Medical Specialty Association Leaders Must Confront An Epidemic of Abuse in Their Residency Programs

A veritable humanitarian crisis at exploitative post-graduate residency programs is irreparably harming physicians in training and jeopardizing patient care.

(This post is stimulated by conversations with numerous residents of diverse specialties over the years who have been wrongfully thrust into fundamentally unfair administrative procedures, whether within their program or in the larger medical regulatory system (e.g. medical boards, PHPs, NPDB et al.) and who have faced great jeopardy as a result of these proceedings. What incentivized writing about this crisis now is my learning about a creative resolution submitted by a PGY to that specialty’s national policy-making body urging a new approach to PGY abuse: getting the national specialty societies to take an active role in investigating and holding accountable post-graduate programs that may be abusing and exploiting the services of its residents. I thought “Why couldn’t that approach be undertaken by every medical and surgical specialty?” ¹

I admit it’s a bit of a longish piece. If you’re short on time or attention, just jump to “A Representative Scenario.” It’s a word picture with a thousand feelings. The PGYs I passed it by immediately said “you nailed it - that’s IT!

“…some programs have devolved into toxic environments characterized by intentional mistreatment, service exploitation, unjust disciplinary actions, and a stark lack of accountability. The consequences for residents caught in these problematic programs are often dire and irreparable.”

A Long Unaddressed Problem in the US Medical and Surgical Post-Graduate Training Program System Has Reached Crisis Proportions

Residency programs, the rigorous, multi-year, immersive clinical training experience that follows graduation from medical school, have their roots in the philosophy of Sir William Osler, the father of modern medical education. These programs were built on an apprenticeship model, promising a delicate balance between service and education. The foundational quid pro quo principle was simple: residents would provide their services under the tutelage of academically educated and clinically experienced physicians, and in return, they would receive invaluable education and mentorship and the blessing of official certification. This fundamental compact has formed the bedrock of all post-graduate medical training, creating a unique, personal relationship that, when executed fairly, benefited both the resident employee students and the institutions they served.

Since its inception, this model has operated under the presumption of ethical self-governance, respectful service expectations, and adherence to established operational principles. It has been well accepted that most residency programs are going to be rigorous, intense immersions into the uniquely complex world of that specialty that thoroughly prepares the next generation of physicians for the diverse array of complex patient management challenges that lay ahead. And it has been an unspoken agreement that, while the training would be demanding, its educational and employment parameters would also be fair and supportive, holding out the promise that graduation into their chosen field would be available for all who pursued the journey in earnest and successfully achieved the agreed-upon learning and skills milestones.

However, abundant evidence strongly suggests that some – perhaps numerous – programs have reneged on that promise, devolving into toxic indentured servitude environments characterized by intentional mistreatment, service exploitation, and unjust disciplinary actions, all in the context of impunity and a stark lack of accountability.

The consequences for residents caught in these problematic programs are often dire, affecting not only their professional development and career opportunities but also their personal well-being. Worse, the current mechanisms for oversight and recourse have proven woefully inadequate in addressing these ethically compromised programs.

The time has come for clinical leaders of all medical and surgical specialties’ national associations to critically examine these abusive programs.

A Representative Scenario: The Fall from Grace

To fully appreciate the urgency of the crisis affecting those enrolled in problematic "integrity challenged" programs, the following fictionalized but reality-based case scenario might best convey these residents’ plight.

Dr. Amina Patel (a pseudonym), a bright, motivated, and enthused foreign medical graduate, entered her seven-year cardio-thoracic surgery residency program with dreams of excelling as a cardio-thoracic surgeon, living her passion for both teaching and mastering the richly challenging art and science of cardiovascular intervention.

Her early PGY years were marked by glowing reviews, with attendings lauding her dedication, meticulous case preparations, and tireless work ethic. As both an FMG (foreign medical graduate) and alien (non-US citizen) visa holder, and in communication with other similarly situated PGYs, Amina was acutely aware of the precarious nature of her position, but her outstanding performance seemed to promise a bright future.

However, as Amina was finally approaching her final years of training, she was faced with an increasingly demanding workload. In the prior years, she had become aware of a pervasive dynamic of unfairness within the program. Her – and other PGYs’ – workload was becoming increasingly unmanageable, with dangerous concurrent multi-institutional coverage responsibilities that stretched her and others thin. Concerns about patient safety, medico-legal liability, manifestations of faculty unprofessionalism, and even suspicions of potential malfeasance gnawed at her conscience. Despite her trepidation and confident of her senior status, Amina gathered the courage to voice her concerns to the program leadership.

The response was swift and chilling. Instead of addressing the issues she raised, the program retaliated. Amina watched in disbelief as her performance assessments, once stellar, began to degrade. Her program director brought forth anonymously sourced complaints about her “deficient communication skills” and feelings voiced by several unnamed career nurses that she wasn't a team player. Suddenly, she was told she needed "further training" and was assigned extra duties. She was told she faced the possibility of being compelled to repeat the training year if she didn't improve. The message was clear: fall in line or face the consequences.

Desperate to protect her educational status and planned career, and driven by a deep sense of ethical responsibility, Amina attempted to navigate the program's obscure grievance channels. But at every turn, she was met with hostility and dismissal, additional accusations of insufficient performance, and even insinuations of impairment. Her program director speculated that her deficient performance, apparent to several faculty attendings, might be due to her 'burnout.' She was incredulous that these personnel whom she thought she knew and could trust with respectfully conveyed concerns, had turned the table and portrayed her as the problem.

The precariousness of her situation escalated rapidly. Without warning, Amina was placed on administrative leave, a move that sent shockwaves through her life and career. The program director, citing vague concerns about her mental health, demanded she report to the state medical board's Physician Health Program for psychiatric evaluation. She sensed it was a thinly veiled attempt to discredit her complaints, call into question her academic and psychological competence, and knowingly impose immense financial and legal burden.

As Amina fought against this unjust treatment, the final blow came. The program moved to terminate her, citing "insubordination" for not promptly complying with the PHP demand for an unaffordable four-day comprehensive psychiatric evaluation in a different state. On that basis alone, the PHP alleged that she potentially posed a threat to patient safety -- the very issue she had tried to address. She was incredulous; the irony was bitter and overwhelming.

The rapidly ensuing consequences of this termination were catastrophic. She sought guidance through the hospital’s HR department but they shunned her, emphasizing that because she was no longer employed, they couldn't help her.

With her employment contract severed, Amina's visa status was immediately jeopardized. She faced not only the end of her cardiothoracic surgical training but also the prospect of being forced to return to her home country, her American dream of an excellent cardiothoracic training and career shattered.

But the nightmare didn't end there. The program's abrupt actions ensured that Amina's dismissal would be reported to various authorities, effectively blacklisting her from other programs across the nation, ending her medical career altogether. In a matter of mere months, she had gone from a rising star to a shamed failure, her future in medicine malevolently erased by a system meant to nurture it.

This scenario, far from being an isolated incident, exemplifies the systemic failures of operational integrity plaguing diverse residency programs. It illustrates the rapid cascade of rights violations that can occur before one even has the ability to respond, much less make sense of them. It highlights the capricious abuse of power by program leadership, and the utter powerlessness of residents -- especially those on visas -- to defend themselves against such a plethora of injustices.

Her story is also a stark reminder of the profound multi-person-orchestrated institutional betrayal experienced by many residents who naïvely enter these mean-spirited programs with hope and persevering dedication, only to find themselves trapped in a nightmare of retaliation and irreparable career destruction.

It underscores the urgent need for prompt intervention and marshaling of resources for investigation, imposing more comprehensive oversight coupled with program leader accountability, and promptly affording protection for those who dare to speak up against dangerous practices and unprofessional program conduct.

Devolution of Residency Training

Based on numerous accounts sharing consistent stories, the US post-graduate residency training landscape is contaminated by the emergence of programs that are abusing residents in grievous ways, and continuing to do so with virtually no oversight or accountability. The fundamental economic quid pro quo - where residents offer their labor and dedication in exchange for guidance and education - has been severely compromised, if not wholly avulsed.

In place of nurturing environments designed to cultivate skilled and compassionate clinicians, these troubled programs more resemble indentured servitude enclaves, characterized by excessively rigorous demands and a culture of maltreatment. Their academic and work atmosphere has become insular to the point of being anaerobic, cut off from the fresh air of honesty, open communication, and compassion that should infuse medical training.

Perhaps most alarming is the malicious abuse of power that has taken root in such problematic programs. These leaders have rationalized tyrannical methods of motivation, treating residents as expendable "hired help." A prevailing attitude of condescension towards residents' concerns has emerged, with legitimate complaints offensively characterized as unreasonable demands from ungrateful trainees. This dynamic is a disturbing replica of the tactics of gaslighting, a form of severe psychological abuse.

Such toxic training cultures are allowed to develop and persist due to ineffective, if not willfully absent, oversight. While the ACGME is assumed to ensure adherence of postgraduate programs to national standards (both academic and program procedural proceses [including due process]), the reality in these programs differs starkly from these ideals. A faculty-centric culture, reinforced by institutional alignment with program leadership, has led to a pervasive disregard of the validity of resident feedback. As a result, these inadequate and toxic training environments continue unchecked, and even worsen.

“This crisis in post-graduate education represents a fundamental betrayal of the profession's highest ideals.”

Residents, with little basis for comparison, are forced to accept mistreatment as normal. The insular nature of these programs and threats of severe retaliation if abuse is disclosed prevent external scrutiny and intervention, allowing these markedly abusive practices to remain well concealed from discovery, even by those charged with oversight. A culture of silence and acquiescence takes hold. As a result, there is a very real risk of compromising patient care as distressed residents, weary and cynically resigned, operate under fear of retaliation.

This crisis in post-graduate medical education and ongoing failure of intervention represents a fundamental betrayal of the Oslerian compact. It is beyond time that we as a profession must confront this despicable maltreatment head-on and take decisive action. We must find a way to hold these programs accountable for the harms they have done and effect change immediately before additional irreparable catastrophic damage is done to our residents.

Residents in Abusive Post-graduate Programs Suffer Unimaginable Harms

Individual Impact

The toll on individual residents in abusive programs is profound and multifaceted. Against the baseline of exhaustion, many experience severe distress that can best be characterized as complex psychological trauma. This repetitive and ongoing trauma is compounded by a cumulative profound moral injury, leaving residents feeling betrayed and disoriented, a state akin to suffering a “psychological concussion.”

An overwhelming sense of disbelief almost invariably immobilizes residents, rendering them unable even to coherently articulate the cascade of rights violations they have faced. It is indeed understandable that they can't. The severity and variety of the sheer breadth of violations is exceedingly challenging to name, even if one were sufficiently versed in the legal concepts and terminology applicable to these myriad wrongdoings.

Educational and career implications for these residents are devastating. Unjust terminations, disciplinary actions, or allegations of impairment or "unfitness" – particularly stinging in the final years of residency – derail promising careers and cause severe psychiatric sequelae. The consequences are especially severe for foreign medical graduates, whose visa status is tied directly to their residency. A single adverse action can result in the immediate jeopardy of their visa status, forcing a return to their home country and effectively ending their pursuit of an American, or for that matter any, medical career.

A particularly troubling tactic employed by such programs is the "singling out" phenomenon. Residents who voice concerns are singled out for harsh criticism and public humiliation and often face severe and irreparable retaliation. Their once-stellar performance assessments may suddenly degrade, and they may find themselves burdened with extra duties or requirements for "further training" - thinly veiled punitive measures designed to silence, subdue, and overwhelm them. And throughout, the targeted resident is entirely powerless and voiceless.

Impact on Entire Cohort

The negative effects extend beyond individuals to entire cohorts of residents. A pervasive culture of fear and silence takes hold, trapping residents in a cycle of abuse where they feel unable to effectively advocate for their rights. This fosters a sense of cynical resignation and embitterment among the group, eroding their trust in their specialty’s post-graduate training system as a whole.

Patient care is at high risk of being compromised in this environment. Residents operating under severe psychological distress are much less likely to report errors or raise concerns about patient safety, fearing blame or further retaliation. This reluctance to speak up necessarily has serious implications for the quality of care provided and, for that matter, patient advocacy.

Perpetuating a Culture of Abuse

Seldom discussed is how, by not addressing the malignancy of such toxic programs, we are contributing to producing psychologically battered attendings who have come to despise both their craft and their future trainees, and even patient care. When residency programs foster environments of abuse, exploitation, and incessant emotional trauma, they strip away the passion and curiosity that drive their motivation and rob them of the capacity for genuine presence and compassion. Physicians who endure such environments are at high risk of emerging as burned out, cynical, and disillusioned from the outset, far from the competent diagnosticians and caring clinicians so desperately needed.

The Comfortable Illusion of Oversight

The Mirage of Due Process and the Complete Failure of Complaint Mechanisms

The mechanisms designed to protect residents and ensure program quality, if they have truly ever been present, have largely failed. This systemic breakdown with utterly no failsafes leaves trainees extremely vulnerable.

At the heart of this crisis lies a fundamental flaw in how residency programs are monitored. The Accreditation Council for Graduate Medical Education (ACGME), tasked with overseeing these programs, seems to operate with limited effectiveness in addressing these concerns. But their presence and professed role may create the dangerous illusion of active oversight and contemporaneous compliance where none may exist. This presumption of adherence to standards has allowed problematic programs to flourish unchecked, shielded by a veneer of respectability.

When residents dare to speak out against mistreatment or substandard conditions, they find themselves navigating a treacherous landscape. The existing channels for addressing concerns are not just ineffective; they can actually be dangerous. The offered complaint pathways are simply ineffective or nonviable. "Well,” says an ACGME representative to a distressed resident, “we are not empowered to address residents’ individual complaints. We encourage you to use internal mechanisms to address your complaint within your program Our primary mission is to identify patterns of deficiency in programs.”²

Residents who nevertheless file a formal complaint often face the risk of covert retaliation, with no proactive measures in place to protect them. This creates a chilling effect, where the very mechanisms meant to give voice to concerns and to effect prompt review instead serve to silence and endanger them.

The Legal Labyrinth

For those brave enough to consider legal recourse, a daunting array of obstacles awaits. The complexity of medical education disputes requires expertise across multiple legal domains – from education and employment law to civil rights and disability issues. Yet, specialists in this niche area are few and far between. Even when found, their services are often financially out of reach for residents already burdened by educational debt. To compound matters, civil courts tend to defer to institutions, operating under the fundamentally flawed assumption that external accountability exists and internal controls are effective.

A System Entirely Stacked Against Voiceless and Battered Residents

The odds are further stacked against residents by the very structure of the programs themselves. The Designated Institutional Officer (DIO) system, meant to serve as an intermediary, often lacks the independence and capacity to truly advocate for residents. Instead of facilitating honest dialogue and collaboratively seeking fair hearings and resolutions, these offices can become yet another barrier to justice.

Hospitals that are host to these programs, despite their role as residents’ actual employers, frequently fail to uphold their end of the educational and employment bargain. They provide no safe channels for residents to voice concerns about programs or personnel. Complaints, when made, are often met with dismissal or delay rather than expeditious review. The absence of guaranteed protection from retaliation further discourages residents from speaking out. Meanwhile, it seems the custom, that the institution promptly utilizes its legal resources to assemble a campaign to discredit the complainant. Words are insufficient to capture the depth of this ethically depraved conspiratorial malevolence that is one of the most significant sources of disorienting moral affront they face.

“What exponentially deepens the hurt of the victim is not the continued cruelty of the abuser but the cowardly silence of the bystander.”

(Adapted from Elie Wiesel)

The Complicity of Silence and the Cost of Inaction

Perhaps most troubling is the widespread acceptance, even normalization, of this dysfunctional status quo. National specialty associations, which should serve as advocates for their future members, customarily defer to ACGME's authority, abdicating their responsibility for ensuring active oversight and protection of resident well-being. There's a pervasive belief that resident complaints are merely universal grumbling, unworthy of serious attention. This attitude, coupled with a misplaced faith in the effectiveness of internal controls and of ACGME authority, allows systemic problems to persist and worsen.

The consequences of this systemic failure are profound and far-reaching. Residents, the desperately needed future practitioners and leaders of their fields, are left vulnerable to unconscionable abuse and exploitation.

What we are dealing with is nothing short of a system-wide humanitarian crisis. But the current state of intervention mechanisms for addressing these abusive and harmful residency programs is severely wanting. What is called for is immediate and comprehensive investigation of its nature, incidence, prevalence, and severity of career and personal morbidity.

Only through acknowledging these failures and taking decisive action can we hope to create an educational environment that truly addresses the needs of the population of residents hostage to these programs.

"If you are neutral in situations of injustice, you have chosen the side of the oppressor."

Archbishop Desmond Tutu

The Urgent Need for Action

As you read this, residents in numerous post-graduate programs across the country are dealing with myriad forms of severe abuse and exploitation that are being concealed by forced silence, but whose programs portray themselves as upstanding ACGME programs conducting legitimately rigorous training and pursuing clinical excellence.

Addressing this hideous abuse is not just a matter of “improving residency programs” or writing lofty position papers filled with lots of ‘shoulds.’ It is about responding to urgent pleas for help from residents whose specialty training and careers are imminently and chronically endangered by exploitative programs.

We believe it is incumbent that each specialty association take the helm and develop an optimal strategy to investigate and intervene in problematic programs where residents face such jeopardy.

Admittedly, the problem is complex and multifactorial, and the targeted solutions may not be readily apparent. And while this scrutinizing oversight task may feel like a new foray into unfamiliar territory – awkward, uncertain, ill-defined – it is vital to appreciate that what is not ill-defined or uncertain is the gravity of the crisis and the irreparable grievous harm that is being done to too many fine, deeply motivated, highly capable residents.

It is unconscionable for us to remain passive bystanders to this malevolent and irreparably harmful abuse. It is our ethical duty to compel our specialty associations to undertake – with haste – a searching inquiry into these matters and act definitively to impose transparent and impactful accountability and restore integrity to every post-graduate program under their watch.

“In the moment of breakthrough, when suffering gives way to freedom, a rush of love flows between the healer and the healed. Both are transformed, both are grateful, and both are filled with renewed hope for the journey ahead."

(Anon.)

1. I discussed the draft of this piece with numerous PGYs and practicing clinicians, and sent around the creative proposal that was submitted by one PGY to one specialty association in advance of its delegates’ meeting. I hope simply bringing forth this post-graduate training program crisis (that I see as a humanitarian crisis, and one that spills out of the confines of the post-graduate arena) into fuller view will stimulate productive dialog and similar creative thinking so that together we might re-humanize the culture of medicine and protect the academic and career well-being of our fellow physicians in training. Please feel free to use the comment section to make connections and deepen the dialog.

2. This is a paraphrased composite quote that I have heard similarly expressed by several PGYs.