Graduate Medical Education “Trainee in difficulty” current remediation practices and outcomes

'The program director's word … it's stronger than the word of God': Epistemic injustice revealed through narratives of remediated graduate medical education residents

BACKGROUND

Though graduate medical education (GME) residency training provides positive experiences for many trainees, it may also result in major stressors and negative experiences, particularly for those requiring remediation. Residents requiring remediation may experience feelings of dismay, shame and guilt that can negatively affect their training, self-efficacy and their medical careers. Power differentials between educators and residents may set the stage for epistemic injustice, which is injustice resulting from the silencing or dismissing a speaker based on identity prejudice. This can lead to decreased willingness of trainees to engage with learning. There is a paucity of literature that explores GME experiences of remediation from the resident perspective.

OBJECTIVE

To synthesise the narratives of physician experiences of remediation during residency through the lens of epistemic injustice.

METHODS

Between January and July 2022, we interviewed US physicians who self-identified as having experienced remediation during residency. They shared events that led to remediation, personal perspectives and emotions about the process and resulting outcomes. Interviews were analysed using narrative analysis with attention to instances of epistemic injustice.

RESULTS

We interviewed 10 participants from diverse backgrounds, specialties and institutions. All participants described contextual factors that likely contributed to their remediation: (1) previous academic difficulty/nontraditional path into medicine, (2) medical disability or (3) minoritised race, gender or sexual identity. Participants felt that these backgrounds made them more vulnerable in their programmes despite attempts to express their needs. Participants reported instances of deflated credibility and epistemic injustices with important effects.

CONCLUSIONS

Participant narratives highlighted that deep power and epistemic imbalances between learners and educators can imperil GME trainees' psychological safety, resulting in instances of professional and personal harm. Our study suggests applying an existing framework to help programme directors (PDs) approach remediation with epistemic humility.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85

BACKGROUND

Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options.

OBJECTIVES

To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners.

METHODS

A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations.

RESULTS

Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions.

CONCLUSION

This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

Psychological Safety as a New ACGME Requirement: A Comprehensive All-in-One Guide to Radiology Residency Programs

RATIONALE AND OBJECTIVES

With the Accreditation Council for Graduate Medical Education recently updating their common program requirements to include components of psychological safety as a core principle, radiology training programs and academic radiology institutions will need to evaluate psychological safety within their residency programs and implement practices to sustain a safety culture. This article reviews current literature to present a concise guide for radiology programs on best practices for implementing psychological safety, considering the plethora of literature that is available.

MATERIALS AND METHODS

We searched PubMed for published studies evaluating safety culture in medical education and residency. The key words used were Psychological Safety, Education, Radiology, Workplace Culture, and Leadership.

RESULTS

Ninety two studies were reviewed that contributed to the topics examined throughout this manuscript, including a brief history of psychological safety, evolving challenges, and a summation of best practices at the institutional, interpersonal, and individual levels that can result in a sustainable psychologically safe culture for radiology residents.

CONCLUSION

This article will highlight unique considerations pertinent to a radiology residency program, including suggestions for creating a less stressful environment during case conferences, fostering and supporting residents who are struggling, and inclusive psychological safety practices that also consider non-resident contributors to a residency program, such as attending physician faculty and non-physician radiology technicians.

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.