The problem resident behavior guide: strategies for remediation

Mapping out Remediation: An Actionable Roadmap to Support Trainees Through Remediation

WHAT'S NEW

This qualitative analysis offers an actionable, stepwise approach to remediation.

INTRODUCTION

The goal of graduate medical education is for trainees to develop the competence needed to practice independently; however, some residents struggle to achieve competency and require remediation. Evidence around how to best facilitate remediation is lacking. The objective of this study was to understand best practices for remediation in pediatrics.

METHOD

A national web-based survey of pediatric residency program directors (PDs) on remediation practices was performed. The survey included 3 open-ended questions about PDs' experiences with remediation. Self-reported barriers to and strategies for remediation were systematically analyzed using inductive thematic analysis to develop a theory of effective remediation in pediatric residency training.

RESULTS

A total of 99 out of 195 (50.8%) program directors responded. Two main themes emerged: developing a personalized plan that ensures competency attainment and fostering psychological safety. Twelve categories outline actionable steps that PDs can take to make the remediation process successful.

DISCUSSION

Built from insight from pediatric PDs, we propose a conceptual model for effective remediation that accounts for competency attainment while safeguarding the emotional health of the resident. The conceptual model breaks the remediation process down into four phases: identification of the learner who struggles, planning the remediation process, implementation of the plan, and assessing the outcome of the process.

KNOWLEDGE, ATTITUDES AND PERCEPTIONS OF REMEDIATION AMONG TRAINEES IN GRADUATE MEDICAL EDUCATION PROGRAMS

BACKGROUND

Remediation of medical trainees is a universal challenge, yet studies show that many residents will need remediation to improve performance. Current literature discusses the importance and processes of remediation and investigates how to recognize residents needing remediation. However, little is known about trainees' attitudes and perception of remediation.

OBJECTIVES

To assess trainees' knowledge of remediation as well as their attitudes and perceptions toward remediation and its process. We hypothesized that trainees have limited knowledge and a negative perception of remediation.

METHODS

A cross-sectional anonymous electronic survey was sent to all graduate medical education trainees at a single institution.

RESULTS

The survey was completed by 132/1095 (12.1%) trainees. Of the respondents, 7.6% were not familiar with the term "remediation." Trainees' knowledge of remediation processes was variable, and they reported overwhelmingly negative thoughts and attitudes toward remediation. Shame was felt by 97/132 (73.5%), 71/132 (53.8%) felt disadvantaged, and 121/132 (91.7%) viewed the term "remediation" negatively. Most trainees felt using a more positive term would improve perceptions, and 124/132 (93.9%) felt residents should be involved in creating individualized remediation plans. Open-ended responses on reactions to being placed on remediation included disappointment, shame, incompetency, anxiety and worry, embarrassment, unhappiness, suicidality, worthlessness, sense of failure, and doubting one's capabilities as a physician.

CONCLUSION

Trainees have limited knowledge and understanding of remediation and strong negative perceptions and attitudes toward the remediation process. Trainees suggested that reframing of remediation using more positive terminology and including residents in creating individualized plans, may improve attitudes and perceptions of this process.

Post graduate remediation programs in medicine: a scoping review

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.

Emotion in remediation: A scoping review of the medical education literature

OBJECTIVES

Remediation can be crucial and high stakes for medical learners, and experts agree it is often not optimally conducted. Research from other fields indicates that explicit incorporation of emotion improves education because of emotion's documented impacts on learning. Because this could present an important opportunity for improving remediation, we aimed to investigate how the literature on remediation interventions in medical education discusses emotion.

METHODS

The authors used Arksey and O'Malley's framework to conduct a scoping literature review of records describing remediation interventions in medical education, using PubMed, CINAHL Complete, ERIC, Web of Science and APA PsycInfo databases, including all English-language publications through 1 May 2020 meeting search criteria. They included publications discussing remediation interventions either empirically or theoretically, pertaining to physicians or physician trainees of any level. Two independent reviewers used a standardised data extraction form to report descriptive information; they reviewed included records for the presence of mentions of emotion, described the mentions and analysed results thematically.

RESULTS

Of 1644 records, 199 met inclusion criteria and were reviewed in full. Of those, 112 (56%) mentioned emotion in some way; others focused solely on cognitive aspects of remediation. The mentions of emotion fell into three themes based on when the emotion was cited as present: during regular coursework or practice, upon referral for remediation and during remediation. One-quarter of records (50) indicated potential intentional incorporation of emotion into remediation programme design, but they were non-specific as to how emotions related to the learning process itself.

CONCLUSION

Even though emotion is omnipresent in remediation, medical educators frequently do not factor emotion into the design of remediation approaches and rarely explicitly utilise emotion to improve the learning process. Applications from other fields may help medical educators leverage emotion to improve learning in remediation, including strategies to frame and design remediation.

An Emergency Medicine Remediation Consult Service: Access to Expert Remediation Advice and Resources

Resident remediation is a complex and common issue in emergency medicine programs and requires a specific knowledge base. The Remediation Task Force (RTF) of the Council of Residency Directors in Emergency Medicine (CORD-EM) was created to identify remediation best practices and to develop tools for program directors. Initially housed on a Wiki page, and now located within the CORD-EM website, the RTF provides resources including accepted universal language for documentation and sample remediation plans. The RTF also created a remediation consult service composed of experienced educators to provide real-time structured feedback and advice to submitted remediation scenarios with consultation outcomes and conclusions uploaded to the website. CORD-EM members now have easy access to online resources and expert advice for remediation queries through the consult service. The combination of online resources and access to real-time expert advice is an innovative approach to improving resident remediation and recognizing best practices.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study

INTRODUCTION

Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).

METHODS

We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.

RESULTS

Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.

CONCLUSION

Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.