that every institution has a graduate medical education (GME) committee to oversee the complaint process, and residents are always included on the committee.

"About 99.9% of the time, issues can be resolved at the local level," said Tom Blackwell, FACP, professor of medicine at the University of Texas Medical Branch and chair of the ACGME Residency Review Committee for Internal Medicine.

Most programs have two tracks for complaints: one that handles institutional grievance procedures and one that seeks to resolve individual problems.

Your institution's grievance procedures won't help you resolve individual problems such as personal disputes between residents or residents and attendings or faculty, complaints about salary, resource allocation, benefits or other contractual issues. But if you have a dispute about issues involving promotion, contract renewal, dismissal, sexual harassment or discrimination, you should go through your institution's grievance procedures.

Programs consider these types of complaints "global" because they can have wider educational ramifications. In the unlikely event that an institution lacks a grievance process, you can file a formal complaint using ACGME's complaint procedures.

If a complaint is global but does not substantially affect your education (a dirty on-call room, for example), you should probably start by talking to your chief resident or housestaff organization. You also can resolve many personal issues—such as dealing with a difficult attending—at lower levels.

Even problems like a bad evaluation can often be handled at lower levels. Dr. Blackwell, for example, suggested talking to the associate program director or the program director to give your side of the story.

The program director will be the final arbitrator in these cases and may consider mitigating circumstances. At the very least, you will have started a self-improvement dialogue.

In addition, Dr. Blackwell urged residents to keep an eye on the big picture. "One bad evaluation doesn't break a career," he said.

Big-picture issues

If you have complaints about larger, systemic issues such as insufficient supervision or a lack of due process, go to your chief resident, program director and your institution's GME committee. If you ultimately need to file a grievance with the GME committee, specify in writing what steps you have taken to resolve the problem. Make sure you include documentation.

Every institution is different, but most GME committees create a review panel to collect documents and interview individuals in an effort to find a solution. If this does not resolve the problem, the committee will usually schedule a hearing, which you are entitled to attend. Afterwards, the review panel will present its findings and recommendations.

If you still have a serious problem after following this procedure, it's time to notify the ACGME. Realize, however, that the ACGME will not adjudicate disputes between individuals and their programs.

Marsha Miller, who handles the resident complaint process at ACGME, said she advises residents who call her organization to start by working within their institution to resolve the problem. "The ACGME should be notified if there is no local attention to the problem," added Dr. Blackwell.

This does not mean that you have no recourse if you think you have been treated unfairly. All institutions are required to have written, formal grievance procedures for residents to present complaints about issues that adversely affect them and violate their institution's procedures and policies. The ACGME's revised accreditation requirements state that residents must be able to raise and resolve issues and grievances without fear of intimidation or retaliation.

Due process

Because training programs vary so much in the due process rights they offer residents, housestaff are often confused about exactly what they are entitled to under ACGME rules. The ACGME requires that institution grievance procedures be in writing, and specify the types of complaints handled, the procedural steps necessary and the resident's right to representation.

As part of due process, if you are dismissed from a program, receive a reprimand or are asked to repeat a rotation, you should receive written notice of the action. This notice should give you the option to contest the action and enough time to respond. If a program puts you on probation, you need an explanation in writing stating how long the probation will last, what you need to do to be taken off probation and how you will be evaluated.

Timing is critical. If you request a hearing, the program must tell you when it will be held. Serious issues like dismissal are best handled in a hearing, experts say, because waiting to talk to a program director may mean missing the hearing deadline. At a hearing, you have the right to be accompanied by an attorney or union representative.

Going to court

Termination of an employment contract can have far-reaching professional consequences, including the possibility that you'll not be able to complete enough training hours to qualify for licensure and board certification. While programs typically terminate resident contracts because of poor performance, residents in some situations have complained that their ouster was due more to racial and ethnic discrimination.

Going to court to seek reinstatement after a wrongful termination is rarely successful, but a handful of such cases have gone to trial. In Delaware, for example, residents' ability to go to court to seek reinstatement may change as a result of a recent state court ruling.

In Bali v. Christiana Care Health Services Inc., the court ruled that "extreme and irreparable harm" is likely to befall improperly discharged residents because they will have difficulty getting into a new program in the middle of the year. The educational relationship between a resident and a hospital is so unique, the court ruled, that reinstatement was the appropriate remedy.

That's why in September 1998, the court found that Christiana Care Health Services had breached its contract with a surgical resident whom it demoted from a PGY-3 "categorical" resident to a PGY-2 "preliminary" resident. In follow-up proceedings the next year, the court ordered the surgeon be reinstated as a PGY-4, even though he had repeated PGY-2 and never completed PGY-3. (The physician has since left the program and is completing his residency elsewhere.)

Because programs will work hard to avoid litigation or a summons for an ACGME survey, your chances are good that you will be able to resolve your grievance while it still is an internal matter.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

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ACGME accreditation requirements

Does your program's grievance procedures follow rules from the Accreditation Council for Graduate Medical Education (ACGME)? Here's a checklist of the information your program is required to provide:

  • Procedures should be in writing. They should be published in some form and available for reference.
  • Procedures should specify both the types of complaints that may be filed and those that will not be accepted by the grievance committee.
  • Procedures should specify the steps that residents need to take when filing a grievance procedure.
  • Procedures should advise residents of their rights to representation.

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Six steps to take when you have a grievance

If you feel your training is suffering because your residency program or institution is not complying with program or institutional requirements, follow these procedures. If the issue is not resolved to your satisfaction, you may want to take it to the next level.

  • Familiarize yourself with your institution's grievance procedures and definitions of what constitutes a grievance. (These are available in your "blue book.") Remember that other pathways are available, depending on the complaint. Your institution's human resources department, for example, usually handles sexual harassment, while racial discrimination complaints should be taken to the affirmative action office.
  • Talk to your colleagues and chief resident. You can also discuss your concerns with attendings. Ask about the best way to go about resolving the issue.
  • Contact the institution's house officers or residents' organization. If you are a union member, contact your representative.
  • Bring the issue to the residency program director or associate director.
  • Notify the institution's graduate medical education committee or similar oversight body.
  • If none of these steps resolves a problem that you believe is broad in scope, send a signed letter to the executive director of the Residency Review Committee for Internal Medicine Residency at ACGME. This committee, overseen by the ACGME, is responsible for accrediting internal medicine residency programs. Complaints must identify a violation of a specific program requirement. You must also list the steps you have taken to resolve the issue, and their results.

The ACGME does not investigate anonymous complaints, but it makes every effort to keep a resident's name confidential. If the ACGME determines that a complaint warrants investigation, it will advise the review committee. The committee then informs the relevant program director and/or institutional representative and requests a response in writing. A site visit may follow in egregious circumstances, and a program could be put on probation.

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