Remediating or Terminating A Senior

Resident

Benjamin T. Jarman MD, FACS

Gundersen Lutheran Medical Foundation

La Crosse, WI

March 21, 2012

Disclosure

• I have not terminated a resident• I have designed successful and unsuccessful remediation plans for senior residents

“10% of residents take 90% of the Program Director’s time” John Potts MD

“10% of residents definitely take 90% of the Program Director’s time” Benjamin Jarman MD

Why?

• Medical knowledge• Patient care• Professionalism• Communication • Mental health • Change of interest/lifestyle concerns • Drug/alcohol abuse• Technically challenged• Failure to meet program requirements

Step back

• Tragic event – 24th/25th grade• How to predict/associated factors?

• Identify problems / DOCUMENT early

• Role for personality or learning assessments?

• Prevention?

Actions• Remediation - the correction of something

bad or defective• Repeat year• Probation – the condition of being given a

chance to redeem failures or misconduct in order to retain an academic classification

• Suspension – punishment by temporary exclusion from work

• Contract non-renewal • Termination –concluding employment

ACGME Requirements

• IR II.D: Resident Appointment• Contract must contain

• Resident responsibilities• Duration of appointment• Conditions of reappointment• Grievance procedures

ACGME Requirements

• IR II.D.4.d(1): Non-renewal of contract• Provision of written notice 4 months prior to end of current contract

• Resident must be permitted to implement grievance procedure

Documentation

• Essential

Gundersen LutheranInstitutional Plan

• Written letter to resident from CPC• List deficiency, resources, plan• Resident option to address with CPC

• Determination of ongoing deficiency• Direct meeting with CPC/resident• Resident response (<3 days)• CPC recommendation

• CPC = Clinical Practice Committee

Gundersen LutheranInstitutional Plan

• Resident response (3 days)• Submit written resignation• Agree with recommendations• Request formal review by DME/GMEC

• Review panel• Meet with resident, CPC, record review

• Formal decision (30 days)

Remediation

RemediationResources

• Clinical Performance Committee (CPC)• Employee assistance program:

• Free • Provide professional, confidential assistance• Address personal and/or work related issues• Conduit for additional services

• Human resources department • Professional counselors • Teaching faculty• Residency coordinator

RemediationPerformance Improvement Plan (PIP)

• Focused plan with endpoints• Define the issue(s) – competency based• Goals for improvement • Action plan with defined interval (3-6 months)

• Ownership – Establish a mentor(s)• Monitoring • Follow up

Remediation(PIP)

• Ramifications/next steps• Completion of PIP• Ongoing remediation • Probation/suspension• Decision to resign• Termination

• Meet with Human Resources and resident

• Resident and program director sign the document

Remediation(PIP)

• Things to consider while PIP ongoing:• Keep faculty engaged • Frequent evaluations/feedback• Keep the resident engaged• Be quick to comment on accomplishments and challenges

• Respond to rumors, word on the street

Resident 1 – Dr. IndecisionProblem• Filled PGY II vacancy with prelim.

resident • Technically behind peers• Problem: difficulty making definitive

intraoperative decisions, trying to appease different attendings’ practice patterns rather than developing independent approach - paralyzing

• Now 4 months until graduation

Dr. Indecision Action plan

• Required lab practice• Encouraged to perform all operations (no

teaching cases) • Altered training for terminal 3 months and

mandated at least 3 months additional training• Contacted ACGME and ABS• One on one mentorship with dedicated

teaching faculty for 4-6 week intervals – focus of establishing operative plan/expectations and completing all aspects of care plan

• Significant improvement• Developed independent style• Improved progress of operations• Deemed able to graduate after additional training• Successful general surgery practice 3 years later• Reasons for success; engaged individual and early

acceptance that additional training would be needed

• To do different; earlier plan of action/alter training earlier in experience

Dr. Indecision Result

Resident 2: Dr. MeanProblem• Filled PGY II vacancy with prelim. resident • Issues:

• Professionalism• Disrespectful• Did not work well with women• Protected himself – dumped on other residents

• Technically/clinically sound• All issues became more evident when in

leadership roles during the PGY IV year

Dr. MeanPlan• Complicating factors

• Transition of program leadership • Inadequate documentation of “events”

• Action plan• Series of meetings/sit downs• Made it clear that graduation was not a given• Established with Employee assistance plan• Strongly recommended professional evaluation• Provided resources – educated about

perceptions

Dr. MeanResult• Improved behavior with on time graduation• Avoidance of some staff• Successful in practice – private/solo• What to do better?

• Better compliance with institutional plan• Avoid hiring / Anticipate challenges• Documentation• Less tolerance with better action plan

Probation

• Similar format as PIP• More dire ramifications with

termination being more likely• May restrict clinical duties or those

related to areas of deficiency• Permanent record

TerminationReasons• Failure of action plans to remediate

clinical or academic performance• Moonlighting• Substance abuse• Theft (skills lab/OR/Hospital)• Injuring patients/peers

Termination Process• Must have written protocol• Must keep up with documentation• Must consult with legal

department/human resources

Conclusions

• Tough situations• High stakes with significant

implications• Identify and manage problems early• Rely on CPC• Rely on written policies

Thank you

Remediating the Competencies• Medical Knowledge

• Reading plan• Establish mentor• Regular testing• Assess learning ability

Remediating the Competencies• Patient care

• Mock oral exams• Establish mentor• Written tests• Alter supervision• Mandate increased communication with regard to decision making

Remediating the Competencies• Practice based learning/improvement• Require evidence based reviews• Establish learning goals• Witness resident education of patients

Remediating the Competencies• Professionalism

• “we own the perceptions we create” talk

• Variety of books• Social media education• Gender/race/culure dynamics education

Remediating the Competencies• Interpersonal skills

• Mandate documentation review• Coding review• Directly monitor resident with patient with feedback

Remediating the Competencies• System based practice

• Assign to inter-professional teams• Assign to systems improvement projects

Remediating the Competencies• Technical

• Use skills lab• Assure getting into OR• Frame future practice• Mandate preoperative discussion• Provide immediate feedback

RemediationPIP• Success?

• Based on testing• Based on clinical or technical evaluations

• Based on peer/staff evaluations• Document improvement/progress

• Failure?• Next steps…….