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Schultz TJ, Zhou M, Gray J, Roseleur J, Clark R, Mordaunt DA, Hibbert PD, Haysom G, Wright M. Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature. Syst Rev 2024; 13:104. [PMID: 38594759 PMCID: PMC11003134 DOI: 10.1186/s13643-024-02501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised. METHODS We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis. RESULTS From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results. CONCLUSION Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.
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Affiliation(s)
- Timothy J Schultz
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia.
| | - Michael Zhou
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jodi Gray
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Jackie Roseleur
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Richard Clark
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
- HealthFX, Melbourne, Australia
| | - Dylan A Mordaunt
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
- Southern Adelaide Local Health Network, Adelaide, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | | | - Michael Wright
- Avant Mutual, Sydney, Australia
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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Leslie K, Bourgeault IL, Carlton AL, Balasubramanian M, Mirshahi R, Short SD, Carè J, Cometto G, Lin V. Design, delivery and effectiveness of health practitioner regulation systems: an integrative review. HUMAN RESOURCES FOR HEALTH 2023; 21:72. [PMID: 37667368 PMCID: PMC10478314 DOI: 10.1186/s12960-023-00848-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/23/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions. METHODS We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework. FINDINGS This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners. CONCLUSION We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.
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Affiliation(s)
- Kathleen Leslie
- Athabasca University, Athabasca, Canada.
- Canadian Health Workforce Network, Ottawa, Canada.
| | - Ivy Lynn Bourgeault
- University of Ottawa, Ottawa, Canada
- Canadian Health Workforce Network, Ottawa, Canada
| | - Anne-Louise Carlton
- Royal Melbourne Institute of Technology (RMIT) University, Melbourne, Australia
| | - Madhan Balasubramanian
- College of Business, Government and Law, Flinders University, Adelaide, Australia
- Menzies Centre for Health Policy and Economics, The University of Sydney, Sydney, Australia
| | - Raha Mirshahi
- University of Ottawa, Ottawa, Canada
- Canadian Health Workforce Network, Ottawa, Canada
| | | | - Jenny Carè
- University of Technology Sydney, Sydney, Australia
| | | | - Vivian Lin
- University of Hong Kong, Hong Kong, China
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Cheong CWS, Quah ELY, Chua KZY, Lim WQ, Toh RQE, Chiang CLL, Ng CWH, Lim EG, Teo YH, Kow CS, Vijayprasanth R, Liang ZJ, Tan YKI, Tan JRM, Chiam M, Lee ASI, Ong YT, Chin AMC, Wijaya L, Fong W, Mason S, Krishna LKR. Post graduate remediation programs in medicine: a scoping review. BMC MEDICAL EDUCATION 2022; 22:294. [PMID: 35443679 PMCID: PMC9020048 DOI: 10.1186/s12909-022-03278-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Recognizing that physicians may struggle to achieve knowledge, skills, attitudes and or conduct at one or more stages during their training has highlighted the importance of the 'deliberate practice of improving performance through practising beyond one's comfort level under guidance'. However, variations in physician, program, contextual and healthcare and educational systems complicate efforts to create a consistent approach to remediation. Balancing the inevitable disparities in approaches and settings with the need for continuity and effective oversight of the remediation process, as well as the context and population specific nature of remediation, this review will scrutinise the remediation of physicians in training to better guide the design, structuring and oversight of new remediation programs. METHODS Krishna's Systematic Evidence Based Approach is adopted to guide this Systematic Scoping Review (SSR in SEBA) to enhance the transparency and reproducibility of this review. A structured search for articles on remediation programs for licenced physicians who have completed their pre-registration postings and who are in training positions published between 1st January 1990 and 31st December 2021 in PubMed, Scopus, ERIC, Google Scholar, PsycINFO, ASSIA, HMIC, DARE and Web of Science databases was carried out. The included articles were concurrently thematically and content analysed using SEBA's Split Approach. Similarities in the identified themes and categories were combined in the Jigsaw Perspective and compared with the tabulated summaries of included articles in the Funnelling Process to create the domains that will guide discussions. RESULTS The research team retrieved 5512 abstracts, reviewed 304 full-text articles and included 101 articles. The domains identified were characteristics, indications, frameworks, domains, enablers and barriers and unique features of remediation in licenced physicians in training programs. CONCLUSION Building upon our findings and guided by Hauer et al. approach to remediation and Taylor and Hamdy's Multi-theories Model, we proffer a theoretically grounded 7-stage evidence-based remediation framework to enhance understanding of remediation in licenced physicians in training programs. We believe this framework can guide program design and reframe remediation's role as an integral part of training programs and a source of support and professional, academic, research, interprofessional and personal development.
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Affiliation(s)
- Clarissa Wei Shuen Cheong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Elaine Li Ying Quah
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Keith Zi Yuan Chua
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Wei Qiang Lim
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Rachelle Qi En Toh
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Christine Li Ling Chiang
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Caleb Wei Hao Ng
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Elijah Gin Lim
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Cheryl Shumin Kow
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Raveendran Vijayprasanth
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Zhen Jonathan Liang
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Yih Kiat Isac Tan
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Javier Rui Ming Tan
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, 117599 Singapore
| | - Limin Wijaya
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Warren Fong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Department of Rheumatology and Immunology, Singapore General Hospital, 16 College Road, Block 6 Level 9, Singapore, 169854 Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore
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Kennedy G, Jacobs N, Freemark L, Madan S, Chan N, Tran Y, Miller PA. Remediation Programs for Regulated Health Care Professionals: A Scoping Review. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 42:36-46. [PMID: 34581709 DOI: 10.1097/ceh.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Clinical competence is essential for providing safe, competent care and is regularly assessed to ensure health care practitioners maintain competence. When deficiencies in competence are identified, practitioners may undergo remediation. However, there is limited evidence regarding the effectiveness of remediation programs. The purpose of this review is to examine the purpose, format, and outcomes of remediation programs for regulated health care practitioners. METHODS All six stages of the scoping review process as recommended by Levac et al were undertaken. A search was conducted within MEDLINE, Embase, CINAHL, ERIC, gray literature databases, and websites of Canadian provincial regulatory bodies. Emails were sent to Registrars of Canadian regulatory bodies to supplement data gathered from their websites. RESULTS A total of 14 programs were identified, primarily for physicians (n = 8). Reasons for remediation varied widely, with some programs identifying multiple reasons for referral such as deficiencies in recordkeeping (n = 7) and clinical skills (n = 6). Most programs (n = 9) were individualized to address specific deficiencies in competence. The process of remediation followed three stages: (1) assessment, (2) active remediation, and (3) reassessment. Most programs (n = 12) reported that remediation was effective in improving competence. CONCLUSIONS Regulatory bodies should consider implementing individualized remediation programs to ensure that clinicians' deficiencies in competence are addressed effectively. Further research is indicated, using reliable and valid outcome measures to assess competence immediately after remediation programs and beyond.
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Affiliation(s)
- Geneva Kennedy
- MSc Physiotherapy Program, School of Rehabilitation Science, McMaster University, Hamilton, Canada
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Price T, Wong G, Withers L, Wanner A, Cleland J, Gale T, Prescott-Clements L, Archer J, Bryce M, Brennan N. Optimising the delivery of remediation programmes for doctors: A realist review. MEDICAL EDUCATION 2021; 55:995-1010. [PMID: 33772829 DOI: 10.1111/medu.14528] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 05/15/2023]
Abstract
CONTEXT Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.
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Affiliation(s)
- Tristan Price
- Collaboration for the Advancement of Medical Education Research and Assessment, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Geoff Wong
- Nuffield Department of Primary Care, Health Sciences, University of Oxford, Oxford, UK
| | | | - Amanda Wanner
- NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Jennifer Cleland
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore City, Singapore
| | - Tom Gale
- Collaboration for the Advancement of Medical Education Research and Assessment, Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Julian Archer
- Faculty of Medicine, Nursing and Healthcare, Monash University, Melbourne, Vic., Australia
| | - Marie Bryce
- Collaboration for the Advancement of Medical Education Research and Assessment, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Faculty of Health, University of Plymouth, Plymouth, UK
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To H, Cargill A, Tobin S, Nestel D. Remediation of Underperformance in Surgical Trainees - A Scoping Review. JOURNAL OF SURGICAL EDUCATION 2021; 78:1111-1122. [PMID: 33139216 DOI: 10.1016/j.jsurg.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/14/2020] [Accepted: 10/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Surgical trainees with significant underperformance require formal support to return to an expected standard, termed remediation. The aim of this scoping review was to define remediation interventions, approaches, and contexts. DESIGN Following scoping review protocols, we set out to identify the evidence-base for remediation of surgical trainees, outline key concepts and uncover areas to stimulate further research. RESULTS From a screen of 80 articles, 24 reported on remediation of surgical trainees. Most were from medical journals (n = 21, 88%) and published in the United States (n = 20, 83%). Ten articles (41%) reported outcomes of remediation of a trainee cohort and 7 (19%) were survey reports from surgical directors. The remainder were a mix of commentaries, editorials or reviews. Thirteen articles (54%) described trainees with deficiencies in multiple competencies, 8 articles (33%) had a singular focus on academic performance, and 1 article (3%) on technical skills. All articles used targeted individualized remediation strategies, a range of intervention methods (some multimodal) and recommended a 6- to 12-month period of remediation (n = 7, 29%). The program director was often the only supervisor (n = 12, 50%). One article reported trainees' perspective of the process and one used educational theory to inform remediation. CONCLUSIONS Data with clearly reported outcomes were limited, but we found that targeted, individualized, multimodal and long-term remediation covering a range of competencies have been reported in the literature for surgical trainees. There is a need for development of explicit frameworks, strengthen the support for supervisors and trainees and further apply educational theory to develop better interventions that remediate deficiencies for all competencies.
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Affiliation(s)
- Henry To
- University of Melbourne, Parkville, Australia.
| | | | - Stephen Tobin
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - Debra Nestel
- Department of Surgery (Austin), University of Melbourne, Heidelberg, Australia; Monash Institute for Health & Clinical Education, Monash University, Clayton, Australia
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Price T, Brennan N, Wong G, Withers L, Cleland J, Wanner A, Gale T, Prescott-Clements L, Archer J, Bryce M. Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.
Objectives
To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.
Design
A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.
Data sources
Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.
Review methods
Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.
Results
A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.
Limitations
Limitations were the low quality of included literature and limited number of UK-based studies.
Future work
Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.
Study registration
This study is registered as PROSPERO CRD42018088779.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Tristan Price
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Jennifer Cleland
- Medical Education Research and Scholarship Unit (MERSU), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Amanda Wanner
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Thomas Gale
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Julian Archer
- Medicine, Nursing and Health Sciences Education Portfolio, Monash University, Melbourne, VIC, Australia
| | - Marie Bryce
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
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Wenghofer EF, Steele RS, Christiansen RG, Carter MH. Evaluation of a High Stakes Physician Competency Assessment: Lessons for Assessor Training, Program Accountability, and Continuous Improvement. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:111-118. [PMID: 33929350 DOI: 10.1097/ceh.0000000000000362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION There is a dearth of evidence evaluating postlicensure high-stakes physician competency assessment programs. Our purpose was to contribute to this evidence by evaluating a high-stakes assessment for assessor inter-rater reliability and the relationship between performance on individual assessment components and overall performance. We did so to determine if the assessment tools identify specific competency needs of the assessed physicians and contribute to our understanding of physician dyscompetence more broadly. METHOD Four assessors independently reviewed 102 video-recorded assessments and scored physicians on seven assessment components and overall performance. Inter-rater reliability was measured using intraclass correlation coefficients using a multiple rater, consistency, two-way random effect model. Analysis of variance with least-significant difference post-hoc analyses examined if the mean component scores differed significantly by quartile ranges of overall performance. Linear regression analysis determined the extent to which each component score was associated with overall performance. RESULTS Intraclass correlation coefficients ranged between 0.756 and 0.876 for all components scored and was highest for overall performance. Regression indicated that individual component scores were positively associated with overall performance. Levels of variation in component scores were significantly different across quartile ranges with higher variability in poorer performers. DISCUSSION High-stake assessments can be conducted reliably and identify performance gaps of potentially dyscompetent physicians. Physicians who performed well tended to do so in all aspects evaluated, whereas those who performed poorly demonstrated areas of strength and weakness. Understanding that dyscompetence rarely means a complete or catastrophic lapse competence is vital to understanding how educational needs change through a physician's career.
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Affiliation(s)
- Elizabeth F Wenghofer
- Dr. Wenghofer: Full Professor, School of Rural and Northern Health, Laurentian University, Sudbury, Ontario, Canada. Dr. Steele: Medical Director of Knowledge, Skills, Training, Assessment, and Training (KSTAR) Physician Programs, A&M Rural and Community Health Institute, Texas A&M University Health Science Center, College Station, TX. Dr. Christiansen: Professor of Medicine, Department of Medicine, University of Illinois College of Medicine, Rockford, IL. Dr. Carter: Clinical Assistant Professor of primary care medicine, Primary Care and Population Health, Texas A&M University Health Science Center, College Station, TX
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To H, Cargill A, Tobin S, Nestel D. Remediation for surgical trainees: recommendations from a narrative review. ANZ J Surg 2021; 91:1117-1124. [PMID: 33538072 DOI: 10.1111/ans.16637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Remediation involves formalized support for surgical trainees with significant underperformance to return to expected standards. There is a need to understand current evidence of remediation for surgical trainees to inform practice and justify investment of resources. METHODS Following the principles of a systematic review, we conducted a narrative analysis to make recommendations for remediation of underperforming surgical trainees. RESULTS From a review of 55 articles on remediation of trainees in medical and surgical sub-specialities, we have identified system and process level recommendations. Remediation is reported as long-term, complex and resource-intensive. Establishing a defined and standardized remediation framework enables co-ordination of multi-modal interventions. System level recommendations aim to consolidate protocols via developing better assessment, intervention and re-evaluation modalities whilst also strengthening support to supervisors conducting the remediation. Process level recommendations should be tailored for the specific needs of each trainee, aiming to be proactive with interventions within a programmatic framework. Regular reassessment is required, and long-term follow-up shows that remediation efforts are often successful. CONCLUSION While remediation within a programmatic framework is complex, it is often a successful approach to return surgical trainees to their expected standard. Future directions involve applying learning theories, encouraging research methods and to develop integrated collaborate protocols and support to synergize efforts.
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Affiliation(s)
- Henry To
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Ashleigh Cargill
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Stephen Tobin
- School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Debra Nestel
- Department of Surgery (Austin), The University of Melbourne, Melbourne, Victoria, Australia.,Monash Institute for Health and Clinical Education, Monash University, Melbourne, Victoria, Australia
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Hanna A, Hanna LA. Topic Analysis of UK Fitness to Practise Cases: What Lessons Can Be Learnt? PHARMACY 2019; 7:E130. [PMID: 31487773 PMCID: PMC6789854 DOI: 10.3390/pharmacy7030130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/31/2019] [Accepted: 09/02/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Fitness to practise (FtP) impairment (failure of a healthcare professional to demonstrate skills, knowledge, character and/or health required for their job) can compromise patient safety, the profession's reputation, and an individual's career. In the United Kingdom (UK), various healthcare professionals' FtP cases (documents about the panel hearing(s) and outcome(s) relating to the alleged FtP impairment) are publicly available, yet reviewing these to learn lessons may be time-consuming given the number of cases across the professions and amount of text in each. We aimed to demonstrate how machine learning facilitated the examination of such cases (at uni- and multi-professional level), involving UK dental, medical, nursing and pharmacy professionals. Methods: Cases dating from August 2017 to June 2019 were downloaded (577 dental, 481 medical, 2199 nursing and 63 pharmacy) and converted to text files. A topic analysis method (non-negative matrix factorization; machine learning) was employed for data analysis. Results: Identified topics were criminal offences; dishonesty (fraud and theft); drug possession/supply; English language; indemnity insurance; patient care (including incompetence) and personal behavior (aggression, sexual conduct and substance misuse). The most frequently identified topic for dental, medical and nursing professions was patient care whereas for pharmacy, it was criminal offences. Conclusions: While commonalities exist, each has different priorities which professional and educational organizations should strive to address.
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Affiliation(s)
- Alan Hanna
- Queen's Management School, Queen's University Belfast, University Rd, Belfast BT7 1NN, UK.
| | - Lezley-Anne Hanna
- School of Pharmacy, Queen's University Belfast, University Rd, Belfast BT7 1NN, UK.
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Matthews DW, Benton KK, Moreland SC, Wagner T. Addressing Nursing Practice Breakdown: An Alternative Approach to Remediation. JOURNAL OF NURSING REGULATION 2019. [DOI: 10.1016/s2155-8256(19)30080-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bourgeois-Law G, Varpio L, Regehr G, Teunissen PW. Education or regulation? Exploring our underlying conceptualisations of remediation for practising physicians. MEDICAL EDUCATION 2019; 53:276-284. [PMID: 30345526 DOI: 10.1111/medu.13745] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/03/2018] [Accepted: 08/31/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT The remediation of practising physicians is coming to the fore in several countries in response to increasing demands for physician accountability and quality improvement initiatives in health care. However, the profession continues to grapple with the concepts and processes of remediation, particularly for physicians in practice who struggle with performance issues related to clinical competence. This suggests that current conceptualisations of remediation might be contributing to this situation. This study therefore, explored how various administration-level stakeholders conceptualise remediation in order to construct a description of the nature and meaning of remediation. METHODS Semi-structured interviews were conducted using purposive sampling across the range of Canadian stakeholders involved in the remediation of practising physicians, including regulatory authorities, universities, national certifying bodies and medical organisations. With the use of constructivist grounded theory processes, analysis proceeded apace with data collection in an iterative process, with initial insights guiding subsequent interviews. RESULTS Participants often simultaneously held two different conceptualisations of remediation: (i) remediation as part of an educational continuum involving different degrees of support, and (ii) remediation as a regulatory process removing an individual's educational autonomy. Interviewees moved between these two conceptualisations but did not always appear to be aware of doing so. These conceptualisations each had different implications regarding the degree to which remediation can be incorporated into professional processes of maintaining competence. CONCLUSIONS Understanding that stakeholders frequently approach the complex issue of remediation with two different perspectives without conscious awareness of doing so may help to explain several challenges in the field, including the issues of what falls under the umbrella of remediation and who should be responsible for offering remediation support. Our findings suggest the need for conceptual clarity around remediation, both to ensure that we illuminate logistical dilemmas in enacting remediation and to address the stigma of 'de-professionalisation' that the provision of even minor educational supports (such as feedback) might invoke by association.
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Affiliation(s)
- Gisèle Bourgeois-Law
- Department of Obstetrics and Gynaecology, University of British Columbia, Victoria, British Columbia, Canada
| | - Lara Varpio
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Glenn Regehr
- Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pim W Teunissen
- Department of Educational Research and Development, Maastricht University, Maastricht, the Netherlands
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Bourgeois-Law G, Teunissen PW, Regehr G. Remediation in Practicing Physicians: Current and Alternative Conceptualizations. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1638-1644. [PMID: 29697432 DOI: 10.1097/acm.0000000000002266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Suboptimal performance in practicing physicians is a decades-old problem. The lack of a universally accepted definition of remediation, the paucity of research on best remediation practices, and the ongoing controversy regarding the institutional responsibility for enacting and overseeing the remediation of physicians suggest that it is not merely a difficult problem to solve but a problem that the community does not grapple with meaningfully. Undoubtedly, logistical and political considerations contribute to this state of affairs; however, other underlying conceptual issues may also play a role in the medical profession's difficulties in engaging with the challenges around remediation.Through a review of the medical education and other literatures, the authors examined current conceptualizations of both reme-diation itself and the individual being remediated, as well as how the culture of medicine influences these conceptions. The authors explored how conceptualizations of remediation and the surrounding culture might affect not only the medical community's ability to support but also its willingness to engage with physicians in need of remediation.Viewing remediation as a means of supporting practice change-rather than as a means of redressing gaps in knowledge and skill-might be a useful alternative conceptualization, providing a good place to start exploring new avenues of research. However, moving forward will require more than simply a reconceptualization of remediation; it will also necessitate a change in how the community views its struggling members and a change in the medical culture that currently positions professional autonomy as the foundational premise for individual practice improvement.
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Affiliation(s)
- Gisèle Bourgeois-Law
- G. Bourgeois-Law is clinical associate professor, Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, and PhD candidate, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands; ORCID: https://orcid.org/0000-0002-4726-3663. P.W. Teunissen is professor of medical education, School of Health Professions Education, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands, and gynecologist, Department of Obstetrics and Gynecology, Vrije Universiteit Medical Center, Amsterdam, the Netherlands; ORCID: http://orcid.org/0000-0002-0930-0048. G. Regehr is professor, Department of Surgery, and associate director for research, Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-3144-331X
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de Leon J, Wise TN, Balon R, Fava GA. Dealing with Difficult Medical Colleagues. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:5-11. [PMID: 29306944 DOI: 10.1159/000481200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 09/03/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
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Prescott-Clements L, Voller V, Bell M, Nestors N, van der Vleuten CPM. Rethinking Remediation: A Model to Support the Detailed Diagnosis of Clinicians' Performance Problems and the Development of Effective Remediation Plans. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 37:245-254. [PMID: 29189494 DOI: 10.1097/ceh.0000000000000173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The successful remediation of clinicians demonstrating poor performance in the workplace is essential to ensure the provision of safe patient care. Clinicians may develop performance problems for numerous reasons, including health, personal factors, the workplace environment, or outdated knowledge/skills. Performance problems are often complex involving multifactorial issues, encompassing knowledge, skills, and professional behaviors. It is important that (where possible and appropriate) clinicians are supported through effective remediation to return them to safe clinical practice. A review of the literature demonstrated that research into remediation is in its infancy, with little known about the effectiveness of remediation programs currently. Current strategies for the development of remediation programs are mostly "intuitive"; a few draw upon established theories to inform their approach. Similarly, although it has been established that identification of the nature/scope of performance problems through assessment is an essential first step within remediation, the need for a more widespread "diagnosis" of why the problems exist is emerging. These reasons for poor performance, particularly in the context of experienced practicing clinicians, are likely to have an impact on the potential success of remediation and should be considered within the "diagnosis." A new model for diagnosing the performance problems of the clinicians has been developed, using behavioral change theories to explore known barriers to successful remediation, such as insight, motivation, attitude, self-efficacy, and the working environment, in addition to addressing known deficits regarding knowledge and skills. This novel approach is described in this article. An initial feasibility study has demonstrated the acceptability and practical implementation of our model.
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Affiliation(s)
- Linda Prescott-Clements
- Dr. Prescott-Clements: Lead Assessment and Intervention Adviser, National Clinical Assessment Service, NHS Resolution, London, United Kingdom. Ms. Voller: Director of NCAS, National Clinical Assessment Service, NHS Resolution, London, United Kingdom. Mr. Bell: Professional Support and Remediation Lead, National Clinical Assessment Service, NHS Resolution, London, United Kingdom. Ms. Nestors: Professional Support and Remediation Manager, National Clinical Assessment Service, NHS Resolution, London, United Kingdom. Prof. van der Vleuten: Professor of Education and Scientific Director of the School of Health Professions Education, Department of Educational Research and Development, Maastricht University, Maastricht, The Netherlands
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Goulet F, Thiffault J, Ladouceur R. Remediation and rehabilitation programmes for health professionals: challenges for the future. BMJ Qual Saf 2017; 26:941-943. [DOI: 10.1136/bmjqs-2017-007187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 11/04/2022]
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Weenink JW, Kool RB, Bartels RH, Westert GP. Getting back on track: a systematic review of the outcomes of remediation and rehabilitation programmes for healthcare professionals with performance concerns. BMJ Qual Saf 2017; 26:1004-1014. [DOI: 10.1136/bmjqs-2017-006710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022]
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