What does remediation and probation status mean? A survey of emergency medicine residency program directors

'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.

Resident Remediation: A National Survey of Urology Program Directors

OBJECTIVES

To describe formal remediation rates and processes in urology training programs nationally.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cross-sectional study by surveying program directors (PDs) through the Society of Academic Urologists. Formal remediation was defined as the process initiated when resident competency deficiencies were significant enough to necessitate documentation and notification of the Graduate Medical Education (GME) office. The primary outcome was the prevalence of urology programs that initiated formal remediation over the past 5 years. Secondary outcomes included reported competency deficiencies and formal remediation processes.

RESULTS

Across 148 institutions, 73 (49%) PDs responded to the survey. The majority of PDs (67%, 49/73) stated that at least 1 resident underwent formal remediation over the last 5 years (median 1). "Professionalism" and "Interpersonal and Communication Skills" were the most common competency deficiencies that prompted formal remediation, whereas "Technical Skill" was the least common. While the majority of respondents notified the GME office of residents undergoing remediation, formal remediation plans varied from faculty coaching and mentorship (80%, 39/49) to simulation training (10%, 5/49). Absence of documented faculty feedback on poor performance was the most commonly cited barrier to formal remediation. The majority of PDs reported documentation in a resident's file (81%, 59/73); however, remediation processes differed with only half of PDs reporting that GME offices were routinely involved in creating and overseeing corrective action plans (56%, 41/73). Over the study period, 15% (11/73) of PDs did not promote a resident to the next year of training, and 23% (17/73) of PDs stated "Yes" to graduating a resident who they would not trust to care for a loved one.

CONCLUSIONS

Formal remediation among urology residency programs is common, and processes vary across institutions. The most common competency areas prompting remediation were "Professionalism" and "Interpersonal and Communication Skills." Future research should address developing resources to facilitate resident remediation.

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.

Changing the Landscape of Remediation: The Creation and Implementation of an Institution-Wide Graduate Medical Education Performance Enhancement Program

Purpose Remediation is a daunting process for both residency leadership and trainees due to several factors including limited time and resources, variable processes, and negative stigma. Our objective was to transform the remediation process by creating a transparent institution-wide program that collates tools/resources, interdepartmental faculty mentors, and positive rebranding. Methods Education leadership across seven specialties created a process for trainees with professionalism and interpersonal-communication skills deficiencies. Formalized departmental program-based improvement plan (PIP) and an institutional house staff performance enhancement plan (HPEP) were developed by consensus of triggers/behaviors. Utilizing published literature, a toolkit was created and implemented. Trainees were enrolled in HPEP if PIP was unsuccessful or exhibited ≥1 major trigger. Wellness evaluations were incorporated into the process to screen for external contributing factors. Surveys were sent to the program director (PD), faculty mentor, and trainee one month and six months after participation. Results Between 2018 and 2021, 12 trainees were enrolled. Overall feedback from PDs and the trainees was positive. The main challenge was finding mutual time for the faculty mentor and trainee to meet. Six-month surveys reported no relapses in unprofessionalism. One-year follow-up of the trainees was limited. Conclusions Utilizing an institution-wide standardized process of performance improvement with the removal of negative stereotyping is a unique approach to remediation. Initial feedback is promising, and future outcome data are necessary to assess the utility. The HPEP may be adopted by other academic institutions and may shift the attitudes about remediation and allow trainees to see the process as an opportunity for professional growth.

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.

Unheard Voices: A Qualitative Study of Resident Perspectives on Remediation

BACKGROUND

Remediation is an important component of residency training that ensures residents are progressing toward competency and unsupervised practice. There is literature describing educators' attitudes about remediation; however, little is known about residents' perspectives regarding peers who are struggling and remediation. Understanding this perspective is critical to supporting struggling residents and developing successful remediation programs.

OBJECTIVE

The objective of this study was to describe residents' perspectives on peers who are struggling and remediation processes within graduate medical education programs.

METHODS

In 2015, we conducted focus groups of residents in a multi-institutional exploratory qualitative study designed to investigate resident perspectives on remediation. Focus groups included questions on identification of residents who are struggling, reasons residents face difficulty in training, attitudes toward remediation, and understanding of the remediation process. Using conventional content analysis, we analyzed the focus group data to discover common themes.

RESULTS

Eight focus groups were performed at 3 geographically distinct institutions. A total of 68 residents participated, representing 12 distinct medical specialties. Four major themes emerged from the participants' discussion: lack of transparency, negative stigma, overwhelming emotions, and a need for change.

CONCLUSIONS

Resident perspectives on remediation are affected by communication, culture, and emotions. The resident participants called for change, seeking greater understanding and transparency about what it means to struggle and the process of remediation. The residents also believed that remediation can be embraced and normalized.

The Correlation Between Emergency Medicine Residents' Grit and Achievement

BACKGROUND

Early identification of emergency medicine (EM) residents who struggle with educational attainment is difficult. In-training examination (ITE) scores predict success on the American Board of Emergency Medicine (ABEM) Qualifying Examination; however, results are not available until late in the academic year. The noncognitive trait "grit," defined as "perseverance and passion for long-term goals," predicts achievement in high school graduation rates, undergraduate GPA, and gross anatomy. Grit-S is a validated eight-question scale scored 1 to 5; the average of responses represents a person's grit. Our objective was to determine the correlation between EM resident Grit-S scores and achievement, as measured by MCAT percentiles, ITE scores, and remediation rates.

STUDY DESIGN AND METHODS

This was a 1-year prospective, multicenter trial involving ten EM residencies from 2017 to 2018. Subjects were PGY-1 to -4 EM residents. Grit-S scores, MCAT percentile, remediation rates, ITE scores, and the ITE score's prediction of passing the ABEM Qualifying Examination were collected. Correlation coefficients were computed to assess the relationship between residents' grit and achievement.

RESULTS

A total 385 of 434 (88.7%) residents participated who completed the Grit-S as part of a larger study. The mean Grit-S score was 3.62. Grit positively correlated with the predicted likelihood of passing the ABEM Qualifying Examination (r = 0.134, n = 382, p = 0.025). There was no correlation between grit and remediation (r = -0.04, n = 378, p = 0.46) or grit and MCAT percentiles (r =- 0.08, n = 262, p = 0.22).

CONCLUSIONS

The positive correlation between Grit-S scores and percent likelihood of passing the ABEM Qualifying Examination demonstrates grit's potential to assist residency leadership in early identification of residents who may attain a lower ITE score.

Guidelines: The dos, don'ts and don't knows of remediation in medical education

INTRODUCTION

Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies.

METHODS

Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus.

RESULTS

We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline.

CONCLUSIONS

Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

Standardized Letters of Concern and Remediation Contracts: Templates for Program Directors

BACKGROUND

Remediation of the struggling resident is a universal phenomenon, and the majority of program directors will remediate at least 1 resident during their tenure.

OBJECTIVE

The goal of this project was to create a standardized template for program directors to use at all stages of remediation.

METHODS

Between 2017 and 2018, the Council of Residency Directors in Emergency Medicine (CORD-EM) Remediation Committee searched for best practices in the medical literature and compiled a survey that was e-mailed to the CORD-EM listserv. After reviewing all information, a standardized remediation contract was created, reviewed by legal counsel, and distributed to members.

RESULTS

Forty-two percent (110 of 263) of program directors or assistant program directors on the CORD-EM listserv answered the initial survey and provided guidance on current remediation practices. The committee created formal and informal standard remediation contracts as both fillable templates and alterable documents. These were reviewed by CORD-EM general legal counsel and approved by the CORD-EM Board of Directors for distribution. The project took approximately 20 hours to complete over 8 months and involved a cost of $480 for legal fees.

CONCLUSIONS

With program director input and legal counsel review, the CORD-EM Remediation Committee produced standardized remediation contracts, which can be used by all emergency medicine programs after comparison to local institutional policy and local legal review. This process was feasible and can be replicated by other specialties.

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.

Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2015

OBJECTIVE

The objectives were to critically appraise the medical education research literature of 2015 and review the highest-quality quantitative and qualitative examples.

METHODS

A total of 434 emergency medicine (EM)-related articles were discovered upon a search of ERIC, PsychINFO, PubMED, and SCOPUS. These were both quantitative and qualitative in nature. All were screened by two of the authors using previously published exclusion criteria, and the remaining were appraised by all authors using a previously published scoring system. The highest scoring articles were then reviewed.

RESULTS

Sixty-one manuscripts were scored, and 10 quantitative and two qualitative papers were the highest scoring and are reviewed and summarized in this article.

CONCLUSIONS

This installment in this critical appraisal series reviews 12 of the highest-quality EM-related medical education research manuscripts published in 2015.

Early predictors of need for remediation in the Australian general practice training program: a retrospective cohort study

Underperforming trainees requiring remediation may threaten patient safety and are challenging for vocational training programs. Decisions to institute remediation are high-stakes-remediation being resource-intensive and emotionally demanding on trainees. Detection of underperformance requiring remediation is particularly problematic in general (family) practice. We sought to establish early-training assessment instruments predictive of general practice (GP) trainees' subsequently requiring formal remediation. We conducted a retrospective cohort study of trainees from a large Australian regionally-based GP training organization. The outcome factor was requirement for formal remediation. Independent variables were demographic factors and a range of formative assessments conducted immediately prior to or during early-stage training. Analyses employed univariate and multivariate logistic regression of each predictor assessment modality with the outcome, adjusting for potential confounders. Of 248 trainees, 26 (10.5 %) required formal remediation. Performance on the Colleague Feedback Evaluation Tool (entailing feedback from a trainee's clinical colleagues on clinical performance, communication and probity) and External Clinical Teaching Visits (half-day sessions of the trainee's clinical consultations observed directly by an experienced GP), along with non-Australian primary medical qualification, were significantly associated with requiring remediation. There was a non-significant trend for association with performance on the Doctors Interpersonal Skills Questionnaire (patient feedback on interpersonal elements of the consultation). There were no significant associations with entry-selection scores or formative exam or assessment scores. Our finding that 'in vivo' assessments of complex behaviour, but not 'in vitro' knowledge-based assessments, predict need for remediation is consistent with theoretical understanding of the nature of remediation decision-making and should inform remediation practice in GP vocational training.

Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2015

OBJECTIVE

The objectives were to critically appraise the medical education research literature of 2015 and review the highest-quality quantitative and qualitative examples.

METHODS

A total of 434 emergency medicine (EM)-related articles were discovered upon a search of ERIC, PsychINFO, PubMED, and SCOPUS. These were both quantitative and qualitative in nature. All were screened by two of the authors using previously published exclusion criteria, and the remaining were appraised by all authors using a previously published scoring system. The highest scoring articles were then reviewed.

RESULTS

Sixty-one manuscripts were scored, and 10 quantitative and two qualitative papers were the highest scoring and are reviewed and summarized in this article.

CONCLUSIONS

This installment in this critical appraisal series reviews 12 of the highest-quality EM-related medical education research manuscripts published in 2015.

A qualitative study of medical educators' perspectives on remediation: Adopting a holistic approach to struggling residents

INTRODUCTION

During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation.

METHODS

We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis.

RESULTS

Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation.

CONCLUSIONS

The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

Effect of Performance Deficiencies on Graduation and Board Certification Rates: A 10-yr Multicenter Study of Anesthesiology Residents

BACKGROUND

This multicenter, retrospective study was conducted to determine how resident performance deficiencies affect graduation and board certification.

METHODS

Primary documents pertaining to resident performance were examined over a 10-yr period at four academic anesthesiology residencies. Residents entering training between 2000 and 2009 were included, with follow-up through February 2016. Residents receiving actions by the programs' Clinical Competency Committee were categorized by the area of deficiency and compared to peers without deficiencies.

RESULTS

A total of 865 residents were studied (range: 127 to 275 per program). Of these, 215 residents received a total of 405 actions from their respective Clinical Competency Committee. Among those who received an action compared to those who did not, the proportion graduating differed (93 vs. 99%, respectively, P < 0.001), as did the proportion achieving board certification (89 vs. 99%, respectively, P < 0.001). When a single deficiency in an Essential Attribute (e.g., ethical, honest, respectful behavior; absence of impairment) was identified, the proportion graduating dropped to 55%. When more than three Accreditation Council for Graduate Medical Education Core Competencies were deficient, the proportion graduating also dropped significantly.

CONCLUSIONS

Overall graduation and board certification rates were consistently high in residents with no, or isolated, deficiencies. Residents deficient in an Essential Attribute, or multiple competencies, are at high risk of not graduating or achieving board certification. More research is needed on the effectiveness and selective deployment of remediation efforts, particularly for high-risk groups.

Defining Uniform Processes for Remediation, Probation and Termination in Residency Training

It is important that residency programs identify trainees who progress appropriately, as well as identify residents who fail to achieve educational milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications. Informal remediation is initiated when a resident's performance is deficient in one or more of the outcomes-based milestones established by the Accreditation Council for Graduate Medical Education, but not significant enough to trigger formal remediation. Formal remediation occurs when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident's file and notification of the graduate medical education office; however, the documentation is not disclosed if the resident successfully remediates. Probation is initiated when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are significant enough to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and occurs when a resident is unsuccessful in meeting the terms of probation or if initial problems are significant enough to warrant immediate termination.

What is the Prevalence and Success of Remediation of Emergency Medicine Residents?

INTRODUCTION

The primary objective of this study was to determine the prevalence of remediation, competency domains for remediation, the length, and success rates of remediation in emergency medicine (EM).

METHODS

We developed the survey in Surveymonkey™ with attention to content and response process validity. EM program directors responded how many residents had been placed on remediation in the last three years. Details regarding the remediation were collected including indication, length and success. We reported descriptive data and estimated a multinomial logistic regression model.

RESULTS

We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications for remediation ranged from difficulties with one core competency to all six competencies (mean 1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%) and professionalism (31.5%). Mean length of remediation was eight months (range 1-36 months). Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In 8.7%, remediation was deemed "unsuccessful." Training year at time of identification for remediation (post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based learning (PBLI) and professionalism were found to have statistically significant association with unsuccessful remediation.

CONCLUSION

Remediation in EM residencies is common, with the most common areas being MK and patient care. The majority of residents are successfully remediated. PGY level, length of time spent in remediation, and the remediation of the competencies of PBLI and professionalism were associated with unsuccessful remediation.