Resident Remediation


Do you also have underperforming residents?

Managing an underperforming physician[1]is a challenging subject faced not uncommonly by medical educators and academic administrators. Challenges cited include the reluctance of supervising physicians to give corrective feedback, the lack of skills to make the right diagnosis for the cause(s) of difficulty, and the uncertainty in the effectiveness of remediation[2].

Two articles[3, 4]in the most recent issue of the Academic Medicine address this topic by answering questions about the prevalence, outcome of remediation and provide a model for remediation of an extreme of unprofessional behavior.

Q1 What is the prevalence of underperforming residents?

100 residents (3%) over 10 years and 2-23 residents (0.2%-1.5%) per year required remediation.

This data is based on 10-year (1999-2009) retrospective study of all residents in difficulty referred to the Board of Examiners for Post-Graduate Programs at the University of Toronto. This prevalence of residents in difficulty did not vary across the reported department[3].

Q2 What are the residents' weaknesses and what is the duration of remediation?

The definition of the resident's difficulty was based on CanMed roles. All residents referred to the Board, had weakness in Medical Expert, Professionalism or both roles. 70% of residents had difficulty in more than one role. Duration of remediation varied by type of remediation as shown in Table 1[3].

Type of Remediation Mean, (Mode) months Range, months
Remediation 6 (6) 2-21
Remediation with probation 8 (3, 6, 12) 2-16
Probation 13 (6) 4-52

Q3 What is the outcome of Remediation?

Based on the system described in the paper, 83% of the residents who underwent remediation were able to complete a residency program, while 17% had to leave their programs [3]. The subgroup that did not complete their training programs had a slight increase in weakness in professional competency as compared to the other two subgroups.

Q4 Since professionalism was a common problem in the paper how was it remediated?

This article[3] does not describe the process of remediation. However, a second paper[4]in the same issue describes a course aimed to remediate disruptive physicians using the principles of transformative learning .

The course, well described using a mock case, is characterized by three days of intensive training followed by three booster sessions over a six months period. The training is preceded by pre-course self-assessment followed by didactic sessions, group discussions, mindfulness activities, role-plays and �intent to change� exercises. Follow-up sessions include a 360 degrees evaluation and group meetings to discuss and reflect on progress towards the intended behavioral changes.

Although the paper does not provide quantitative outcomes, it reports positive letters obtained from participants and institutions on the effectiveness of the program.

Lessons Learned
  1. It is not uncommon to encounter an underperforming resident
  2. Medical Knowledge and Professionalism are the two most common competencies that underperforming physicians struggle with
  3. Remediation works for the majority
  4. Designing remediation programs using theoretical grounds can be effective

Further Reading:

  1. Papadakis, M.A., et al., Perspective: The Education Community Must Develop Best Practices Informed by Evidence-Based Research to Remediate Lapses of Professionalism. Acad Med, 2012.
  2. Audetat, M.C., et al., What is so difficult about managing clinical reasoning difficulties? Med Educ, 2012. 46(2): p. 216-27.
  3. 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.
  4. Samenow, C.P., et al., Transformative Learning in a Professional Development Course Aimed at Addressing Disruptive Physician Behavior: A Composite Case Study. Acad Med, 2012.

Reviewed in November 2012 by:
Thurayya Arayssi M.D., FACP, FACR
Associate Professor of Medicine
Associate Dean for Graduate Medical Education