Resident dismissal: Suing the system

More than 3,400 residents left their programs last year. Although half transferred to other programs, 892 quit and another 250 were fired or not offered contracts.

Those 1,142 residents represent 1.2% of total residents, a number that has remained fairly constant since 1997, according to a survey of graduate medical education by the American Medical Association. In the pressure-cooker environment of modern academic medical centers, residents leave programs for reasons as simple as deciding they want to change their specialties or as complicated as personal problems.

But sometimes residents are asked to leave programs because attending physicians, who are responsible for supervising residents and ensuring quality, believe the residents aren't able to safely take care of patients.

When this happens, many residents leave quietly. But Danny Colton, MD, and Vijay Boinapally, MD, did not. Both men had dreamed of becoming doctors and returning home to serve their communities. Those dreams fell apart during residency, and when they believed they had been discriminated against and had exhausted their due process rights, they sued.

"The most frequent reason residents complain is due process," said David Leach, MD, executive director of the Accreditation Council for Graduate Medical Education. "Residents usually sue when they are unhappy with the outcome of due process."

In separate lawsuits, Dr. Colton and Dr. Boinapally claim they were drummed out of their programs because of racial and ethnic discrimination. Dr. Colton was not offered a fourth year in surgery at Detroit Medical Center and Dr. Boinapally was fired from his job as a second-year anesthesiology resident at the University of Tennessee at Memphis.

Medical school officials at Wayne State University and the University of Tennessee -- the institutions sued -- say the residents washed out because of poor performance.

School officials don't deny that the incidents alleged by the residents took place. But they maintain that the incidents, although regrettable, had nothing to do with decisions made to let the residents go.

In trials expected to begin later this year, juries will ultimately decide whether Dr. Colton and Dr. Boinapally lost their jobs because of poor performance or because of a conspiracy among faculty to discriminate.

From his days as a youth living in the ghettos of Detroit, Dr. Colton, 34, dreamed of becoming a surgeon and returning to the inner city to practice medicine. He did all the things he needed to do to make that dream come true.

A graduate of Wayne State University School of Medicine in 1992 with a master's in public health from the University of Michigan in 1996, Dr. Colton was accepted as a provisional surgery resident in June 1996. He published award-winning research papers and was featured in 1998 on the Learning Channel in "Trauma: Life in the ER."

But during rounds as a first-year resident at Detroit Medical Center, Dr. Colton's dream of becoming a surgeon effectively ended. One of the attending physicians told a story with racial connotations in front of Dr. Colton, who is African-American, several medical students, another resident and an unconscious African-American patient.

According to Dr. Colton, "After I complained about the racial slur to my program director, my evaluations, which were very good up until then, began to go downhill."

Acknowledging his in-service examinations were low, Dr. Colton did his best to raise them to the 27th percentile from the 11th percentile. However, officials had warned Dr. Colton that he would be terminated if he did not reach the 50th percentile by the end of his third year.

Despite improvement by Dr. Colton, Wayne State officials said performance problems continued to hound him. But during his three years, Dr. Colton said he performed more than 800 surgeries. "If I was considered a bad surgeon, then why did they want me to do so many surgeries?" he asked.

While waiting for trial, Dr. Colton is finishing up an occupational medicine residency at the University of Michigan.

"I am the doctor for 1,300 workers at a Ford Motor Co. clinic. If you get hurt working on cars or suffer a health problem -- seizures, heart attacks, lacerations -- you come to me," he said.

But Dr. Colton still wants to complete his surgery residency. "Occupational medicine is great, but I want surgery. I came out of the ghettos of Detroit and I want to give back to my community."

Dr. Boinapally, 32, grew up in Hyderabad, India. He came to the United States in August 1992 after receiving his medical degree at Sri Venkateshwara Medical College.

His dream was to study with some of the greatest physicians in the world and return to his home country armed with cutting-edge knowledge.

Now, after two bad experiences in U.S. residency programs, he regrets that decision.

In October 1998, during his second year as an anesthesiology resident at University of Tennessee Medical Center, Dr. Boinapally was fired for alleged poor performance and patient safety reasons.

In his lawsuit, Dr. Boinapally cited more than seven derogatory comments by faculty and staff. He said most comments derided his Indian heritage and culture. He said he was paid less than his peers who were Americans. He said he didn't receive performance evaluations, as required by ACGME, with which he has filed a complaint.

"I get really angry sometimes when I think about what was done to me," Dr. Boinapally said. "I want to be reinstated and complete my training. But I also am going through all these lawsuits because I don't want this to happen to anyone else."

Before joining Tennessee's program, Dr. Boinapally was a second-year internal medicine resident at the State University of New York in Buffalo. In 1995, he was terminated from that program, allegedly for academic reasons. He has a pending discrimination lawsuit against SUNY with two Pakistani residents, who also were terminated.

"There is a dark side to IMGs working in the American system," Dr. Boinapally said. "We are needed and greeted with open arms because they need workers. But then we are expected to take insults, humiliation and discrimination without objection and then just go home when we are not needed or wanted anymore."

Although the nearly two dozen physicians named in the two suits were advised not to comment, university lawyers spoke with AMNews.

Both Sarah Hall, general counsel with the University of Tennessee, and Louis Lessem, Wayne State's general counsel, said their universities have denied the two residents' claims of discrimination.

"Dr. Boinapally received poor evaluations from the beginning," Hall said. "We gave him several chances to improve. We counseled him. When he didn't [improve], we had to terminate him."

Said Lessem, "The notion that you make a bad comment to a person and the universe of all other surgeons closes ranks and acts in grand conspiracy to get rid of you is pretty far-fetched. Our position is they are unrelated activities. [Dr. Colton] was dismissed for amply demonstrable performance problems."

Hall said Tennessee didn't know Dr. Boinapally had been kicked out of the SUNY program. "We found out about this later. He didn't disclose that in his application," she said. Dr. Boinapally said he informed Tennessee faculty members of his SUNY residency during his interview.

Lessem said Dr. Colton's evaluations went down after the alleged bigoted incident because faculty physicians generally are tougher on residents after their first year. "A first-year resident is not expected to do what a fourth-year would do."

Of the alleged racist remark, Lessem said: "I have heard two or three versions of the story. I believe some remarks were made and Colton was offended about it. [The program director] asked the [attending] to apologize, and he did. That didn't satisfy Dr. Colton."

Although fewer than 20 residents file lawsuits annually, experts believe that number is increasing. One possible reason for the increase is new job protection accreditation standards approved by ACGME to enhance due process and discourage discrimination and psychological abuse of physicians in training.

"The more due process residents get, the more the possibility that process is not attended to and the more possibility there will be lawsuits," said Michael Scotti Jr., MD, the AMA's vice president of medical education.

Surveys show that 90% of residents reported they were the target of belittling or humiliating comments, 43% reported physical abuse and 69% of the women reported sexual harassment. Some 81% of residents said the sources of mistreatment were attending physicians and 76% were residents at a higher level, according to a 1998 report from the AMA's Council on Medical Education.

Although not commenting on any particular lawsuit, Dr. Scotti said most lawsuits are not frivolous. "They do indeed have a factual basis. This is not to say there was a good or bad resident or there wasn't a performance problem. But program directors sometimes don't provide residents with proper due process."

Clarita Herrera, MD, chair of the AMA's international medical graduate section, said discrimination and resident abuse are too common.

"We don't feel like we have had a board meeting unless we have a discussion about discrimination," said Dr. Herrera.

"Discrimination is hard to prove. Most will just put up with it because they know they have a finite time to deal with a director. It is very difficult for one person to prove their case and win. The only way to change the system is to file a class action lawsuit."