Guiding principles for resident remediation: recommendations of the CORD remediation task force

Can USMLE and COMLEX-USA Scores Predict At-Risk Emergency Medicine Residents' Performance on In-Training Examinations?

PURPOSE

The United States Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores are standard methods used to determine residency candidates' medical knowledge. The authors were interested in using the USMLE and COMLEX part 2 scores in our emergency medicine (EM) residency program to identify at-risk residents who may have difficulty on the in-training exam (ITE) and to determine the cutoff values under which an intern could be given an individualized study plan to ensure medical knowledge competency.

METHODS

The authors abstracted the USMLE and COMLEX part 2 scores and the American Board of Emergency Medicine (ABEM) ITE scores for a cohort of first-year EM residents graduating years 2010-2022, converting raw scores to percentiles, and compared part 2 and ABEM ITE scores with Pearson's correlation, a Bland-Altman analysis of bias and 95% limits of agreement, and ROC analysis to determine optimal the cut-off values for predicting ABEM ITE < 50th percentile and the estimated test characteristics.

RESULTS

Scores were available for 152 residents, including 93 USMLE and 88 COMLEX exams. The correlations between part 2 scores and ABEM ITE were r = 0.36 (95%CI: 0.17, 0.52; p < 0.001) for USMLE and r = 0.50 (95%CI: 0.33, 0.64; p < 0.001) for COMLEX. Bias and limits of agreement for both part 2 scores were -14 ± 63% for USMLE and 13 ± 50% for COMLEX in predicting the ABEM ITE scores. USMLE < 37th percentile and COMLEX < 53rd percentile identified 42% (N = 39) and 27% (N = 24) of EM residents, respectively, as at risk, with a sensitivity of 61% and 49% and specificity of 71% and 92%, respectively.

CONCLUSION

USMLE and COMLEX part 2 scores have a very limited role in identifying those at risk of low ITE performance, suggesting that other factors should be considered to identify interns in need of medical knowledge 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.

Blue Skies With Clouds: Envisioning the Future Ideal State and Identifying Ongoing Tensions in the UME-GME Transition

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability charged the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.

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.

Interactive Narrative Simulation as a Method for Preceptor Development

(1) Background: This proof-of-concept study assessed an interactive web-based tool simulating three challenging non-academic learning situations—student professionalism, cross-cultural interactions, and student well-being—as a means of preceptor development. (2) Methods: Three scripts focused on professionalism, cross-cultural interactions, and student well-being were developed and implemented using a commercial narrative tool with branching dialog. Delivered online, this tool presented each challenge to participants. Participants had up to four response options at each turn of the conversation; the choice of response influenced the subsequent conversation, including coaching provided at the resolution of the situation. Participants were invited to complete pre-activity, immediate post-activity, and one-month follow-up questionnaires to assess satisfaction, self-efficacy, engagement, and knowledge change with the tool. Knowledge was assessed through situational judgment tests (SJTs). (3) Results: Thirty-two pharmacist preceptors participated. The frequency of participants reflecting on challenging learning situations increased significantly one-month post-simulation. Participants affirmatively responded that the tool was time-efficient, represented similar challenges they encountered in precepting, was easily navigable, and resulted in learning. Self-efficacy with skills in managing challenging learning situations increased significantly immediately post-simulation and at a one-month follow-up. Knowledge as measured through SJTs was not significantly changed. (4) Conclusions: Preceptors found an interactive narrative simulation a relevant, time-efficient approach for preceptor development for challenging non-academic learning situations. Post-simulation, preceptors more frequently reflected on challenging learning situations, implying behavior change. Self-efficacy and self-report of knowledge increased. Future research is needed regarding knowledge assessments.

Optimising the delivery of remediation programmes for doctors: A realist review

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.

Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

AIMS OF THE STUDY

Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges.

METHODS

We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework.

RESULTS

We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…).

CONCLUSION

Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

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.

Developing a process to manage challenges encountered by experiential education administrators

INTRODUCTION

This study explored preceptor and student related issues reported in pharmacy experiential education settings and solutions that experiential education administrators (EEAs) applied to inform a process to manage these challenges.

METHODS

This mixed-methods study was conducted in two phases. In phase one, five EEAs from three schools of pharmacy collected quantitative and qualitative data over a two-year period on issues reported by students and preceptors and the solutions EEAs employed. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. Interviews with six EEAs from four schools were completed in phase two. An additional school was added in phase two. Open coding, pattern coding, and summative analysis were completed on interview data.

RESULTS

Preceptors and students reported 156 and 65 issues, respectively. The most common issues reported were student reliability/responsibility (22, 14%) and preceptor communication (13, 20%). The most frequently applied solutions were coach preceptor (51, 24%) and meet with student (20, 24%). Interviews revealed more information about the strategies EEAs used. Approaches included reactive responses such as talking to and coaching preceptors or students. Preventative strategies were desired, such as tracking data and training.

CONCLUSIONS

Results informed two approaches that EEAs can employ to resolve student and preceptor issues. In the proactive process, issues are tracked to inform student and preceptor development. The reactive approach involves meeting with the preceptor or student, gathering information from both parties, coaching the preceptor or student, and involving other administrators as needed for serious concerns.

Remediation for surgical trainees: recommendations from a narrative review

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.

Remediation of learners struggling with communication skills: a systematic review

BACKGROUND

Communication skills is a core area of competency for healthcare practitioners. However, trainees deficient in those skills are not identified early enough to address the deficiency. Furthermore, faculty often struggle to identify effective remediation strategies for those who fail to meet expectations. We undertook a systematic review to determine which assessment methods are appropriate to identify learners that struggle with communication skills and the strategies used to remediate them.

METHODS

The literature was searched from January 1998 through to May 2019 using academic databases and grey literature. Trainees were defined as healthcare practitioners in undergraduate, graduate and continuing education. Characteristics of studies, assessment and intervention strategies and outcomes were synthesized qualitatively and summarized in tables.

RESULTS

From an initial 1636 records, 16 (1%) studies met the review criteria. Majority of the learners were medical students. A few studies (44%) included students from other disciplines, residents and physicians in practice. The remediation programs, in the studies, ranged from 1 week to 1 year. Around half of the studies focused solely on learners struggling with communication skills. The majority of studies used a format of a clinical OSCE to identify struggling learners. None of the studies had a single intervention strategy with the majority including an experiential component with feedback.

CONCLUSIONS

A few studies collectively described the diagnosis, remediation intervention and the assessment of the outcomes of remediation of communication skills. For a remediation strategy to be successful it is important to ensure: (i) early identification and diagnosis, (ii) the development of an individualized plan and (iii) providing reassessment with feedback to the learner.

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.

Advancing Simulation-Based Orthopaedic Surgical Skills Training: An Analysis of the Challenges to Implementation

Simulation-based surgical skills training is recognized as a valuable method to improve trainees' performance and broadly perceived as essential for the establishment of a comprehensive curriculum in surgical education. However, there needs to be improvement in several areas for meaningful integration of simulation into surgical education. The purpose of this focused review is to summarize the obstacles to a comprehensive integration of simulation-based surgical skills training into surgical education and board certification and suggest potential solutions for those obstacles. First and foremost, validated simulators need to be rigorously assessed to ensure their feasibility and cost-effectiveness. All simulation-based courses should include clear objectives and outcome measures (with metrics) for the skills to be practiced by trainees. Furthermore, these courses should address a wide range of issues, including assessment of trainees' problem-solving and decision-making abilities and remediation of poor performance. Finally, which simulation-based surgical skills courses will become a standard part of the curriculum across training programs and which will be of value in board certification should be precisely defined. Sufficient progress in these areas will prevent excessive development of training and assessment tools with duplicative effort and large variability in quality.

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.

Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure

PURPOSE

Medical practice is uncertain and complex. Consequently, even outstanding performers will inevitably experience moments of underperformance and failure. Coping relies on insight and resilience. However, how physicians develop and use these skills to navigate struggle remains underexplored. A better understanding may reveal strategies to support both struggling learners and stressed practitioners.

METHOD

In 2015, 28 academic physicians were interviewed about their experiences with underperformance or failure. Constructivist grounded theory informed data collection and analysis.

RESULTS

Participants' experiences with struggle ranged from patient errors and academic failures to frequent, smaller moments of interpersonal conflict and work-life imbalance. To buffer impact, participants sometimes shifted their focus to an aspect of their identity where they felt successful. Additionally, although participants perceived that insight develops by acknowledging and reflecting on error, they sometimes deflected blame for performance gaps. More often, participants seemed to accept personal responsibility while simultaneously sharing accountability for underperformance or failure with external forces. Paradoxically, participants perceived learners who used these strategies as lacking in insight.

CONCLUSIONS

Participants demonstrated the protective and functional value of distributing responsibility for underperformance and failure. Shifting and sharing may be an element of reflection and resilience; recognizing external factors may provide a way to gain perspective and to preserve the self. However, this strategy challenges educators' assumptions that learners who deflect are avoiding personal responsibility. The authors' findings raise questions about what it means to be resilient, and how assumptions about learners' responses to failure may affect strategies to support underperforming learners.

To fail is human: remediating remediation in medical education

INTRODUCTION

Remediating failing medical learners has traditionally been a craft activity responding to individual learner and remediator circumstances. Although there have been moves towards more systematic approaches to remediation (at least at the institutional level), these changes have tended to focus on due process and defensibility rather than on educational principles. As remediation practice evolves, there is a growing need for common theoretical and systems-based perspectives to guide this work.

METHODS

This paper steps back from the practicalities of remediation practice to take a critical systems perspective on remediation in contemporary medical education. In doing so, the authors acknowledge the complex interactions between institutional, professional, and societal forces that are both facilitators of and barriers to effective remediation practices.

RESULTS

The authors propose a model that situates remediation within the contexts of society as a whole, the medical profession, and medical education institutions. They also outline a number of recommendations to constructively align remediation principles and practices, support a continuum of remediation practices, destigmatize remediation, and develop institutional communities of practice in remediation.

DISCUSSION

Medical educators must embrace a responsible and accountable systems-level approach to remediation if they are to meet their obligations to provide a safe and effective physician workforce.

Critical Deficiency Ratings in Milestone Assessment: A Review and Case Study

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) requires programs to report learner progress using specialty-specific milestones. It is unclear how milestones can best identify critical deficiencies (CDs) in trainee performance. Specialties developed milestones independently of one another; not every specialty included CDs within milestones ratings. This study examined the proportion of ACGME milestone sets that include CD ratings, and describes one residency program's experiences using CD ratings in assessment.

METHOD

The authors reviewed ACGME milestones for all 99 specialties in November 2015, determining which rating scales contained CDs. The authors also reviewed three years of data (July 2012-June 2015) from the University of Cincinnati Medical Center (UCMC) internal medicine residency assessment system based on observable practice activities mapped to ACGME milestones. Data were analyzed by postgraduate year, assessor type, rotation, academic year, and core competency. The Mantel-Haenszel chi-square test was used to test for changes over time.

RESULTS

Specialties demonstrated heterogeneity in accounting for CDs in ACGME milestones, with 22% (22/99) of specialties having no language describing CDs in milestones assessment. Thirty-three percent (63/189) of UCMC internal medicine residents received at least one CD rating, with CDs accounting for 0.18% (668/364,728) of all assessment ratings. The authors identified CDs across multiple core competencies and rotations.

CONCLUSIONS

Despite some specialties not accounting for CDs in milestone assessment, UCMC's experience demonstrates that a significant proportion of residents may be rated as having a CD during training. Identification of CDs may allow programs to develop remediation and improvement plans.

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.

The problem resident behavior guide: strategies for remediation

In 2012, the ACGME supplemented the core competencies with outcomes-based milestones for resident performance within the six competency domains. These milestones address the knowledge, skills, abilities, attitudes, and experiences that a resident is expected to progress through during the course of training. Even prior to the initiation of the milestones, there was a paucity of EM literature addressing the remediation of problem resident behaviors and there remain few readily accessible tools to aid in the implementation of a remediation plan. The goal of the "Problem Resident Behavior Guide" is to provide specific strategies for resident remediation based on deficiencies identified within the framework of the EM milestones. The "Problem Resident Behavior Guide" is a written instructional manual that provides concrete examples of remediation strategies to address specific milestone deficiencies. The more than 200 strategies stem from the experiences of the authors who have professional experience at three different academic hospitals and emergency medicine residency programs, supplemented by recommendations from educational leaders as well as utilization of valuable education adjuncts, such as focused simulation exercises, lecture preparation, and themed ED shifts. Most recommendations require active participation by the resident with guidance by faculty to achieve the remediation expectations. The ACGME outcomes-based milestones aid in the identification of deficiencies with regards to resident performance without providing recommendations on remediation. The Problem Resident Behavior Guide can therefore have a significant impact by filling in this gap.

Assessment and Management of Professionalism Issues in Pathology Residency Training: Results From Surveys and a Workshop by the Graduate Medical Education Committee of the College of American Pathologists

Professionalism issues are common in residency training and can be very difficult to recognize and manage. Almost one-third of the milestones for pathology recently instituted by the Accreditation Council for Graduate Medical Education encompass aspects of professionalism. Program directors are often unsure of how and when to remediate residents for unprofessional behavior. We used a case-based educational approach in a workshop setting to assist program directors in the management of unprofessional behavior in residents. Eight case scenarios highlighting various aspects of unprofessional behavior by pathology residents were developed and presented in an open workshop forum at the annual pathology program director’s meeting. Prior to the workshop, 2 surveys were conducted: (1) to collect data on program directors’ experience with identifying, assessing, and managing unprofessional behavior in their residents and (2) to get feedback from workshop registrants on how they would manage each of the 8 case scenarios. A wide range of unprofessional behaviors have been observed by pathology program directors. Although there is occasionally general agreement on how to manage specific behaviors, there remains wide variation in how to manage many of the presented unprofessional behaviors. Remediation for unprofessional behavior in pathology residents remains a difficult and challenging process. Additional education and research in this area are warranted.

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

OBJECTIVES

Emergency medicine (EM) residency program directors (PDs) nationwide place residents on remediation and probation. However, the Accreditation Council for Graduate Medical Education and the EM PDs have not defined these terms, and individual institutions must set guidelines defining a change in resident status from good standing to remediation or probation. The primary objective of this study was to determine if EM PDs follow a common process to guide actions when residents are placed on remediation and probation.

METHODS

An anonymous electronic survey was distributed to EM PDs via e-mail using SurveyMonkey to determine the current practice followed after residents are placed on remediation or probation. The survey queried four designations: informal remediation, formal remediation, informal probation, and formal probation. These designations were compared for deficits in the domains of medical knowledge (MK) and non-MK remediation. The survey asked what process for designation exists and what actions are triggered, specifically if documentation is placed in a resident's file, if the graduate medical education (GME) office is notified, if faculty are informed, or if resident privileges are limited. Descriptive data are reported.

RESULTS

Eighty-one of 160 PDs responded. An official policy on remediation and/or probation was reported by 41 (50.6%) programs. The status of informal remediation is used by 73 (90.1%), 80 (98.8%) have formal remediation, 40 (49.4%) have informal probation, and 79 (97.5%) have formal probation. There was great variation among PDs in the management and definition of remediation and probation. Between 81 and 86% of programs place an official letter into the resident's file regarding formal remediation and probation. However, only about 50% notify the GME office when a resident is placed on formal remediation. There were no statistical differences between MK and non-MK remediation practices.

CONCLUSIONS

There is significant variation among EM programs regarding the process of remediation and probation. The definition of these terms and the actions triggered are variable across programs. Based on these findings, suggestions toward a standardized approach for remediation and probation in GME programs are provided.

Resident remediation, probation, and dismissal basic considerations for program directors

OBJECTIVES

To suggest a basic new approach for pathology training programs to consider when a resident requires remediation, probation, or dismissal.

METHODS

Remediation, probation, or dismissal of the poorly performing pathology resident is one of the most difficult and challenging aspects of any pathology training program. The poorly performing resident requires extra time and resources from the faculty and the program and can be disruptive for the entire program. Effective remediation requires faculty development, a well-constructed remediation or probation plan, and documentation.

RESULTS

Despite best efforts, not all remediation plans are successful and dismissal of the resident will need to be seriously considered.

CONCLUSIONS

Approaches to dealing with resident performance issues can be variable and need to be tailored to the issue being addressed.

Early detection of factual knowledge deficiency and remediation in otolaryngology residency education

OBJECTIVES/HYPOTHESIS

Within otolaryngology residency training, the annual Otolaryngology Training Examination (OTE) is the primary method used to assess, quantify, and compare the factual knowledge acquired by each resident. The objective of this study was to develop a more frequent method for tracking of factual knowledge to prevent educational delay.

STUDY DESIGN

Retrospective analysis of educational scores.

METHODS

For each didactic lecture within a single otolaryngology residency training program, multiple choice questions were provided before and after each lecture. Questions were based on lecture objectives that were derived from the American Board of Otolaryngology curriculum. Scores were tracked over the course of 1 academic year and compared to the scores of residents on the OTE administered in that year to determine correlation with a validated measure of factual knowledge. The effect of remedial measures on improvement in OTE scores was determined.

RESULTS

Over the course of 1 academic year, there were 328 questions presented to 12 residents before and after 32 lectures in the didactic program. Ten residents completed an average of 244 questions. Overall OTE scores demonstrated a significant and very strong correlation to lecture question scores (Pearson r = 0.86, P = .002). Remedial measures for residents during the previous 5 years who had inadequate OTE scores were successful in improving scores (P = .002).

CONCLUSIONS

A structured didactic program that uses review questions to assess knowledge can be used to track acquisition of factual knowledge. Early identification of residents with deficiencies facilitates the development of individualized learning plans that result in successful remediation.