All that glitters

The year was 2016. I had just been accepted into an internal medicine residency program in the US; or in other words, made "it". I felt like I was on top of the world. Like I had finally achieved what I was looking for and could see myself very close to being a successful physician. I was welcomed into the program with an orientation event organized for all freshly inducted interns. I had high expectations. Even higher, as I was told, were the expectations set by the university in charge of my program. I listened closely to all the presentations about different aspects of the US healthcare system and was intrigued by the strategies shown throughout the event.

I was most impressed by one particular idea which was completely new to me: running healthcare as an HRO. If you're not familiar with an HRO, it stands for a high reliability organization. Wikipedia defines it as "an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity". What this essentially means is that the entire organization works as a synchronous unit and any problems are analyzed and rectified by identifying its root causes. The best example of an HRO is the airlines industry which uses this root cause analysis method to its fullest. Imagining healthcare being run by the same principles sounded too good to be true.

And it was, as I will illustrate.

Using logic and reason helped me shape my personality in a very methodological way. Granted I became less and less emotional all my life, but it enabled me to be a better doctor. I was able to make better decisions for my patients and used to lead my interns very well during my residency back home. I had always been a problem-solver. I was always looking for "the next best step in management" of all the problems in my life and while helping others. Knowing I would be practicing in such an organization made be believe I would have the perfect environment to grow.

The first few months were amazing. I had the pleasure of working with outstanding attending physicians in the intensive care and inpatient settings. I, myself, was able to demonstrate good medical knowledge and was appreciated for it. At times I did feel overworked but seeing my superiors working just as hard, always kept me pushing myself harder. I had the pleasure of being involved in making patient care decisions and was almost always up to the mark.

But this time was not without fault. Being someone who was always mystified by the curiousness of medicine, I was at times guilty of missing details of less importance. My documentation, which was criticized almost always for being too short, needed a lot of work. But I believe I was told about it early enough that I was able to overcome this problem to a great extent. For my benefit, I reviewed my notes multiple times and used good notes by other residents as standards to look forward to. It took some time, but I was able to be later appreciated for the quality of my notes.

However, that was not all. My tendency to argue for what I believed to be right got the better of me. I never did this to portray myself as a genius but only to tailor the best management plan with discussion. This particular trait was appreciated by the more experienced colleagues but not so much by the competitive ones. At times, I was made painfully aware of how critical thinking was not welcome by some. This was accompanied by stricter scrutiny of my documentation and clinical skills. Most of the time, I was up to the mark but at times I was found to be short. For example one particular attending grilled me for writing "Cranial nerves II-XII intact" in my notes (which was from the template used by all interns) and also accused me of committing fraud when I documented "no murmurs" in a patient with tricuspid regurgitation (although the patient was in rapid ventricular response when I had examined him).

I was failed in all clinical competencies by that attending, which never happened before or after that rotation. That included medical knowledge, which again had been appreciated by almost all before and after that. Nevertheless, this resulted in an immediate letter of probation from my program. But I didn't take this criticism lightly. Although I had been doing what most residents do, technically I was responsible for every word written in my note and they should have been accurate to the highest degree. The "he/ she did it too", although valid, is the worst kind of defense. Being a perfectionist, I spent days creating my own templates for notes for both the inpatient and outpatient sides. Thenceforward, I did not have a major problem with my documentation.

However, a general air of arrogance was perceived by others around me and I had no way of disproving it. I asked other people for advice and the most common suggestion was "just try to be invisible and do what you're told quietly". While this did make the most sense to me, it was not what HRO's stand for. This was the polar opposite of the scientific method. I knew that I needed to control myself to survive but whenever I was told to do something because "I said so" or "just to be sure", I was triggered. 90% of the US health budget is spent on the last ten years of life. I used to argue for the best course of action because at many occasions, I was concerned about patient harm or the cost-effectiveness of something. At times I was caught between internal struggles like "save yourself or this patient's kidneys" and I always chose to risk myself, which was the logical option in my mind. One time, I remember, a resident signaled me to stop from behind the attending when he thought the attending was getting irritated. That, I believe, was my biggest weakness. The lack of that sixth sense, which could tell me when to shut up just for the sake of avoiding confrontation. Still, most attendings and residents were really appreciative of me and applauded me for always aiming for perfection.

This, however, could not stop the avalanche that had started. Since I had been getting good evaluations even before the probation, it was no surprise that they could not make a difference afterwards either. Although I was promoted to second year, I was still on probation. This flipped a switch in my mind that no matter what I do or how hard I try, I would not be able to escape what was coming. I begged my attendings for feedback and they always said my performance was perfect/ near perfect. What followed was a vicious cycle of anxiety, depression and absentmindedness that I could not control. I was summoned by my PD multiple times a month about one problem or another. No matter how logical my explanation was, they were not satisfied and always reminded me of the fact that I could be dismissed.

And then it happened. I was called into the PD's office and told that they had decided to dismiss me. I was told that there was no sudden event that caused this, rather the continuous reporting of minor events. I was devastated. It felt like I had been sprinting in a marathon all my life and someone hit me with a chair in the face just before the finish line. I even thought about hurting myself and spent a day in a crisis center. A psychiatrist gave me happy pills and I started seeing a therapist. The perfect illusion of happiness, in modern terms. Residents and attendings alike were shell-shocked and started calling me to ask what happened. I could not explain. I had no answers for my parents either, who had sacrificed so much for my education. Attendings said they would vouch for me if asked by the reviewer while residents said they wanted to support me but were afraid of losing their own jobs in fear of retaliation.

I was told I had the option of appealing the decision twice, which I did. Both times, the attendings supporting me said this is all a big misunderstanding and it will be reversed. Both times, however, I was told that the "process was carried out according to the policy". This phrase was repeated as an answer to all my questions. A process that was supposed to take two weeks, took four months. And I was not told why. But I did not have the right to ask that question, nor request transparency.

And that's the sad ugly truth. No matter how hard you work and no matter how honest you are, being a resident in the US is a lot like the bullying before entering a fraternity. They will make you dance to their music and jump through hoops till you fall to the ground. If, however, you even dare to speak up, you're out. It does not matter how hard you worked all your life or how determined you are in doing what's right, it comes down to being likeable by those who matter.

What followed was an intense internal struggle. Whether to gamble myself into residency again or to go down fighting. A few of my colleagues who shared the same background, offered to pool money for a lawyer as they believed the dismissal was so unfair. But I knew better. I knew that this injustice was the worst kind of itself, i.e. legal injustice; whereby a private organization can prove they "followed their policy" somebody signed on, no matter how ridiculous the whole process seems to common sense.

So I chose a third option- committing myself to make sure someone else does not have to go through what I did. I wish to raise awareness about the trials and tribulations residents have to go through. I hope to break the sickening silence everybody assumes when talking about the mistreatment of residents. Roughly one-third of residents in the US suffer from depression and resident suicide is not that uncommon either but nobody talks about it. Even if a resident brings it up, its disregarded as an excuse (as it was in my case). I know that my medical career in the US is most likely over, but I have taken a solemn vow to do everything in my power to prevent what's happened to me from happening to someone else.