Remediating the struggling

resident
Sheilah Bernard, MD, APD
Chair, Clinical Competence Committee
April 8, 2013
Wilkins Board Room
 Goals
• Gain familiarity with Milestones and
Entrustable Professional Activities (EPA's)
• Identify some sources of poor
performance
• Understand the different mechanisms by
which remediation occurs
Training the successful physician

MODELING
ATTITUDES
SKILLS
KNOWLEDGE
 Brainstorm: characteristics of
struggling resident
(“It’s like pornography, you recognize it
when you see it…..”)
 “Heads up”
• PGY1 is disorganized, writes notes late
(PC, P, MK)
• PGY1 having difficulty synthesizing
medical information (MK, PC)
• PGY2 is quiet, not effectively leading team
(IPSC, MK, PC)
• PGY2 is distracted, can’t multitask
effectively (PC, PBLI, P)
• PGY3 has “checked out” (P)
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the problem
• Determine the appropriate corrective action plan
• Identify the appropriate administrative setting for
the action plan
• Determine whether the corrective action plan
has been successful
• Attend to due process issues
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
What evaluations are in our “toolkit”?
• Faculty and Peer block evaluation (rarely use NET not
enough time). Your observations even over a 1 wk period
will still provide useful information
• 360°’s from MS’s, patients, RN’s, discharge planners, Peer
review from residents/CMR’s
• Conferences: interactions during morning report, CREX,
EBM, Journal Club, Board review, Hopkins modules
• Clinical interaction/Critical Incidence report (STARS):
Reportable activity, reflects performance under stress
• Quality Improvement processes: Hospital reporting
systems may identify poor performance by resident
(Logician Reds, Duty Hour Violations)
• OSCE’s, Sim, Mini-CEX’s directly observed exercises
 Infrastructure: Clinical
Competence Committee
• Reviews monthly all evaluations < 4 or other
concerns brought to Program Office
• Corroborates concerns with other evaluative
tools (CMR’s, discussions with evaluators,
MiniCEX, peer reviews)
• Advisor (PD/APD) meets and discusses
performances, reviews feedback already
received
• Sets goals to improve performance, directed to
feedback
• Recommends remediation if goals not met
 Critical Remediation Timeline
First evaluations
identify at risk PGY1’s
Implement further
evaluation methods
CMR’s deployed

July June

October
 Critical Remediation Timeline
Implement remediation
plan if further evals
below average
December

July June
 Critical Remediation Timeline
Formalize PGY
extension if required
April

July October December June

 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the
problem
 Recognize and characterize the
problem
• Assumption: Curricular and personal goals are
reviewed by residents (in NI under block
schedule)
– Truth: never reviewed
– Phone calls directly to program office
• “Heads up”
• “Red flag”—tardiness, late notes, any single
circumstance with adverse outcomes
• Inefficiencies in care
• Behavioral issues
 Recognize and characterize the
problem
• Red flags
– A disproportionate amount of attention by training
personnel is required
– Grumbling from peers
– The trainee’s behavior does not change as a function
of feedback, remediation efforts, and / or time
invested (by trainee or program director!!!)
• Faculty and peer evaluations
– Document
– Document
– Document
Peer review

J Grad Med Educ. 2012 March; 4(1): 47–51.

doi: 10.4300/JGME-D-11-00145.1
 Competence problems that should
be documented:
• Lack of or poor judgment
• Inadequate clinical skills/patient care
• Deficient technical or procedural skills
• Ineffective communication skills
• Inability and/or unwillingness to acquire and
integrate professional standards into one’s
repertoire of professional behavior
• Lack of personal insight or self-awareness
• Inability to control personal stress or emotional
reactions that interfere with professional
functioning (conduct or emotional problem) and
participation in teams
 EPA: Demonstrate professional
behavior

• Milestone: Responds promptly and

appropriately to clinical responsibilities
including but not limited to calls and pages
• Milestone: Dress and behave
appropriately
• Milestone: Maintain appropriate
professional relationships with patients,
families and staff
 Evaluations
• Any rating less than 5 merits attention by
program office (below average)
• No single evaluation will “fail” a resident;
be honest and objective within each
competence
• Remember, evaluation is SUMMATIVE
and judgmental. It should reflect
FORMATIVE feedback already provided to
the resident
 Feedback might reveal:

• Transition issues
• Mild performance anxiety
• Mild discomfort with diverse patient groups
or multi-disciplinary team members
• Initial lack of understanding of the
attending’s/facility’s standards
• Lack of certain skill sets, but an openness
and readiness to acquire them
 6 D’s of
unprofessional behavior
• Depression
• Deprivation (sleep, food)
• Distraction (finances, family/SO, illness)
• Disability (neurocognitive, physical)
• Disordered personality (ADHD, borderline)
• Drugs (alcohol, narcotics)
 Performance Standards
• Outstanding
– Resident demonstrates truly outstanding
performance in all competences, achieving
milestones before normal trajectory
– Modeling
 Performance Standards
• Outstanding--Models
• Good/Satisfactory--Teaches/manages
– Resident meets all expectations for performance in all
domains over time and demonstrates no deficiencies
– Compensation fallacy: Erroneously labeling residents
as “good” who have some strong characteristics
(professionalism) that “cancel out” their unsatisfactory
characteristics (patient care/judgment)
– Halo effect: some residents are truly outstanding in
one or two areas, and deficiencies in other areas are
overlooked
 Performance Standards
• Outstanding
• Good/Satisfactory
• Marginal – still learning
– Resident is not particularly strong and has poor
or ambiguous competencies in some domains
– Faculty want to give benefit of doubt
– Faculty feel that resident is not incompetent
(ergo must be competent)
– Faculty do not want to label resident
 Performance Standards
• Outstanding
• Good/Satisfactory
• Marginal
• Unsatisfactory and unsuitable for promotion
despite remediation
Why reluctance to grade low?
 Problems with post-rotation
evaluations
• grade inflation (is 7 average?)
• attending physicians' lack of willingness to
document poor performance
• lack of knowledge about how to document
performance concerns
• comments section often does not correlate
with the numeric ratings

J Grad Med Educ. 2012 March; 4(1): 47–51.

doi: 10.4300/JGME-D-11-00145.1
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the problem
• Determine the appropriate corrective
action plan
 CCC Remediation with
Individualized Educational Plan:
• Identifies deficiencies in context of core
competence and EPA/milestone
• Reviews block rotations
• Identifies task-oriented demonstration of
skills
 Evaluation methods
• MK: Record review, Chart stimulated recall, 360
evals, Simulations, ITE/conf attendance/Hopkins
• PBLI: record review, use of EBM, portfolios
• IPSC: OSCE, simulations, Patient Survey
• PC: Check list, 360 evals, OSCE, CSR, Record
review
• P: OSCE, PS, 360 evals, MiniCEX
• SBP: 360, PS, OSCE, portfolios, QI project
 CCC Remediation with
Individualized Educational Plan:
• Identifies deficiencies in context of core
competence and EPA/milestone
• Reviews block rotations
• Identifies task-oriented demonstration of skills
• Arranges mentor/coach outside of CCC (core
faculty, master clinicians)
• Uses different skill sets
• Sets timeline with goals
• States ramifications of failure to achieve goals
• Arranges follow-up to assess progress
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the problem
• Determine the appropriate corrective
action plan
• Identify the appropriate administrative
setting for the action plan
 Setting for action plan
• Warning
• Remediation may or may not be on probation
– Inpatient service
• Prewarn service attending
• Rotation? Colleagues?
– Ambulatory service
– Elective time in areas of deficit
– Regular meetings with coach to review notes, discuss
management, identify knowledge
– Self-reflection/insight
• Non-promotion, nonrenewal of contract, no credit,
extension of training, suspension, withdrawal from
program, termination
 Case for discussion
• PGY2 first ward block is inefficient, doesn’t
recognize sick patients, makes superficial
assessments, misses important clinical
clues
• Core Competence: Patient care
 Individualized learning plan
• PC-C1 Clinical Reasoning (12 mos): synthesize
all available data, including interview, physical
exam, and preliminary laboratory data, to define
each patient’s central clinical problem.
– Chart stimulated recall on patients
– Observed MiniCEX by preceptor, coach, attending
– Chart audit: review and discuss admission notes,
consultations, discharge summary by faculty, CMR’s
• PC-B2 (12 mos): accurately track important
changes in the physical examination over time in
the outpatient and inpatient settings
– Preceptor chart-stimulated recall of changes in
diabetic PE
– CMRs discuss changes in CHF exam on CMP
 Critical Remediation Targets
• PGY1
– Identify 75% of residents requiring remediation
– Identify 100% of residents requiring extension
• PGY2
– Identify remaining 25% of struggling residents
– No residents requiring extension
– No “Holy Cow” residents
• PGY3
– Rare remediation issues
– Patient safety issues trump all other evaluations
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the problem
• Determine the appropriate corrective
action plan
• Identify the appropriate administrative
setting for the action plan
• Determine whether the corrective
action plan has been successful
 Success!
• Successful completion of all remediation
steps
– Remove from remediation
– Continue on rising trajectory
• No further evaluations < 5
• Completes anticipated milestones for
promotion
 How to identify and remediate the
struggling resident
• Develop a comprehensive evaluation
infrastructure
• Recognize and characterize the problem
• Determine the appropriate corrective action plan
• Identify the appropriate administrative setting for
the action plan
• Determine whether the corrective action plan
has been successful
• Attend to due process issues
Homework handout
backups
Clinical Competence Committee

• ACGME requires a resident to complete an

approved 3-year medical residency before sitting
for ABIM certification exam
– Clinical Competence Committee assesses
noncompensatory competence in other cores of
Patient Care, Interpersonal Skills and
Communication, Systems based Practice, Practice-
based Learning and Improvement, and
Professionalism
• Successful passage of ABIM certifying exam
reflects residents’ fund of Medical Knowledge
The academic year for PGY’s
 Context issues to be
considered:
• Separation from support systems
• Adjustment issues to new setting both
personally and professionally
• Changes in status (finances or power)
• Impact of significant life events
• Personal risk factors (substance abuse,
ADD, other psychiatric disorders, etc.)
 Due process
• Meetings with advisor, PD, Chair CCC
• Boston Medical Center is obligated to make
reports to the Board of Registration in Medicine
(“BORM”) when it takes disciplinary action
against a House Officer.
• The hospital must file a report with the BORM
when there is a reasonable basis to believe that
a House Officer is in violation of any
Massachusetts law relating to the practice of
medicine or regulations of the BORM.
• Right to appeal to CMO at BMC
 Disciplinary actions which must be
reported to the BORM:
• Written reprimand or admonition for behavior
relating to competence to practice medicine or
violation of a law, the regulations of the BORM,
or hospital bylaws
• Probation: Such action is taken in accordance
with the requirements of the HOA/CIR contract
• Suspension: seriously inappropriate behavior to
patients, colleagues or others or significant
failure to comply with hospital policies
 Reportable to BORM
• Termination or nonrenewal for behavior
relating to competence to practice medicine
or violation of a law, the regulations of the
BORM or hospital bylaws
• Resignation related to competence to
practice medicine or violation of a law, the
regulations of the BORM or hospital bylaws
• Leave of absence related to competence to
practice medicine (administrative leave
does not qualify)
 Characteristics of rotation evals
suggesting need for remediation:

• presence of “outlier” evaluations (>2 SD)

• the amount of comments
• the percentage of negative or ambiguous
comments

J Grad Med Educ. 2012 March; 4(1): 47–51.

doi: 10.4300/JGME-D-11-00145.1