Jenny Sanders, MD
The road to success isn’t always straight. Some of the greatest minds and talents in recent history had their share of struggles. Albert Einstein was slow to speak and difficulties in school; Michael Jordan was cut from his Varsity basketball team; Steve Jobs was fired from his own company. Medic al trainees may also struggle to meet various standards of performance across one or more clinical competencies. Identifying the problem resident/fellow and formulating an organized approach to remediation can be a struggle.
The problem trainee is one who is unable to meet the standards of performance in core competencies as defined by the Accreditation Council on Graduate Medical Education (ACGME). Those competencies include medical knowledge, patient care, interpersonal skills and communication, professionalism, practice-based learning and systems-based practice. The ACGME Milestones Project provides competency-based outcomes tailored to specialties, and allows for a longitudinal assessment of trainees and provides transparent expectations. Identifying the problem trainee can be difficult but some tools such as monthly rotation evaluations by faculty, in-service exam results, trainee self-evaluation, clinical competency committee assessments and 360 evaluations are helpful.
Once a trainee has been identified as having a problem, it is important to consider if secondary issues might be contributing to the situation. Lucey and Boote describe the “7 D’s”:
- Sleep Deprivation
- Depression and other affective disorders
- Drugs and alcohol
- Disease (acute or chronic medical illness)
- Learning Disabilities
- Personality Disorders
Those trainees who have a secondary issue may not benefit from remediation until the secondary disorder is addressed and controlled.
Trainees will each reach the ACGME milestones at different stages. Some trainees require little assistance, while others require a systematic organized approach to get back on track. A recent paper by Smith et al, defines the processes for remediation, probation and termination in residency training (Figure 1). Smith proposes a remediation schema for trainees at risk of not meeting milestones. Informal remediation is the first step in the remediation process and should be initiated when there is a deficiency in one or more milestones but the problems are not significant enough to warrant formal remediation. The authors surveyed several program directors and found that some programs create official documentation at this stage of remediation while others may use “shadow files” that can be disposed of once the trainee corrects the action or behavior, and does not become a part of the trainee’s official file. Failure to remedy the concerns addressed during informal remediation, or significant problems should result in formal remediation. The unresolved deficiencies should be documented, and a corrective action plan should be created. The action plan should include clearly defined outcomes, a timeframe for reassessment and consequences of remediation failure. A strong action plan should be faculty mentored, targeted to the trainee’s specific deficiencies and time-limited. The Graduate Medical Education (GME) office should be aware of formal remediation, but in most cases, that documentation is not disclosed in the trainee’s final employment letters or verification of training certificate. Probation should follow formal remediation if the trainee is unsuccessful in correcting the actions proposed, or if the problems are significant enough to warrant immediate probation. Probation includes documentation that does extend to employment letters and verification of training certificates. Termination occurs if the terms of probation are not met.
Figure 1: Remediation schema as per Smith et al
The remediation process can be difficult and there are some common pitfalls. The first is lack of supporting data that highlights the problem. Faculty and the program director should provide honest feedback and fill out timely rotation evaluations. Another common problem is that the trainee may not believe that he/she has a problem. Supporting data, in terms of feedback and evaluations, may help obtain trainee buy-in. It is also important for faculty to continue to support the trainee so that he/she does not feel labeled as a failure. The trainee may also progress too slowly, requiring an extension to standard training time. There are also some problems/concerns that may be so egregious that require immediate dismissal from training. These issues are rare and are typically unprofessional behaviors.
Luckily, most trainees are very motivated and with some assistance and direction, can be back on track to graduate on time and go on to obtain good jobs. As educators, we must provide timely and honest feedback to trainees so that they can stay on track and perform to their fullest potential.
Lucey CR, Boote R. Working with problem residents: a systematic approach. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby Elsevier; 2008:201-216
Smith JL, Lypson M, Silverberg M, et al. Defining Uniform Processes for Remediation, Probation and Termination in Residency Training. Western Journal of Emergency Medicine. 2017;18(1):110-113. doi:10.5811/westjem.2016.10.31483.