approach to the resident in need of remediation -...

Approach to the Resident Approach to the Resident in Need of Remediationin Need of RemediationJeannette Guerrasio, MDJeannette Guerrasio, MDDirector of Resident Remediation ProgramDirector of Resident Remediation ProgramEva Aagaard, MDEva Aagaard, MDAssociate Chair, EducationAssociate Chair, EducationSuzanne Brandenburg, MDSuzanne Brandenburg, MDInternal Medicine Residency Program DirectorInternal Medicine Residency Program DirectorUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center

Kelly Kieffer, MDKelly Kieffer, MDInternal Medicine Primary Care Program DirectorInternal Medicine Primary Care Program DirectorDartmouthDartmouth--Hitchcock Medical CenterHitchcock Medical Center

From Failure to SuccessFrom Failure to Success

Delayed acquisition of speechDelayed acquisition of speechWeak studentWeak student–– Significantly delayedSignificantly delayed–– ““HeHe’’ll never make a success of anythingll never make a success of anything””

Failed college entrance exam Failed college entrance exam –– Zurich Polytechnic Institute Zurich Polytechnic Institute

1921 Nobel Prize for Physics1921 Nobel Prize for PhysicsBest known for his theory of relativityBest known for his theory of relativity–– MassMass--energy equivalentsenergy equivalents

Cut as a sophomore from his highCut as a sophomore from his high--school school basketball team in Wilmington, N.C. basketball team in Wilmington, N.C.

Joined the NBAJoined the NBAWon 6 NBA championshipsWon 6 NBA championships5 time MVP and Defensive Player of the 5 time MVP and Defensive Player of the YearYearHas appeared on the Wheaties box more Has appeared on the Wheaties box more than any other athletethan any other athlete

Dismissed from drama school for being too Dismissed from drama school for being too quiet and shy quiet and shy Began her performing career on Broadway, Began her performing career on Broadway, was hiredwas hired——but then quickly firedbut then quickly firedNext, she was fired from a Shubert Brothers Next, she was fired from a Shubert Brothers production production

As star performer in her own TV show in As star performer in her own TV show in 1948, she went on to win:1948, she went on to win:–– 13 Emmy Awards13 Emmy Awards–– 12 Golden Globes12 Golden Globes–– Lifetime Achievement AwardLifetime Achievement Award–– International FameInternational Fame

Shows continue to run daily, around the world.Shows continue to run daily, around the world.

ObjectivesObjectives

Identify residents in need of remediationIdentify residents in need of remediationIdentify methods for obtaining constructive Identify methods for obtaining constructive resident evaluation and feedbackresident evaluation and feedbackDiagnose common specific areas of learner Diagnose common specific areas of learner difficultydifficultyDevelop a plan for remediation specific to Develop a plan for remediation specific to the learnerthe learner’’s areas of difficultys areas of difficulty

Timeline:Timeline:

15min15min -- Brief literature overviewBrief literature overview-- Index CaseIndex Case

50min50min -- Interactive discussion: approach to Interactive discussion: approach to resident in difficulty resident in difficulty

-- Diagnose key areas of learner difficulty Diagnose key areas of learner difficulty -- Explore identification and remediation of Explore identification and remediation of

deficiency deficiency -- FollowFollow--up on presented casesup on presented cases

15min 15min -- Summary of approach to resident in Summary of approach to resident in need of remediation need of remediation

10min 10min -- Session EvaluationSession Evaluation

Resident in Need of Resident in Need of RemediationRemediation

ABIM: ABIM: ““a trainee who demonstrates a a trainee who demonstrates a significant enough problem that significant enough problem that requires intervention by someone of requires intervention by someone of authority, usually the program director authority, usually the program director or chief residentor chief resident””

IntroductionIntroduction

PointPoint prevalence of residents in need prevalence of residents in need of remediation was 7% of remediation was 7% ABIM estimates that 8ABIM estimates that 8--15% of 15% of residents have significant areas of residents have significant areas of learner difficulty learner difficulty The percent of residents in difficulty The percent of residents in difficulty has continued at the same frequency has continued at the same frequency over timeover time

Yao DC and Wright SM. JAMA 2000; 284;1099-104."The Problem Resident" VHS videocassette produced by ABIM; 1992.

Most Common DeficitsMost Common Deficits

0 10 20 30 40 50

Unethical behaviorsTardiness or AbsencessUnsatisfactory Humanistic BehaviorsUnsatisfactory Clinical SkillsProvision of Poor or Inadequate Care to PatientsInappropriate Interactions w/ Colleagues or StaffInefficient Use of TimePoor Clinical JudgementInsufficient Medical Knowledge

Yao DC and Wright SM. JAMA 2000; 284;1099-104.

Most Common DeficitsMost Common Deficits

Substance UsedSubstance Used % of IM Residents% of IM ResidentsAlcoholAlcohol 97.4 97.4 MarijuanaMarijuana 64.3 64.3 CocaineCocaine 28.7 28.7 BenzodiazepinesBenzodiazepines 23.623.6AmphetaminesAmphetamines 20.320.3OpiatesOpiates 7.57.5PsychedelicsPsychedelics 14.514.5LSDLSD 9.99.9BarbituratesBarbiturates 7.87.8

Hughes, PH et al. Am J Psychiatry 1992. 149(10): 1348-1354.

Why is this important?Why is this important?

Impact patient safety and timely careImpact patient safety and timely careIncrease the amount of time spent by Increase the amount of time spent by facultyfacultyAdd additional responsibilities and work Add additional responsibilities and work onto their resident colleagues onto their resident colleagues Affect the morale of the entire training Affect the morale of the entire training programprogramOur obligation to residentsOur obligation to residents

Reamy, BV & Harman, JH. Fam Med. 2006;38(4):252-7.Adapted from Lecture given by J. Wiese at Tulane.

……Despite the magnitude of theDespite the magnitude of theproblem, we struggle to adequately problem, we struggle to adequately and accurately identify and and accurately identify and

remediate residents.remediate residents.

Who identifies residents Who identifies residents in difficulty?in difficulty?

0 10 20 30 40 50 60 70 80 90

The Resident HPatients and FaNursingAttendings, WriOther ResidentProgram DirectAttendings, VerChief Resident

Yao DC and Wright SM. JAMA 2000; 284;1099-104.

How are Residents How are Residents Identified?Identified?

Processes that identified problem Processes that identified problem resident:resident:

82% Direct Observation82% Direct Observation59% Critical Incident59% Critical Incident45% Poor Performance45% Poor Performance33% Neglecting Patient Care 33% Neglecting Patient Care

ResponsibilityResponsibility

Yao, DC & Wright, SM. JAMA. 2000;284:1099-1104.

Why do residents in need of Why do residents in need of remediation come to our remediation come to our

attention so late?attention so late?

(Ab)Use of Likert scales(Ab)Use of Likert scales

Schwind, CJ et al. Acad Med. 2004;79:453-457.

Comparison of Numeric and Comparison of Numeric and Written EvaluationsWritten Evaluations

Evaluations of 30 Surgical residents with Evaluations of 30 Surgical residents with deficiencies requiring remediationdeficiencies requiring remediation

88--20% identified a deficiency in the written 20% identified a deficiency in the written commentscomments22--4% identified a deficiency in the rating 4% identified a deficiency in the rating scalescale2323--55% with excellent ratings in the area of 55% with excellent ratings in the area of deficiencydeficiency

60% of program directors felt that it 60% of program directors felt that it was difficult to convince residents of was difficult to convince residents of their deficiencies because of in their deficiencies because of in adequate/inaccurate written adequate/inaccurate written evaluationsevaluations

Yao, DC & Wright, SM. JAMA. 2000;284:1099-1104.

Deficits in Eval System:Deficits in Eval System:

ACGME competenciesMedical KnowledgePatient CareInterpersonal Skills and CommunicationProfessionalismPractice-Based LearningSystems of Care

DeficienciesMedical KnowledgeClinical SkillsClinical Judgment and ReasoningOrganization and time managementCommunicationInterpersonal skillsProfessionalism Mental Health

Adapted from Lecture given by Wiese at Tulane, 2005. Winter RO. Fam Med 2002;34(3):190-6. Packard, C. RIME competencies.

Limitations Identified Limitations Identified By EvaluatorsBy Evaluators

Standards are not well definedStandards are not well definedLack the ability or knowledge of the grading Lack the ability or knowledge of the grading systemsystemLack knowledge of what and how to Lack knowledge of what and how to documentdocumentQuestion their ability to fairly and fully assess Question their ability to fairly and fully assess the residentsthe residentsUnwilling to record negative evaluationsUnwilling to record negative evaluations

Dudek, NL et al. Acad Med 2005;80:10.Shapiro, J et al. Fam Med. 1987:19:368-75.

Interactive Discussion:Interactive Discussion:

50min50min -- General approach to residents in difficulty General approach to residents in difficulty -- Index case presentation Index case presentation

For each of 3 scenarios:For each of 3 scenarios:-- Diagnose key areas of learner difficulty Diagnose key areas of learner difficulty -- Explore identification & remediation of Explore identification & remediation of deficiency deficiency -- FollowFollow--up on caseup on case

15min 15min -- Summary of approach to resident in Summary of approach to resident in need of remediation need of remediation

10min 10min -- Session EvaluationSession Evaluation

Case PresentationCase Presentation

In January, a 30 y.o. PGY1 internal medicine In January, a 30 y.o. PGY1 internal medicine resident joins your general ward service. resident joins your general ward service. –– patient presentations are below the level of his peers patient presentations are below the level of his peers –– does not appear to know his patients very welldoes not appear to know his patients very well–– presents similar physical exam and review of systems for presents similar physical exam and review of systems for

all of his patients. all of his patients. –– objective data is neither clear nor organizedobjective data is neither clear nor organized–– missing relevant informationmissing relevant information–– assessments do not demonstrate a clear thought process assessments do not demonstrate a clear thought process –– plan is present but briefplan is present but brief–– his attendance at morning report and noon conferences is his attendance at morning report and noon conferences is

less than 25%.less than 25%.

Case PresentationCase Presentation

You are concerned with his overall performance You are concerned with his overall performance and contact the program director. and contact the program director. His prior evaluations reflect an average resident, His prior evaluations reflect an average resident, scoring 5scoring 5--6 out of 9 on the numeric likert scales for 6 out of 9 on the numeric likert scales for each of the 6 ACGME competencies. each of the 6 ACGME competencies. There are only a few written comments on his prior There are only a few written comments on his prior evaluations and they document a significant evaluations and they document a significant knowledge deficit. knowledge deficit. The program director feels that this is inconsistent The program director feels that this is inconsistent as his USMLE 1 and 2 scores which are >98, >240.as his USMLE 1 and 2 scores which are >98, >240.

Diagnosing the ProblemDiagnosing the Problem

Does the resident have deficiencies?Does the resident have deficiencies?

Does the resident have deficiencies? Does the resident have deficiencies?

Yes!Yes!

What is the differential?What is the differential?

What is the differential?What is the differential?–– Medical KnowledgeMedical Knowledge– Clinical Skills– Clinical Judgment and Reasoning– Organization and Time Management– Communication– Interpersonal skills– Professionalism – Mental Health +/- Substance Abuse

What additional information/data do What additional information/data do we need to narrow the differential?we need to narrow the differential?

Additional InformationAdditional Information

Ability to collect H&PAbility to collect H&PIntegration of Integration of information, represent information, represent problemproblemFormulation of ddx, A/PFormulation of ddx, A/PEfficiencyEfficiencyPrioritizing tasksPrioritizing tasksAbility to summarize Ability to summarize casecaseFormulation of questionsFormulation of questionsChart reviewChart review

Responsiveness to Responsiveness to colleagues/nurses/ colleagues/nurses/ patientspatientsArrival/departure timeArrival/departure time360360˚̊ evaluationsevaluations–– InteractionsInteractions–– OwnershipOwnership

Reading materialsReading materialsSocial StressorsSocial StressorsSubstance AbuseSubstance AbuseResidentResident’’s Perspectives Perspective

Scenario 1:Scenario 1:

Attempting to get a better understanding of the Attempting to get a better understanding of the residentresident’’s difficulties, you decide to observe him s difficulties, you decide to observe him admit a patient. admit a patient. –– H&P takes twice as long as you would have expected. H&P takes twice as long as you would have expected. –– appears to have no focus, gathering much extraneous appears to have no focus, gathering much extraneous

informationinformation–– unable to prioritize his differential diagnosisunable to prioritize his differential diagnosis–– orders too many testsorders too many tests–– On further questioning, unable to assign pre and post test On further questioning, unable to assign pre and post test

probabilitiesprobabilities–– Answers all direct factAnswers all direct fact--based questions correctly based questions correctly

Scenario 1: DiagnosisScenario 1: Diagnosis

What are his deficiencies?What are his deficiencies?–– Medical KnowledgeMedical Knowledge– Clinical Skills– Clinical Judgment and Reasoning– Organization and Time Management– Communication– Interpersonal skills– Professionalism – Mental Health +/- Substance Abuse

What additional assessments may help What additional assessments may help differentiate and define the underlying differentiate and define the underlying problem?problem?

How would you target his How would you target his remediation?remediation?

FollowFollow--upup

Case 1: Clinical ReasoningCase 1: Clinical Reasoning–– Identified via 1 negative evaluation early Identified via 1 negative evaluation early

in intern yearin intern year–– Prompt feedback and discussion of Prompt feedback and discussion of

concernsconcerns–– 22ndnd negative evaluation and negative evaluation and

communicated concerns led to probationcommunicated concerns led to probationClinical reasoning deficitsClinical reasoning deficits

FollowFollow--upup

Case 1: Clinical ReasoningCase 1: Clinical Reasoning–– Remediation Plan:Remediation Plan:

Standardized patient cases, videotapedStandardized patient cases, videotapedReview taped with mentorReview taped with mentorMet with mentor regularlyMet with mentor regularlySchedule changes to allow resident to Schedule changes to allow resident to practice independently for additional 4 practice independently for additional 4 monthsmonths

–– Assess ability to integrate and process informationAssess ability to integrate and process information

FollowFollow--upup

Case 1: Clinical ReasoningCase 1: Clinical Reasoning–– Successful remediationSuccessful remediation–– Accepted into the competitive fellowship Accepted into the competitive fellowship

of choiceof choice

He is routinely 15 minutes late to daily rounds, He is routinely 15 minutes late to daily rounds, often appearing disheveled. often appearing disheveled. During daily rounds, you decide to ask him to lead During daily rounds, you decide to ask him to lead the interaction with his patient. As he introduces the interaction with his patient. As he introduces the team, it appears that the patient does not the team, it appears that the patient does not recognize him. recognize him. He proceeds with a vague presentation. The He proceeds with a vague presentation. The patientpatient’’s family interjects to add relevant s family interjects to add relevant informationinformation. .

Before you leave, you call the intern to see if Before you leave, you call the intern to see if the team has any more questions. the team has any more questions. –– You soon learn that he has left an hour early. You soon learn that he has left an hour early. –– In following up with the onIn following up with the on--call team, you learn call team, you learn

that he has signed out an inappropriate amount that he has signed out an inappropriate amount of work. of work.

–– The frustrated covering resident blurts out, that The frustrated covering resident blurts out, that he is not surprised and that he has given up he is not surprised and that he has given up arguing with this resident.arguing with this resident.

What additional assessments may help What additional assessments may help differentiate and define the underlying differentiate and define the underlying problem(s)?problem(s)?

Scenario 2: RemediationScenario 2: Remediation

FollowFollow--upup

Case 2: ProfessionalismCase 2: Professionalism–– First reported end of 2nd yearFirst reported end of 2nd year

Inappropriate communication: confrontational Inappropriate communication: confrontational and threateningand threatening

–– Prompt feedback and written warningPrompt feedback and written warning–– Recurrent unprofessional behavior Recurrent unprofessional behavior

towards physicians and stafftowards physicians and staff

FollowFollow--upup

Case 2: ProfessionalismCase 2: Professionalism–– Remediation Plan:Remediation Plan:

Evaluation by Colorado PhysiciansEvaluation by Colorado Physicians’’ Health Health Program (CPHP)Program (CPHP)Regular meetings with mentorRegular meetings with mentorRole playing and practicing alternative Role playing and practicing alternative methods of communication methods of communication Strict behavior guidelinesStrict behavior guidelinesRequired: 100% passing evaluations & Required: 100% passing evaluations &

no additional unprofessional behaviorno additional unprofessional behavior

FollowFollow--upup

Case 2: ProfessionalismCase 2: Professionalism–– Placed on probation 3Placed on probation 3rdrd year foryear for

Unexcused absencesUnexcused absencesFailing score for professionalismFailing score for professionalismUnreliable and failed to complete required Unreliable and failed to complete required assignmentsassignmentsOngoing conflicts with Attendings and StaffOngoing conflicts with Attendings and Staff

FollowFollow--upup

Case 2: ProfessionalismCase 2: Professionalism–– Successful completion of requirements Successful completion of requirements

during residencyduring residency–– Obtained employment, following Obtained employment, following

graduationgraduation–– Continues to have professionalism Continues to have professionalism

problems at place of employmentproblems at place of employment–– Practicing with active license, no actionsPracticing with active license, no actions

He spent 2 years between medical school and He spent 2 years between medical school and residency doing research and learning English, as a residency doing research and learning English, as a second language. second language.

During observed patient encounters, he appears to During observed patient encounters, he appears to miss valuable information and the opportunities to miss valuable information and the opportunities to ask followask follow--up questions.up questions.

On rounds, he is disorganized and has difficulty On rounds, he is disorganized and has difficulty participating in discussions. participating in discussions. –– However, if you ask him specific questions, he However, if you ask him specific questions, he

answers them correctly. answers them correctly.

Concerned that he may have missed some Concerned that he may have missed some information on rounds, you review his to do list.information on rounds, you review his to do list.–– He has only written down about half of the He has only written down about half of the

necessary tasks, and is unable to tell you which necessary tasks, and is unable to tell you which of the previously mentioned tasks are missing. of the previously mentioned tasks are missing.

He has much difficulty signing his patient out to He has much difficulty signing his patient out to another team.another team.

It is clear that he is a hardworking and It is clear that he is a hardworking and dedicated intern and that he is trying his best. dedicated intern and that he is trying his best.

You are shocked to hear a rumor among the You are shocked to hear a rumor among the residents that he doesnresidents that he doesn’’t work well with t work well with women and doesnwomen and doesn’’t take direction from t take direction from them. them.

Nurses complain that he does not Nurses complain that he does not communication well with them. communication well with them.

How additional assessments may help How additional assessments may help differentiate and define the underlying differentiate and define the underlying problem(s)?problem(s)?

Scenario 3: RemediationScenario 3: Remediation

FollowFollow--upup

Case 3: CommunicationCase 3: Communication–– Identified late winter of intern yearIdentified late winter of intern year

Communication, Organization, Medical KnowledgeCommunication, Organization, Medical Knowledge

–– Placed on ProbationPlaced on Probation–– Remediation Team Reviewed CaseRemediation Team Reviewed Case

Regular meetings with mentorRegular meetings with mentorSpecific examples identified and exploredSpecific examples identified and exploredAreas of weakness more clearly definedAreas of weakness more clearly definedAddressed reasons for communication deficienciesAddressed reasons for communication deficiencies

FollowFollow--upup

Case 3: CommunicationCase 3: Communication–– Successful remediation on wards and Successful remediation on wards and

clinic, PGYclinic, PGY--1 completed with 2 additional 1 completed with 2 additional monthsmonths

–– Critical incident during ICU as PGYCritical incident during ICU as PGY--22Premature ClosurePremature ClosureLack of ConfidenceLack of Confidence

–– Successful remediation of ICUSuccessful remediation of ICU

Summary:Summary:

Train the evaluatorsTrain the evaluatorsUnderstand the expectations for each Understand the expectations for each skill setskill setLook for competencies Look for competencies andand deficiencies deficiencies

Summary:Summary:

Emphasize the importance ofEmphasize the importance ofidentifying the residentidentifying the resident’’s greatest deficit?s greatest deficit?

–– Where should we concentrate our efforts Where should we concentrate our efforts –– Remediation of which problem will give the best Remediation of which problem will give the best

yieldyield

Early communication with the program Early communication with the program director, if deficiencies presentdirector, if deficiencies present

Summary:Summary:

How to best document or convey How to best document or convey strengths and weaknessesstrengths and weaknesses–– Correlating numeric score with commentsCorrelating numeric score with comments–– Consider changing size of rating scale to Consider changing size of rating scale to

5 points5 points–– Anticipated distribution of scoresAnticipated distribution of scores–– Provide percentile among peersProvide percentile among peers

SummarySummary

Challenge of struggling residents exist in all Challenge of struggling residents exist in all residency programsresidency programs

Our current evaluation system does not always Our current evaluation system does not always identify residents in need of remediationidentify residents in need of remediation

Identifying and helping residents with learner Identifying and helping residents with learner difficulty is both a challenge and an obligationdifficulty is both a challenge and an obligation

Improvements in the evaluation system and culture Improvements in the evaluation system and culture could help with early identification and interventioncould help with early identification and intervention

SummarySummary

Helping struggling residents requires:Helping struggling residents requires:–– Early awarenessEarly awareness–– Careful diagnosisCareful diagnosis–– Diligent reportingDiligent reporting–– Individualized remediation planIndividualized remediation plan

ReferencesReferences1. 1. Dudek, NL et al. Failure to Fail: The perspectives of Clinical SDudek, NL et al. Failure to Fail: The perspectives of Clinical Supervisors. Aca upervisors. Aca

Med 2005;80:10.Med 2005;80:10.2. 2. Hughes, PH et al. Resident Physician Substance Use, By Specialty. Am J

Psychiatry 1992. 149(10): 1348-1354. 3. Packard, C. RIME competencies.3. Packard, C. RIME competencies.4. Reamy BV and Harman JH. Residents in Trouble: An In4. Reamy BV and Harman JH. Residents in Trouble: An In--depth assessment of depth assessment of

the 25yr experience of a single family medicine residency. Fam Mthe 25yr experience of a single family medicine residency. Fam Med ed 2006;38(4):2522006;38(4):252--257.257.

5. Schwind, CJ et al. Do individual attending' post rotation per5. Schwind, CJ et al. Do individual attending' post rotation performance ratings formance ratings detect residents' clinical performance deficiencies? Aca Med. 20detect residents' clinical performance deficiencies? Aca Med. 2004:79;45304:79;453--457.457.

6. Shapiro, J et al. Working with the resident in difficulty. Fa6. Shapiro, J et al. Working with the resident in difficulty. Fam Med. 1987:19:368m Med. 1987:19:368--75.75.

7. "The Problem Resident" VHS videocassette produced by ABIM; 197. "The Problem Resident" VHS videocassette produced by ABIM; 1992.92.8. Wiese, J COUGAR. Grand Rounds8. Wiese, J COUGAR. Grand Rounds9. Winter RO. Working with impaired residents: trials, tribulat9. Winter RO. Working with impaired residents: trials, tribulations, and ions, and

successes. Fam Med 2002;34(3):190successes. Fam Med 2002;34(3):190--6.6.10. Yao DC and Wright SM. A national survey of internal medicine10. Yao DC and Wright SM. A national survey of internal medicine residency residency

program directors regarding problem residents. JAMA 2000; 284;10program directors regarding problem residents. JAMA 2000; 284;109999--104.104.11. Yao DC and Wright SM. The challenge of problem residents. J11. Yao DC and Wright SM. The challenge of problem residents. J Gen Intern Gen Intern

Med 2001: 16:486Med 2001: 16:486--492.492.

Thank youThank you

……for the audience participation!for the audience participation!

approach to the resident in need of remediation -...

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