Lebanon — During Kevin Koo’s hardest day as a resident at Dartmouth-Hitchcock Medical Center, he sat in a conference room with the family of a critically ill patient as they debated which, if any, invasive medical steps should be taken to keep their loved one alive through the coming night.
“In that moment I had to call on all of the lessons about the patient’s disease, about the patient’s physiology, about the patient’s prognosis, about the data that we had, about what worked and hadn’t worked,” Koo said. “Most of all, I had to be a doctor and communicate these things in a way that made sense, that expressed my understanding, but also my empathy.”
Koo, who is in his second year of residency and specializes in urology, is one of nearly 400 residents and fellows navigating one of Dartmouth-Hitchcock’s 46 graduate medical education programs, each focused on a distinct medical specialty or sub-specialty. For new doctors fresh out of medical school, such programs at hospitals across the United States are required next steps toward becoming licensed physicians.
This transition stage between being a student and being an independent professional can be intense, demanding, satisfying and frustrating, according to interviews with Dartmouth-Hitchcock residents. A member of the hospital’s public relations staff helped initiate some of the interviews for this story and was present during all of them.
“Graduate medical education” — the term included in the name of the agency that accredits programs as well as the title of Marc Bertrand, the Dartmouth-Hitchcock doctor who oversees the hospital’s residency and fellowship programs as associate dean for graduate medical education — is a construct that can puzzle an outsider.
Those being educated are contracted employees who work long hours, although not as long as in the past, for relatively low pay. During those hours, residents teach, learn, participate in group discussions and, under the supervision of an experienced doctor, treat patients.
And although prospective residents interview and express preferences for the hospitals and specialties where they will receive their graduate educations, those destinations are determined by a complex mathematical formula that pairs residents with the institutions that pay and teach them. They typically find out in the spring of their final year in medical school, in an event nationally known as “Match Day.”
“It’s left into the hands of the computer,” said Melissa Masaracchia, a resident in her fourth and final year in Dartmouth-Hitchcock’s anesthesiology program. “It’s such a crazy process.”
Some residents relish the experience of graduate medical education — or much of it. Jeremy Whyman, a second-year resident in internal medicine, Dartmouth-Hitchcock’s largest program, said his best days are those “where I’ve felt like I’ve really connected with patients and had a genuine sense of feedback that you’re really helping somebody.”
But, he added, such feelings can get crowded out: “I think that sometimes you are so busy as a resident, have got so many responsibilities, so many patients to see, you’re racing around like crazy, that sometimes it becomes easy to forget a little bit why you went into this, which is to help people, to make people better.”
The stakes are high. Hours are long, and the pressure can be intense. And when the relationship between a young doctor and the veteran doctors and institution responsible for his or her education sours, it can be very sour.
In recent years, a few former residents have reacted to the involuntary terminations of their educations by suing Dartmouth-Hitchcock.
In June 2012, Thersia Knapik had completed five years in the surgical residency program at Dartmouth-Hitchcock and was at her home with friends and relatives preparing for graduation when one of the doctors who taught students in the program arrived and told her she had been fired, according to her lawsuit.
According to court filings, the decision to send Knapik packing was made after Dartmouth-Hitchcock doctors discovered that she had anonymously contacted a doctor leading a Kentucky fellowship program. Knapik sent the Kentucky doctor a copy of a 2011 letter written by an attending physician at Dartmouth-Hitchcock to another Dartmouth-Hitchcock resident outlining concerns about a second resident’s performance.
After the Kentucky doctor, who had reviewed the second resident’s application for a fellowship, contacted Dartmouth-Hitchcock, doctors there identified Knapik as the source of the letter. Dartmouth-Hitchcock officials concluded that Knapik’s anonymous communications had violated her program’s standards for ethics and professionalism and dismissed her from the program.
Knapik sued the hospital for wrongful termination, breach of contract and unfair dealing. In February, Judge William Sessions of the U.S. District Court in Burlington, threw out Knapik’s claim. In his order, Sessions found that Dartmouth-Hitchcock had not followed its own disciplinary rules, which make a grievance procedure available to a resident facing dismissal, when it dismissed Knapik, but said it didn’t have to because her dismissal was an “academic decision.”
Knapik, who through her lawyer, Norman Watts of Woodstock, declined a request to be interviewed, has asked the judge to reconsider his ruling.
Watts said Knapik had also filed a complaint with the Accreditation Council for Graduate Medical Education. Dartmouth-Hitchcock spokesman Rick Adams confirmed that such a complaint had been filed and said Dartmouth-Hitchcock would “work with (the council) to address the concerns raised in the complaint.”
Watts said he is contacted by two or three residents a year who have issues at DHMC and want to see whether they have grounds for a lawsuit. “It’s a rough life,” he said. “It’s tough as hell to be a resident.”
Bertrand, the graduate medical education associate dean, was familiar with the Knapik case but declined to discuss it. “That individual has challenged the decision, so I’m not really at liberty to comment on something that’s still in litigation.”
Adams pointed to a portion of the judge’s ruling that, according to Adams, questioned Knapik’s trustworthiness, candor and honesty, but declined to comment further “out of respect for Dr. Knapik.”
Years of Training
Institutions, residents and the public all have high stakes in graduate medical education. Residency programs prepare participants for life-and-death actions and decisions and weed out individuals who are not suited or qualified to provide care in a certain field.
That puts a heavy burden on program directors, Bertrand said. “Assuming a resident gets to the end of training in any of our programs here, (a director is) responsible for signing off on a piece of paper saying this individual is capable and qualified to practice in their specialty independently,” he said. “That’s a tremendous responsibility. We take that very seriously. We take the safety of the patients and the public very, very seriously.”
Most residents survive the weeding and pass the board certification examinations required to get licensed in their specialties, Bertrand said. “Last year when I looked at it our fellowship program board certification rate was in the mid-90s,” he said. “And the residency programs — it varies with the program — are generally around 90 percent.”
Prior to testing, residents train for years. They start early, stay late and sometimes work around the clock. They learn, teach and care for patients. They develop confidence in their knowledge and an awareness of its limits.
“One of the most important lessons I’ve learned is the importance of admitting to yourself when you’re not sure what’s going on,” Whyman said. He said he has also become more comfortable with seeking out “a senior physician in the department for help or asking for another specialty to come help with this.”
Dartmouth-Hitchcock encourages such interactions, Whyman said. “People are incredibly approachable,” he said. “There is a real collaborative attitude that pervades the institution which I think isn’t always present in academic medicine.”
The hospital’s small size relative to other teaching hospitals helps, Masaracchia said. “I really like the one-on-one feel,” she said. “The attendings here know almost all of the residents by their first name (and) a little bit about each of the residents.”
While residents depend on hospitals to get the training required for licensing, hospitals rely on residents to take some of the load off of staff doctors by providing care to patients and teaching medical students.
Salaries, benefits and administrative expenses of Dartmouth-Hitchcock’s graduate medical education programs total about $30 million annually, Bertrand said. And the hospital is looking to add programs in nursing and other disciplines, he said: “We are looking to expand.”
E. Ann Gormley, a Dartmouth-Hitchcock urologist who heads up the hospital’s residency program in her specialty, said that, in addition to the job of teaching and training residents, graduate medical education programs must meet expectations for the number of patients to be seen, the number of hours to be worked and the caseloads to be carried.
Residents carry their portion of the load for much lower compensation than is paid to fully licensed physicians. During the current academic year, annual stipends for residents at Dartmouth-Hitchcock range from $52,400 during the first year of post-graduate training to $70,000 in the eighth year, according to the hospital’s website. In fiscal 2013, a dozen Dartmouth-Hitchcock doctors had compensation packages that exceeded $500,000, according to the hospital’s tax returns.
In interviews, residents accepted, without enthusiasm, their pay scale. “Reward comes in a lot of forms,” Koo said, dryly.
“Considering that for the four years of medical school I was making negative 60,000 (dollars) a year, it’s a huge improvement,” Masaracchia said. “We live comfortably on what we make here.”
But, she added, she and many of her colleagues remain burdened by the student loans they must repay. “I could buy a house with the amount of debt I owe still.”
Bertrand, who was a resident at the University of Arizona during the 1980s, said that, while viewing newly minted doctors as a source of cheap labor might have been “a modestly true perspective given what the status of a resident was back in my training days,” things have changed.
Locally, some of that change came in the wake of a 2011 settlement in which Dartmouth-Hitchcock, without admitting liability, agreed to pay $2.2 million to resolve a lawsuit by a former staff doctor and the U.S. Justice Department. The lawsuit alleged that, from 2001 until 2007, the hospital’s anesthesiology and radiology departments had improperly billed Medicare for services that had been performed by residents without attending physician present as supervisors.
More broadly, Gormley noted that some outsiders have the impression that residents are “a cheap work force to do certain aspects of care in the middle of the night.”
But Bertrand rebutted that notion: “We don’t have residents running the hospital at night with nobody else here.” Among the factors that have shifted the focus of residency from staffing to learning are the increased role in caregiving of licensed doctors who focus on in-patient services and of nurse practitioners and physician assistants, he said.
Restrictions on resident work hours have also tightened up in recent years. “First-year residents are now limited to a 16-hour work day,” Bertrand said.
Gormley said that when she was a resident in Canada there were “very few regulations” about total work hours, either there or in the U.S. But in 2011, the Accreditation Council for Graduate Medical Education instituted a rule limiting residents’ working time to “80 hours per week, averaged over a four-week period.”
Gormley embraced the limits on resident hours. Recalling her own training, she said, “many of the things we did in working such long hours probably didn’t contribute much to our education.”
Still, the hours on a resident’s schedule can be formidable. Said Whyman: “I think one of the greatest challenges of being a resident, which I think you get anywhere, is figuring out how to balance being sane with how many hours you spend in the hospital.”
Yet, Koo said, there are lot of positive milestones along the way, such as “a great diagnosis I made or participating in a really satisfying surgery where we cured someone of their cancer or … seeing a patient who was very sick finally get better and leave the hospital or … having a really great teaching session with our medical students.”
He added: “Most days I leave this place having done something or learned something or met someone that gets me going the next day.”
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Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.
