Surgeons as Educators A Guide for Academic Development and Teaching Excellence

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as a successful outcome measure for underperforming surgery residents is compli-
cated by the high attrition rate of about 20% among general surgery residents,
irrespective of in-residency performance [ 54 ]. Unfortunately, as measured by
board certification and licensure, residents who underperform may experience con-
tinued difficulties after graduation [ 6 , 14 ]. Among the 102 residents on probation
across all specialties described by Guerrasio et al. [ 14 ], 52% ultimately graduated.
These graduates were less likely than their matched peers to be in practice or fel-
lowship (96% versus 100%), and those that were in practice were less likely to be
board certified (64% versus 100%) and more likely to have an encumbrance on
their medical license (6.9% versus 0%). In a retrospective analysis of categorical
general surgery residents in 1 program over 30 years, Williams et al. [ 6 ] identified
17 residents with substantial problems. They found the residents often had deficits
in multiple areas and continued to have substantial performance problems at the
end of the program, even with interventions. Sixteen out of the 17 residents ulti-
mately graduated from the program, although two repeated a year. They continued
to underperform after graduation. Compared to matched controls, they were less
likely to be board certified (59% versus 100%) and less likely to hold active medi-
cal licensure (88% versus 100%).

The Legal Context of the Poorly Performing Resident

Are residents considered employees or students? On November 26, 1999, the
National Labor Relations Board (NLRB) rendered a decision holding resident phy-
sicians to be “employees” under the National Labor Relations Act (NLRA). This
decision reversed two prior decisions (1976, 1977) that residents were not employ-
ees (but instead, students) under the NLRA.  The impact of the 1999 decision
allowed for residents to organize in labor unions and collectively bargain as
“employees” with full rights and protections of the NLRA; however, this decision
also opened legal pathways for residents to take action against their employers
under employment laws. Principles adopted by the ACGME related to the NLRB
decision are outlined in Fig. 17.1

1. Residents are first and foremost students, rather than employees, and all accreditation
   standards and activities reflect this distinction.


2. Residents need to be protected as students with respect to their educational environment
   and the clinical settings in which they learn.


3. Residency settings vary substantially from place to place throughout the country.
   Thus, solutions to the resident protection issues which have been articulated
   should be implemented at local levels rather than by a single national plan.
   Institutions must be accountable for addressing resident concerns and issues at
   the local level.

Fig. 17.1 ACGME Principles

17 Optimizing Success for the Underperforming Resident