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Residents on pins and needles

On May 1, the Accreditation Council for Graduate Medical Education (ACGME) sent a letter to the College of Medicine listing nine citations against the anesthesiology program.

The letter stated that the faculty doesn’t provide enough supervision of residents, there is not enough scholarly activity and publication in the program, that “most residents feared retribution for negative comments they made in the course of the survey interviews” and that “faculty intimidation of residents has occurred.”

The program has been on probation since March 18, 2004 and has until July 1 of this year to respond to nine areas in need of improvement. The program was assessed by the Residency Review Committee for Anesthesiology (RRC) under the authority of the ACGME’s authority. By law, RRC Executive Director Judith Armbruster could not comment on the letter.

“I can’t specify why the citations are in the report,” Associate Dean for Graduate Medical Education Peter Fabri said. “I assume that the source is anonymous letters. I really don’t know any details about what triggered most of these citations.”

According to Fabri, the letter is not accurate in its depiction of the way residents are treated.

“I meet with the residents often,” he said. “I would have to tell you that the residents do not fear reprisal. Sometimes they don’t like the way that they are spoken to, but I suspect that you and I might sometimes feel that way too.”

Most of the residents contacted would not comment. Three residents, who wished to remain anonymous, made statements which contradicted Fabri’s. One resident described many instances where the anesthesiology faculty has retaliated against residents.

“We feel there is the presence of retribution all around us,” one resident said. “We have seen what happens to residents who speak up about issues that need significant changes. We have publicly heard, in crowded hallways, (attending doctors) and administration speak very poorly of residents who have spoken up.”

Another resident described the program’s intimidation tactics.

“It’s quite easy to intimidate a resident,” said another resident. “There are a million and one ways they can make your life miserable and affect your career down the line. It actually happens in all residencies. It was just worse in ours.”

Another resident said, after the RCC’s letter was received, a meeting with attending physicians was held.

The resident said, “During the large meeting one attending (physician) attacked with, ‘Explain to me Dr. X! Just how do you think that you are being intimidated? Why don’t you tell the whole crowd where you think there is retaliation?’ The resident replied, ‘Well, due to the fact that you are yelling at me and your jugular veins are popping out, I say that’s pretty intimidating retaliation, don’t you?'”

A third anonymous resident knew residents who attended this heated meeting.

“I haven’t had any experience with intimidation, but I have colleagues who have. I’m actually pretty disgusted with the program,” the resident said.

Michael Hoad, associate vice president for communications at USF Health, said he had heard the reason the accreditation committee evaluated USF was because residents sent multiple negative letters to the RCC, but he couldn’t confirm it.

“They don’t actually tell you that as a formal reason,” Hoad said. “This is a public university. The notion that, in some way, we’re going retaliate against somebody for complaining, to be honest, it’s silly. That’s not what happens here. Nobody has the time to go around finding who said what.”

An anonymous resident said that the program would have faced losing its accreditation regardless of resident complaints.

“It’s a political minefield, this whole thing,” the resident said. “The whole joke of this program is that they are trying to blame everything on the residents, as if it’s the residents’ fault. I think the program might have even closed down without the letters to the RRC.”

Most of the program’s problems stem from its affiliation with the private firm Florida Gulf-to-Bay Anesthesiology Associates (FGTBAA). FGTBAA is a private anesthesiology firm where residents receive most of their training.

“(The accreditation committee) didn’t feel that it was appropriate for the private group to be in charge of the residents,” Dean of the College of Medicine Stephen Klasko said.

According to the accreditation committee’s letter, most members of the anesthesiology faculty are employed by FGTBAA, not USF. Only four members of the anesthesiology faculty were appointed for academic purposes; all others have a “voluntary status.” The letter states that residents are concerned about the faculty’s lack of experience with instructing in residency programs.

“Most of the (attending doctors) who are at Gulf-to-Bay never wanted to be part of any academic program,” a resident said. “They made it clear they had no interest in teaching.”

According to a resident, the differences between USF’s program and those at other schools only serve to exacerbate problems.

“There is a lack of academics in our program, mostly that’s because the attendings are from a private group,” said one resident. “With most academic programs, attendings are involved in research a lot and they are very up to date on medical literature. They will be doing research themselves or be involved in writing a book. They will kind of discuss things before they begin a case, based on the latest evidence or research here. Here, it just seems like they aren’t teaching us.”

Also noted in the ACGME letter is a lack of resident supervision by attendings.

“The faculty do not provide adequate supervision of the residents in the preoperative evaluation clinic at Tampa General Hospital,” the letter said. “The surveyor reported that the residents have no interaction with a teaching anesthesiologist during this rotation, and that the rotation is heavily weighted toward service over education.”

“Essentially, the attending goes in the room with us at the beginning of each case,” an anonymous resident said. “They supervise us putting the patient to sleep, securing the airway by placing the breathing tube, then they essentially walk out. There is minuscule to no teaching. On a given day, we work between 10 and 14 hours. I would say on average, a resident would get between five and 10 minutes of teaching a day, if that.”

Fabri said that those who are dissatisfied with their education are few and far between.

“I spend a lot of time with residents.” Fabri said. “For the most part, the anesthesia residents like their training program. They get to take care of a lot of complicated patients. For the most part, the faculty that supervises them are very, very competent. If you start calling people, you are going to find a few people who like to complain.”

The program is also undergoing steady improvement, Fabri said.

“The new chairman, Dr. (Enrico) Camporesi and I, over the last year have been working very, very diligently,” he said. “The program is improving month by month.”

However, the site report administered by RRC indicated that there might be a conflict of interest between FGTBAA and Camporesi.

According to the site report, “FGTBAA pays a dean’s tax to USF. The salary component of the anesthesiologists practicing at TGH comes through clinical fees collected by FGTBAA. This payment is said to include a significant portion of Dr. Camporesi’s salary (55 percent).”

In addition, residents feel overworked and underpaid.

“The residents’ salaries are paid by Medicare,” said a resident. “Essentially, Gulf-to-Bay gets to use and exploit the residents as free labor.

“One Certified Nurse Anesthetist (CRNA) makes over $100,000 per year working 40 hours per week. A resident works 80 hours per week. Do the math. Gulf to Bay can make an extra $200,000 per year for each resident that they can exploit simply by not paying the salary of two CRNA’s that year.”

“It’s a complete conflict of interest,” said a resident. “It’s a bold fact. You don’t have to be a rocket scientist to figure that out. You can’t have a program with a chairman who is having a large chunk of his salary paid by a private practice. How can he possibly make decisions that are for the good of the residents?”

Both Camporesi and Dr. Devanand Manger, the president of Gulf-to-Bay, declined to comment.

The site report states that, “since the last site visit there has been significant attrition of residents. Four transferred into other anesthesiology programs. One transferred to a family medical program. Two left for medical reasons. One left medicine to join his family business. Another committed suicide.”

Fabri said that the individual’s suicide had nothing to do with his anesthesia residency at USF.

“When this individual committed suicide, we actually used an outside group of experts to evaluate the suicide,” Fabri said. “The outside group of experts said that the suicide had no apparent connection to this individual’s work or his residency. There were numerous, strong reasons to explain why this individual committed suicide that had nothing to do with being an anesthesia resident.”

According to anonymous residents, the resident who committed suicide extubated a patient’s breathing tube too early. In a following “Morbidity and Mortality” conference, a meeting where medical complications are discussed, the resident was told that he “would get his throat slit” if he did it again. This resident committed suicide about two months later.

“Sometimes people use language in ways where they aren’t saying what they mean to say,” Fabri said. “Sometimes people become hyperbolic, where they say exaggerated things, because they feel very strongly about something. I was not at this meeting, so I can’t tell you what actually happened. I’m absolutely sure that the individual didn’t actually mean that they were actually going to slit somebody’s throat.”

Though some residents are disappointed with the program, one said that they make sure that their patients continue to be the main focus of their education.

“As miserable as I am right now, I go to work everyday and spend as much time as I can with my patients,” the anonymous resident said. “Just seeing the gratuity in their eyes and that I get to make a difference, that’s what keeps me going back to work. If I can do that, I know that I haven’t wasted my life and I know that I’m doing the right thing. I’ll get through this.”