As many faculty members have experienced first-hand, residents in difficulty are encountered in all programs and at a fairly regular rate of ~8-15% according to the American Board of Internal Medicine1. Residents requiring remediation typically have difficulties that fall into cognitive and/or behavioral categories2. Cognitive difficulties include weak critical thinking, poor fund of knowledge, technical skill deficiency, disorganization and learning disabilities. Behavioral examples include poor motivation, overconfidence, non-assertiveness, attitudinal problems, poor communication or interpersonal skills, substance abuse problems and mental illness. Learners in difficulty impact the educational system at multiple levels. The learner may have limited insight into their difficulties resulting in blame or denial and an inability to develop a solution without assistance. Faculty may become discouraged and peers frustrated. Patient care provided by the physician may suffer both during and after residency3. As such, developing a just and effective remediation curriculum becomes of the utmost importance in order for both the resident and the program to thrive.
A robust residency program should be designed in such a way as to identify at-risk residents early and allow the opportunity for primary prevention. Such a program is built on a strong and progressive curriculum that balances service and education and has clearly defined educational goals and expectations. The curriculum should likewise include integrated programs for stress reduction/management and team-building activities. Adequate resident supervision, with frequent 360Â° evaluations and feedback that starts at the earliest stages of training, will usually identify residents who need additional help before getting to the point of requiring formal remediation. Fifty percent of residents requiring remediation are identified during the 1st post-graduate year and >90% by the second year1. Interestingly, self-assessment shows poor correlation with other raters as high-performers tend to underestimate their skills and low-performers tend to overestimate, especially as it relates to communication, interpersonal skills and professionalism4.
Ratan et al. (2008) described a stepwise approach to developing a formal remediation program. The critical first step is to accurately identify the problem5. The routine evaluation system within a program will pick up on potential issues. Faculty may speak informally to the program director (PD). Once potential problems have been flagged, a more diligent assessment must take place. The PD, or his designee, can conduct interviews with faculty, staff and peers to get concrete examples of the resident’s performance through which the nature of the problem can be clearly defined. Once sufficient feedback has been solicited, the case should be reviewed to determine if formal remediation is warranted5. This decision may be undertaken by the PD or in larger programs, a formal remediation committee may be formed that manages the tasks of information gathering, decision to remediate and subsequent necessary steps.
Any barriers to remediation need to be addressed before the process can truly begin. For example, if a resident is suspected of having learning disabilities, substance abuse, marital problems, etc., these must be managed first. Clearly, such problems require the involvement of external resources such as cognitive learning assessment, psychiatric or medical evaluation, etc., as assessment and management extends beyond the scope of the PD alone. The resident and PD meet formally to review identified problems and to mutually agree upon the need for remediation. A written summary documenting the meeting should be entered into the resident’s official file5.
Since there exists a potential for bias by virtue of the program director position, it is preferable that the remediation is directly led by other faculty whom the PD and resident jointly identify as suitable mentors. A faculty mentor will act as facilitator, nurturer, disciplinarian, diagnostician and modeler and clearly define expectations throughout the remediation process6,7. Working with the PD and with adequate support, mentors develop an objective plan of action with a strict timeline to which the resident is expected to adhere. Consequences of unsuccessful remediation should be clearly delineated in writing as well. At this point, the PD may need to consult with the departmental or institutional education committee to ensure consensus with the remediation. Likewise, discussion with the institution’s legal counsel should be considered to ensure due process, to protect the department and to determine if remediation will affect the resident’s future licensing and privileging applications (i.e. having to answer “yes” to questions about disciplinary action)5. Although initial remediation is successful almost 85% of the time (~40% for professionalism issues), some residents may require repeated remediation, escalation to probation or ultimately dismissal8, 9.
Throughout the remediation process, flexibility and revision will be needed. Mentors will need to follow up regularly, document progress and successful completion. If it has been determined by the PD and educational committee that the remediation will impact how questions regarding probation, suspension, etc. should be answered on future licensing and employment paperwork, then the PD should prepare a formal answer that can be given in response to such future queries7.
Remediation may have ramifications on the residency program. Immediate effects include developing a “culture of fear” but conversely often result in increased peer support for the remediated resident and increased faculty support for mentors. If a resident has to have adjustments to his/her clinical schedule or if suspension is required, this may alter rotation schedules. In the long-term, a successful remediation program leads to improved faculty teaching and evaluation skills. It enriches departmental educational goals and drives future departmental policy. The program, ideally, would develop a reputation for being supportive of its residents5.
The remediation curriculum should be modular and directly linked to the ACGME core competencies which are Patient Care, Medical Knowledge, Practice-Based Learning & Improvement, Interpersonal & Communication Skills, Professionalism and Systems-Based Learning & Improvement10. Such a module-based curriculum addresses the resident’s individual deficiencies and can be mixed and matched in the future to create tailored programs as needed5.
Sample Remediation Curriculum
|Clinical Knowledge 5
|Objective: Improve fund of knowledge in field.
|Curriculum: Hour-long weekly didactic session on core topics with faculty mentor, pre-assigned readings and self-study
|Competency: Medical Knowledge
|Technical Skills 5
|Objective: Improve technical / surgical skills
|Curriculum: Modified OR schedule with designated faculty and/or Simulation
|Competency: Practice-based learning improvement
|Behavioral Issues 5, 11
|Objective: Address attitudinal and behavioral issues
|Curriculum: Psychiatric and/or medical evaluation, interpersonal skills course, regular follow-up with a therapist, simulated patient encounters, use of Johari window technique and transformative learning
|Competency: Professionalism / Interpersonal and communication skills
Hopefully, with a successful resident remediation program in place, a program director will never have to feel this way:
“If Elizabeth Kubler-Ross had been a Surgical Residency Program Director”12
|Stage I, Denial: This resident really isn’t so bad.
|Stage II, Anger: How did this uncivilized klutz ever get into our program?
|Stage III, Bargaining: Although the remediation is not necessary, I am confident that it will work.
|Stage IV, Depression: Oh my God, this resident is going to sow unconscionable mayhem upon the unsuspecting public and reflect poorly on our program.
|Stage V, Acceptance: It’s too late to do anything about this now. I sure hope that the American Board of Surgery picks this guy up—I am certain that he’ll never pass his boards.
Summary of Remediation Model Development Steps:
- Identify and accurately define the nature of the problem.
- Determine if remediation is warranted.
- Remove any barriers to remediation.
- Hold a formal meeting with the learner.
- Summarize meeting with formal documentation in the resident’s file.
- Identify mentors.
- Objective plan of action with timeline.
- Develop and utilize a modular curriculum linked to the ACGME core competencies
- Be flexible and revise as needed
- Consult (ex. legal counsel, departmental education committee)
- Investigate resources that are available at home institution
- Document progress and conclusion or failure of remediation
- Be prepared to deal with possible ramifications
- Reamy BV and Harman MD, Residents in Trouble: An In-depth Assessment of the 25- year Experience of a Single Family Medicine Residency. Fam Med 2006;38:252-7.
- Hicks P, Cox S, Espey E et al. To the point: Medical education reviews – Dealing with student difficulties in the clinical setting. American Journal of Obstetrics and Gynecology 2005;193: 1915–22.
- Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;9: 244-9.
- Lipsett PA, Harris I, Downing S. Resident self-other assessor agreement Arch Surg. 2011;146:901-906.
- Ratan RB, Pica AG and Berkowitz RL. A model for instituting a comprehensive program of remediation for at-risk residents. Obstet Gynecol 2008;112:1155-1159.
- Winston KA, Van Der Vleuten C, Scherpbier AJ. The role of the teacher in remediating at-risk medical students. Medical Teacher 2012;34: e732-e742.
- McLaughlin K, Veale P, McIlwrick J, de Groot J and Wright B. A practical approach to mentoring students with repeated performance deficiencies. BMC Med Ed 2013;13:56.
- Zbieranowski, I., et al., Remediation of Residents in Difficulty: A Retrospective 10-Year Review of the Experience of a Postgraduate Board of Examiners. Acad Med, 2012.
- Paglia JM, Frishman G. The trainee in difficulty: a viewpoint from the USA. The Obstetrician & Gynaecologist 2011;13:247–251.
- Accreditation Council for Graduate Medical Education. ACGME Institutional Requirements. Effective: July 1, 2013. Available here. Retrieved March 10, 2015.
- Luft J, Ingham H. The Johari Window, a graphic model of interpersonal awareness. In: Proceedings of the western training laboratory in group development, Los Angeles; 1955.
- Harken AH. Commentary: Kubler-Ross 5 stages in the recognition of poor surgical resident performance. Surgery, 2009;145:661-662
Written for April 2015 by
Moune Jabre, MD, FACOG
Attending Physician in Obstetrics and Gynecology
Sidra Medical & Research Center