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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
172
S. M. Carek et al.
sionalism that fosters communication, teamwork, conict
resolution, and continuous improvement.
Understanding individual and environmental factors contributing to resident performance is essential to creating targeted interventions with the aim of supporting the
development of a resident into an independent, highfunctioning physician (Fig.18.1). Understanding these personal and environmental factors for resident performance is
akin to learning about the unique experiences and challenges
patients face in managing their health. There is a signicant
interplay among these variables, which can have profound
effects on a resident’s performance and, ultimately, in the
care of patients.
Medical Education System
Program Setting (Academic v Community v Military v other)
Educator Values and Teaching Perspectives
Evaluative Tools
Advising and Mentorship
Educational Material and Resources
Administrative support
Faculty Supervision/Graduated autonomy
Culture of Feedback
Regulatory requirements (ACGME)
Residency programs must be able to address deciencies
in performance and create individualized learning or remediation plans that are supportive and cultivate meaningful
and sustainable changes that prepare the resident for independent practice. Unfortunately, there is no uniform system
or structure to achieve remediation. However, there are many
examples and success stories that provide insights and guidance to approach each situation that a program director may
encounter. This chapter delves into the various performance
issues that family medicine residents might encounter, providing comprehensive insights, strategies, and best practices
to mentors, supervisors, and educators to guide residents
toward improvement and success.
Healthcare System
Practice Characteristics
Workplace Culture
Facilities
Healthcare Regulations
Financial Stability
EMR Usability
Administrative Burden
Workplace Safety
Workforce Size/Availability
Specialty Access
Physician
Performance
and Learning
Individual Physician Factors
Individual Efficiency
Personal Values
Responsiveness to Feedback
Personal Characteristics (Confidence, Burnout, Perceived
Autonomy, Communication Skills)
Mental Health (Depression, Anxiety Disorders, OCD/OCPD,
PTSD)
Physical Health (Chronic Illness, Substance Use Disorder,
Disability)
Personal Support System
Financial Stability
Fig. 18.1 A summary of some of the many factors that contribute to resident performance in patient care [1]
Patient Factors
Socioeconomic Status
Social Determinants of Health
Cultural and Ethnic Background
Adherence and Engagement in Medical Care
Personality or Behavioral Conflicts
Personal Values
Chronic Disease Burden/Medical Complexity of Patient
Health Literacy
Communication Skills and Barriers
18 Addressing Medical Resident Performance Issues: Strategies forImprovement
173
Identifying Performance Issues
Learners commonly struggle at some point in their medical
training and residency programs. Although most family
medicine residents successfully meet the Accreditation
Council of Graduate Medical Education (ACGME) core
competency requirements for graduation, many struggle in
one (or some) of the six required competency areas: medical
knowledge, patient care, interpersonal communication skills,
practice-based learning and improvement, systems-based
practice, and professionalism. Almost 10% of family medicine residencies have residents who fail to meet the required
level of competency in one or more ACGME core competencies during their training [2]. Residents will present with a
range of performance issues, from minor deciencies to
more serious concerns, which can signicantly impact their
performance as a physician and their well-being. Given that
there will always be residents who struggle, the residency
program has a responsibility to have the necessary infrastructure in place to identify, assess, remediate, and reassess
these learners. The remediation process can be taxing for
both the resident and faculty and requires considerable time,
energy, and effort. Accommodations are often needed,
including increased supervision and communication as well
as alterations to clinical and rotational scheduling. Ultimately,
the faculty (led by the program director) has a societal obligation to help struggling residents to ensure that upon graduation they have the skills, knowledge, and attitudes to
practice medicine safely and competently.
In internal medicine, deciencies in the performance of
ACGME core competencies occur most commonly in patient
care (53%), followed by medical knowledge (47.9%) [3].
Deciencies in organization/prioritization, communication,
and professionalism are also observed, with each occurring in
more than 40% of residents dened as “in difculty.” For family medicine, professionalism is the most likely competency
identied for remediation (59.6%), followed by clinical decision-making (49.6%), teamwork and communication (43.3%),
and clinical knowledge (34.0%) [4]. These deciencies may
be observed and reported by a wide array of healthcare team
members. Most often, the supervising faculty identify areas in
need of improvement. Resident peers, nurses, nonclinical
staff, and even nondepartmental staff are often involved in the
process. Residents in difculty can also be identied through
patient complaints and adverse event reports.
The wide range of individuals who may have concerns
speaks for the importance of 360-degree evaluations and
allowing all members of a healthcare team opportunities to
provide feedback on performance. Information obtained
from 360-degree evaluations can guide feedback to residents
on their interpersonal and communication skills and may
lead to improved patient care [5]. Cultivating faculty pro-
ciency in assessment, evaluation, teaching, and mentoring is
important to the ongoing success of the training program.
Unfortunately, faculty have low condence in their ability to
conduct remediation, a problem that can be improved
through targeted faculty development [6].
Of those residents with deciencies, program directors
report that remediation was most successful for those with
issues related to medical knowledge (85.9%) and least successful for those with problems with professionalism
(48.6%). With this nding, we can project that most residents
will be successful with remediation of their deciencies;
however, attainingcertain competencies will likely present
unique challenges to overcome.
Factors that may contribute to residents in difculty include
depression, anxiety, and personality disorders, which are associated with almost a third of residents in difculty reports.
Learning disability is a factor in 6.6% of cases. Illness, substance use disorder, and divorce are all reported less than 5%
of the time. Other factors, such as a dysfunctionalsocial support system, nancial insecurity, and job dissatisfaction, are
also considerations that impact a resident’s performance and
should be considered and reviewed with the resident as the
root causes of unanticipated issues related to performance.
The Resident withProblems
The term “resident with problems” refers to a family medicine resident who experiences time-limited difculties or
challenges that impact their professional performance, wellbeing, or overall functioning within their training program.
Residents with problems may exhibit a range of issues such
as academic struggles, interpersonal conicts, unprofessional behavior, impaired clinical skills, mental health concerns, or substance abuse. Identication can be facilitated
through structured evaluations, feedback from peers and
attendings, self-assessment, and programmatic monitoring.
Multiple factors contribute to the emergence of problems
among residents, including personal stressors, burnout, lack
of coping skills, mismatch of expectations, mental health
disorders, and external pressures. Cultural, institutional, and
programmatic factors can also play a role in exacerbating or
mitigating these challenges. Residents with problems may
experience negative consequences such as compromised
patient care, decreased learning outcomes, diminished team
dynamics, and increased risk of professional misconduct.
The well-being and mental health of residents with problemsmay be signicantly affected, leading to decreased job
satisfaction and increased risk of burnout.
Early identication and intervention are crucial to address
problems and prevent further deterioration. Individualized
support plans, mentorship, counseling, and peer assistance
174
S. M. Carek et al.
programs can provide guidance and resources to residents
facing difculties. Programs should strive to create a nonpunitive environment that encourages residents to seek help
and provide opportunities for improvement. Residency programs should establish clear policies, procedures, and guidelines for addressing residents with problems, thus ensuring
fair and consistent processes.
A multidisciplinary approach involving program directors, faculty, counselors, and other healthcare professionals
can provide comprehensive support. Building a supportive
and inclusive program culture can promote early reporting,
reduce stigma, and encourage residents to seek help when
needed. Efforts to mitigate the impact of external stressors,
improve work–life balance, and enhance well-being can contribute to reducing the occurrence of problems among residents. By creating a supportive and nurturing learning
environment and providing appropriate resources, medical
education programs can help residents overcome difculties
and thrive in their professional and personal development,
ultimately beneting both their well-being and the quality of
patient care they provide.
The “Dicult Resident”
The concept of the “difcult resident” or “problem resident”has been a subject of interest and concern within medical education and training programs. This term refers to
residents who exhibit personalitytraits, behaviors, or attitudinalcharacteristics that may hinder their professional development, patient care, or overall functioning within a
healthcare team. The literature on the “difcult resident”
highlights identication, underlying causes, impacton others, and strategies for management and improvement.
Difcult residents may display behaviors such as unprofessionalism, poor communication, lack of accountability, disruptive conduct, inadequate clinical skills, or failure to meet
performance standards. This is in contrast to a resident with
problems or challenges, who presents as a learner with individualized challenges that can often be corrected with coaching or an individualized learning or remediation plan.
Table18.1 compares and contrasts the different behaviors of
the “difcult resident” and the resident with problems.
Objective evaluation tools, self-assessment, and feedback
Table 18.1 Comparing and contrasting the “difcult resident” with the resident with problems
Characteristic The “difcult resident” The resident with problems
Denition A resident whose behavior, attitude, or actions
consistently disrupt the peace, safety, or harmony of
the program and clinical learning environment
Behavior Often exhibits disruptive, aggressive, or
confrontational behavior toward faculty, staff, or
other residents
Root causes Behavioral issues may stem from personality
disorders, substance abuse, or unresolved conicts
Impact on others Can negatively impact the Well-being and safety of
other residents and staff members
Interventions Requires specialized interventions like behavior
management plans, counseling, and possibly
medication to address disruptive behaviors
Faculty interaction Often requires more intensive and frequent
interactions with faculty to manage and address
behavior issues
Social integration Tends to isolate themselves or have strained
relationships with other residents due to disruptive
behavior
Potential outcomes May face disciplinary action (probation,
remediation) or termination if disruptive behavior
cannot be effectively managed
Focus of care and treatment Emphasis is on behavior modication and conict
resolution
Facility resources Requires signicant allocation of resources for
managing the resident’s behavior and safety
concerns
Long-term outlook The long-term prognosis may be uncertain, and it
may be challenging to achieve lasting behavior
change
A resident who faces challenges or issues during their
resident training, such as medical conditions, social
difculties, or emotional struggles
May exhibit problematic behaviors but generally does
not disrupt the overall environment
Problems are primarily related to health conditions,
learning disabilities, family issues, or emotional
struggles
May require additional support and resources but
typically does not harm others intentionally
Needs appropriate medical treatment, therapy, or
social services to address their specic issues or
conditions
May require regular monitoring and support from
staff but not necessarily extensive interventions
May face social challenges but can still engage in
positive social interactions with peers
Can achieve improvement in health, emotional
Well-being, or social functioning with appropriate
support and intervention
Focuses on addressing the underlying health,
emotional, or social issues that impact learning
Requires resources for medical care, therapy, and
social support
With appropriate treatment and support, there may be
opportunities for long-term improvement and
stability
18 Addressing Medical Resident Performance Issues: Strategies forImprovement
175
from peers, attendings, nurses, staff, and patients are often
used to identify these residents.
Multiple factors can contribute to problematic behaviors,
including personal stressors, burnout, mismatch of expectations, inadequate communication skills, mental health issues,
and external pressures. Individual and institutional factors,
such as personality traits, learning styles, and program culture, can inuence the emergence of problematic behaviors.
These residents can impact team morale, patient safety, and
learning environments, affecting the overall quality of medical education and patient outcomes.
Persistent negative behaviors may undermine teamwork,
hinder effective communication, and erode trust among
healthcare professionals. Early identication and intervention are essential to address problem behaviors and prevent
escalation. Structured feedback, performance improvement
plans, mentorship, close monitoring, and regular feedback
can guide residents toward recognizing and addressing their
deciencies. Examples of other remediation strategies
include communication skills training, professionalism
workshops, and counseling services.
In severe cases, formalized and structured remediation
processes, probation, or dismissal may be necessary to maintain patient safety and program standards. Residency programs should have clear policies and procedures in place to
address difcult residents, thus ensuring fairness, consistency,
and due process while limiting bias. Ultimately, cultivating a
supportive learning environment, promoting open communication, and providing opportunities for feedback can help prevent the emergence of problematic behaviors. Identifying and
collaborating with a “difcult resident” underscores the
importance of early identication, effective intervention, and
programmatic support to address problematic behaviors
among medical residents. By addressing these challenges,
medical education programs can foster a culture of professionalism, collaboration, and patient-centered care, ultimately
beneting both residents and the patients they serve.
Interpersonal Conict Among Residents
work styles, cultural backgrounds, or values. Contributing
factors include stress, long working hours, high-pressure
environments, and hierarchical structures. Interpersonal
conict can negatively affect team dynamics, collaboration,
and patient care. Resident morale, job satisfaction, and
well- being may be compromised, potentially leading to
burnout and reduced quality of patient care. Interpersonal
conicts can have implications for patient care, potentially
leading to miscommunication, errors, and compromised
teamwork.
Open communication and active listening are crucial for
addressing interpersonal conicts among residents. Other
conict resolution strategies may include early intervention,
facilitated discussions, mediation, and the establishment of
clear expectations for communication and teamwork. Teambuilding exercises, communication skills workshops, and
conict resolution training can help residents develop the
skills needed to navigate conicts effectively. These interventions can promote a culture of mutual respect, understanding, and collaboration.
Program leadership plays a key role in creating an environment that encourages open communication, having difcult conversations when needed, promotes psychological
safety, and addresses conicts promptly and constructively. Offering resources such as mentorship, counseling
services, clearing sessions, and wellness programs can
support residents in managing conicts and promoting
well-being.
Prolonged or unresolved conicts can contribute to stress,
emotional exhaustion, and decreased job satisfaction among
residents. Addressing conicts proactively can enhance residents’ psychological well-being and engagement.
Interpersonal conict with medical residents underscores the
importance of effective communication, conict resolution
skills, and programmatic support in addressing and preventing conicts. By promoting a culture of collaboration, open
communication, and mutual respect, residency programs can
mitigate the negative impact of interpersonal conict on resident well-being, team dynamics, and patient care.
Interpersonal conict among medical residents is another
common and signicant issue within medical education and
training programs. This conict can arise from a variety of
sources, including differences in communication styles, personality clashes, competing priorities, or misunderstandings.
The literature on interpersonal conict with medical residents addresses various aspects, including causes, consequences, resolution strategies, and the impact on resident
well-being and patient care.
Interpersonal conict among family medicine residents
may stem from differences in communication preferences,
A Framework forIdentifying Areas
ofResident Diculty
Whether a resident is labeled a “resident with problems” or a
“problem resident” (or a “difcult resident”),identifying a
root etiology or cause of these behaviors or problems is
important to correctly identify and remediate the issue. Like
addressing an undifferentiated patient, a differential diagnosis based on available evaluation information and conversations with a learner can be made and tested with the hope of
improving performance.
176
S. M. Carek et al.
The Overlap Between Clinical Performance
andMental Health Concerns
While a resident may present with decits in multiple
domains, it is important to determine whether a common
unifying root problem is present. Primary, underlying issues
related to mental health and well-being, psychosocial stressors, emotional distress, or substance use need to be ruled out
and addressed if present. Treatment and interventions
focused on these conditions should be a priority and planned
in collaboration with the resident. Often, these are manifested through sudden or inconsistent changes in performance. Residents may have progressed as expected, or even
excelled in performance, but may suddenly deteriorate or
deviate in their performance; this points to an acute stressor
that has greatly impacted the resident’s ability to function.
There may often be physical manifestations: Does the resident appear tired? Is their appearance disheveled? Has personal hygiene deteriorated? Are they unintentionally losing
weight? Do they appear withdrawn, at, anxious, or sad?
While issues related to underlying learning disabilities
are typically persistent and may be identied early in a resident’s medical career, several reasons why they have not
been addressed by a medical or behavioral professional may
be present. Often, lack of time, inadequate nances, or fear
of stigma exist and lead a resident to avoid addressing the
underlying learning disabilities.
When addressing changes in performance, one should
rst look beyond the behavior and meet with the resident to
discuss their physical and mental health, life circumstances,
coping skills, personality, and assessment of self. A safe and
neutral environment that is separate from the clinical environment and that involves individuals that are not directly
overseeing decisions on promotion or remediation should
be used to provide an unbiased space. A peer or another
physician or a mental health physician could add insights
into the resident’s current state. Programs should consider
having struggling residents undergo an assessment for mental health conditions, regardless of the behavior, or at least
offer it to residents to explore the root causes of their
struggles.
Program directors should consider remaining separate
from the evaluation, remediation plan, and monitoring of a
resident’s problems given their responsibilities to both the
learner and the program. Advisors or mentors are the people
who can provide direct guidance and partner with the resident through their remediation plan. The program director’s
responsibilities should be to provide clear expectations for
performance, lay out a timeline for expectations and consequences if those expectations are not met, document concerns, and organize reassessment after remediation is
concluded to assess the effectiveness of the intervention.
Core Competencies ofResident Performance
As previously stated, the ACGME has a standard assessment
list of six competencies that all physicians are required to
demonstrate prior to graduating from residency and in the
context of their specialty. Additional assessment frameworks
to utilize in conjunction with these competencies are specialty-focused milestones and entrustable professional activities, which are tailored to the needed skill set and behaviors
of a successful physician in a given eld. One should consider each of these tools when crafting a plan for performance improvement. For example, one should evaluate
whether a resident with issues of delayed documentation is a
product of poor medical knowledge or patient care (lacking
condence in pathophysiology, pharmacology, or clinical
reasoning, leading to uncertainty in documentation), professionalism (inability to adhere to deadlines or prioritize tasks),
or other domains in varying capacities. Ultimately, through
review of evaluations, direct observation, and conversations
with the resident and faculty, a few theories or hypotheses
should emerge as the likely root cause. Some residents will
have multiple decits. Having an understanding of how each
individual competency may present is important when identifying and crafting remediation plans that aim to support
and help a resident.
Medical Knowledge
Often, medical knowledge may be the most apparent decit
and is reected in low written exam scores or poor performance on knowledge assessment during rounds or precepting. Often, a pattern of poor medical knowledge may be
apparent on a resident’s application, such as failed courses,
shelf tests, or board examinations. Underlying learning difculties, such as attention-decit/hyperactivity disorder
(ADHD) or dyslexia, may be present and signicantly contribute to the problem. Poor study habits, or an inability to
appropriately retain information that is reviewed when
studying, are also commonly noted. Often, residents are
aware of these issues but may be shy or ashamed to discuss
with their peers or faculty.
Patient Care
Patient care represents a broad category of behaviors with a
variety of factors that can lead to poor performance. Dr.
Jeannette Guerrasio in Remediation of the Struggling
Medical Learner separates this category into clinical skills,
clinical reasoning and judgment, and time management and
organization [7]. Following this structure, residents with
decits present in the following manner:
1. Typically, poor clinical skills are directly observed as
having poor physical exam skills, an inability to correctly
18 Addressing Medical Resident Performance Issues: Strategies forImprovement
177
identify normal or abnormal presentations, and poor procedural/surgical skills.
2. Poor clinical reasoning and judgment may deliver
patient presentation with extraneous information, may
have difculty in prioritizing a differential diagnosis, or
may be unable to individualize treatment plans and
instead rely heavily on general guidelines or observed
practice patterns of other physicians.
3. Those that struggle with time management and organi-
zational skills are often unprepared for deadlines or
rounds or may submit late or disorganized documentation
or presentations.
Interpersonal Skills/Communication
Decits in interpersonal skills are particularly challenging for
faculty to directly identify. Careful communication or evaluations from clinical staff or residents can often reveal residents
struggling with interpersonal skills. The interprofessional and
multidisciplinary team dynamics of healthcare will make this
domain apparent through 360-degree evaluations and direct
feedback about residents. They can exist in extremes: either
through delegation of all tasks or through avoidance of working with the team by assuming all responsibilities. While this
inappropriate delegation can sometimes appear unprofessional, their behavior is likely a product of long-standing
challenges with socialization or team interactions or an
underlying personality disorder, learning disability, or previous experience that has perpetuated these behaviors.
Communication also falls into this category. Unlike some
of the issues seen with patient care, such as disorganized
notes or reasoning, residents who struggle with communication can appropriately gather and organize information but
are unable to apply the same to the patient and clinical setting. Presentations are often poorly articulated, and conversations with patients lack uidity. The resident may have an
underlying speech impediment or a noticeable accent that is
challenging for others to understand. English may be a second language for the affected resident, and, as such, they do
not necessarily have the condence or experience to communicate in a tone or dialect that is familiar to the community or region in which they work. They may also not
understand idioms, slang, or patients with heavy local or
regional accents.
Professionalism
Professionalism is an all-inclusive domain that can be challenging to directly assess but can have broad-reaching implications for patient safety, quality of care, and interpersonal
relationships. While a lack of consensus denition exists,
professionalism can be considered as any behavior, characteristic, or action that engenders trust between physicians,
patients, and co-workers or medicine and society.
A few conceptual models can help frame behaviors and
traits that embody professionalism. The rst is virtue, which
includes the characteristics of accountability, integrity, and
ethical and legal understanding. The second is behaviorbased, the professional skills that can be objectively dened
and assessed as well as monitored as outcomes over time.
These tend to be behaviors that the ACGME captures in their
core competencies. The nal is professional identity formation. Professional identity is developed and occurs in stages
that are sequential and build upon one another.
Regarding patient safety and care, residents who are
unprofessional lack accountability or do not claim ownership
of their patients. They may take shortcuts in patient care,
lack thoroughness, or may be delinquent in responding to
patient messages or lab results. These activities compromise
patient care and lead to unintended problematic consequences. Actions toward staff or peers may be dishonest or
unethical, such as lying about sick time, not following residency protocols, or expecting unreasonable accommodations be made that disrupt the clinical or educational
operation of the program.
Practice-Based Learning andImprovement
Decits in practice-based learning and improvement are
often due to an inability to accept feedback or initiate selfdirected learning. These residents may not review, or are
highly skeptical of, their evaluations and other forms of data
such as in-training examination (ITE) scores, individual
quality data, or patient satisfaction surveys. The learner may
not understand their limitations nor do they seek feedback or
assistance when needed. They make the effort to research a
clinical question but will often not follow through with presenting the needed information or maydelegate the task to
another resident. They lack the insight to develop a learning
plan or address underlying knowledge decits.
Systems-Based Practice
Residents with decits in systems-based practice often struggle to understand their specic role within the medical team.
They struggle, or ignore, the available resources or staff that
can contribute toward patient care in a meaningful way. A
lack of knowledge about the specic roles or skills of the
members of a multidisciplinary team or an inability to organize the specic needs of patients in their care plan is present. These residents may also lack the knowledge about or
insights into the cost of care and may order unnecessary
tests,radiographic images,or medications that are not part of
a typical treatment algorithm, or unnecessarily refer to subspecialty colleagues for consultation. They may lack insights
into the importance of transitions of care or hand- offs and
omit critical information that could lead to an adverse outcome in patient care.
178
S. M. Carek et al.
Remediation
Remediation is an important component of resident education. In medical education, it is the “act of facilitating a correction for trainees who started out on the journey toward
becoming a physician but have moved off course” [8]. It can
be described in three steps: identication of deciencies in a
learners’ performance, attempt to provide remedial education to that learner, and reassessment to determine the impact
of that education [9]. There are no formal remediation standards or guidelines. Remediation processes can vary across
and within specialties, mainly due to inconsistencies in
remediation denitions and procedures [10]. The identication of residents requiring remediation early in their training
is important for several reasons: benet to the resident and
the clinical care they deliver, allowing time for proper evaluation and implementation of a plan, and ensuring that a resident unable to provide care independently is not able to
obtain medical licensure.
The Clinical Competency Committee (CCC) is designed
to make recommendations to the program director on promotion, remediation, probation, and dismissal based on the
committee’s consensus decision of trainee performance as
well as proposed learning or remediation plans. Programs
should invest in training faculty members regarding the process of determining resident competence. Individual programs have latitude in recommending remediation
plans.Fortunately, a signicant majority (77–90%) of residents demonstrating difculty successfully remediate [11,
12], and most complete remediation within 12 months of
being placed on a remediation plan[13].
It can be overwhelming to determine where to start with a
remediation plan, particularly if the learner has deciencies
in multiple domains or competencies. An initial goal of
remediation is to target and address the greatest decit. This
strategy allows for a focused approach to a problem, with a
plan for incremental improvements and trust that the learner
will gain condence and skill mastery through the process.
Once one decit is improved, the others may improve simultaneously or spontaneously without targeted intervention.
For example, for residents with poor time management and
clinical reasoning skills, focusing on improving their clinical
reasoning and decision-making will likely also improve their
time management skills if indecisiveness or uncertainty was
the root cause of their deciency.
Factors such as substance abuse, mental health, or issues
with well-being must be prioritized as they likely contribute
to poor performance in multiple domains as well as components in their personal or professional lives. Additionally,
understanding the resident’s own willingness and drive to
participate in a remediation plan is important. The best plans
are those for which the resident has provided input and has
the drive to succeed. If a resident resists, denies, or refuses
participation, their motives for doing so need to be explored
or a discussion initiated with a third party or human resources
to determine the appropriate course of action to be taken.
Developing aRemediation Plan
A team-based approach should be utilized when developing
a remediation plan. The team may include the program director, faculty members who have worked closely with the resident, the resident’s advisor, faculty with experience in the
remediation process, and, most importantly, the resident
involved. Involvement of the resident is essential to creating
an individualized plan and getting buy-in from the learner.
Collaborating with residents to outline actionable steps for
improvement and timelines for progress can also provide
insight into the learner’s level of understanding of their difculties as well as additional perspectives on how to effectively remediate. Frequent, accurate, and direct feedback,
which includes self-assessment at timely intervals that
focuses directly on the goals of remediation, is essential.
Deliberate practice involves repeated performance of a skill,
followed by external and internal feedback to improve one’s
ability to master that skill. Feedback from faculty and selfassessment to drive new action plans or strategies for
improvement of the skill needing remediation are required.
Through more experience and exposure of a skill, the resident will be able to deliberately improve upon their weaknesses. Intentional and regular feedback from observers can
drive improvement or reinforce desired behaviors.
Medical Knowledge
Medical knowledge is often a straightforward competency to
remediate, assuming that the resident is motivated and
invested in improving. Ample resources such as journals, test
question banks, podcasts, and review courses are available to
aid the resident. Troubleshooting prior barriers to studying
and associated poor patterns of learning may be needed.
Review of prior performance on standardized tests can help
identify specic topics or domains in which the resident has
struggled.
The remediation team should meet with the resident and
understand their root problem(s) or seek an explanation for
their learning decit. Additionally, the passive methods of
learning that may have brought success in their college or
medical school may have not translated to their residency
career. In this case, a plan to incorporate more active learning
18 Addressing Medical Resident Performance Issues: Strategies forImprovement
179
or learning through direct patient care or review of patient
cases should be considered.
Patient Care
Remediation of patient care, broken down by clinical skills,
clinical reasoning and judgment, and time management and
organization, may also be amenable to fairly rapid remediation. This competency often involves more resources and
hands-on teaching with faculty to remediate. Much like medical knowledge, many available resources such as textbooks,
on-linemodules, courses, and patient care simulation laboratories are available.
To identify decits or gaps in clinical skills that a resident
has, such as physical examination maneuvers or procedures,
remediation through direct observation of clinical encounters (either recorded or in person) and standardized assessments (such as objective structured clinical examinations or
OSCEs) can be used. Oncea deciency is identied, assigning reading, learningmodules, and videos on physical examination skills or procedures can be recommended to help
train and develop skills as part of the remediation plan. When
the resident is reassessed, feedback on theresident’simprovement and direction regarding other areas in need of improvement should be provided. For physical examinations and
procedures, repetition is an essential element, and the resident must know how to practice and rene their skills to
achieve improvement and eventual mastery.
Clinical reasoning can be the most labor-intensive, complex and time-consuming skill to remediate. Because this
skill is slower to remediate, a perceived sense of urgency
given the need to “catch up” as well as implications related
to patient care and safety exist. Remediation for clinical reasoning can seem intimidating and laborious; however, having a standardized approach or framework is helpful to guide
residents through this process. Some clinical reasoning exercises to consider are:
1. Teaching common frameworks to make a differential
diagnosis and to know when each should be used. There
are three common frameworks: an anatomical framework
(e.g., the structures of the shoulder and the reasons for
shoulder pain), a systems approach (the bodysystems and
disease states involved in a general complaint, such as
shortness of breath), and a pathophysiological framework
(considering volume status when working up
hyponatremia).
2. Having the resident practice creating differentials based
on age, gender, race/ethnicity, and chief complaint and
considering the most common diagnoses, the most urgent
diagnosis, the most treatable diagnoses, and the occasional “zebra” diagnosis.
3. Having the resident create general “illness scripts” for
certain conditions: How would a patient with this diagnosis present? What symptoms would a patient endorse?
Which physical examination, laboratory, or imaging ndings would the resident expect to nd? What kinds of
questions should be asked to rule in or rule out certain
illnesses?
4. Having the resident create treatment plans for certain
diagnoses and prioritize the steps needed to ensure safe
patient care.
Interpersonal Skills/Communication
Role modeling, increased supervision, addressing the underlying causes, and professional coaching and development
can help manage decits in interpersonal skills and communication. When indicated, further assistance in mental
health evaluation and treatment would be strongly recommended. One remediation strategy may be to have the resident write a reection on how their specic decit in
communication or interpersonal skills may affect the workplace or patient care. Citation of specic, observed examples where the resident’s behaviors have affected their
performance or relationships with colleagues or patients is
helpful. If there is a high level of interpersonal conict, the
resident should reect on their level of anger, fatigue, burnout, or anxiety and work to “set it aside” before interacting
with others. Simulated or recorded encounters, where
observers can comment on the pace of speech, nonverbal
cues, balance of communication, and energy levels, can create enhanced self-awareness. Arranging meetings with role
models or mentors the resident has identied to discussprofessional relationships, communication strategies, andbest
practices for development of interpersonal skills, or to
review consequences of problematic behaviors that occur
both in residency and post- residency are useful activities.
Other remediation strategies include:
1. Implementing communication skills workshops or simulations to improve patient interactions, team collaboration, and interdisciplinary communication as well as to
teach residents to navigate difcult conversations, deliver
bad news, and engage in patient-centered
communication.
2. Promoting awareness and understanding of cultural differences to enhance rapport with diverse patient populations by addressing implicit biases and stereotypes that
may impact communication and patient care. This can be
180
S. M. Carek et al.
accomplished through assigned reading, on-line modules, and implicit bias.
3. Completing 360-degree evaluations with peers, clinical
staff, and patients.
Professionalism
Often, unprofessional behavior in medical school and residency is associated with subsequent disciplinary action by
a state medical board. Lapses in professionalism may be
associated withskill,decits including deciencies in medical knowledge, condence, or clinical reasoning.
Ultimately, addressing the underlying cause may lead to
improvement in performance. At times, system-level factors may contribute to unprofessional behaviors. Residents
must learn how to address their lapses in professionalism
constructively, productively, and courteously so that their
energies can focus on xing problems as opposed to being
reactive or destructive. Professional identity formation is
akey as it empowers the learner to think, act, and feel like
a physician. This typically occurs in stages with the goal of
meeting the behavioral andsocial expectations of a physician while developingpersonal values and exhibiting personal and professional growth through self-reection.
Ultimately, remediation of professionalism decits may
need to start with the recognition of basic behaviors
expected of a physician and the development of a more
mature identity and self-image.
Ways to remediate professionalism may include selfreection exercises that outline personal and social responsibilities, reecting on how professionalism throughout the
workday can facilitate or hinder patient care, or writing an
apology to someone that has been affected by theresident’s
unprofessional behavior. An outline of strict behavioral
expectationsand appropriate interpersonal boundaries such
as adherence to program requirements or social norms may
be needed. Providing examples of concerning professional
behavior and performing a root cause analysis to determine
the cause of the behavior may need to occur. Talking about
goals, perspectives, and perceptions related to the examples
and allowing the resident toself-reect and provide alternatives to their behaviors would be appropriate. If the resident
acts in an unprofessional manner to nurses or staff members,
shadowing and assisting the nurse or staff member to learn
about their specic roles may be enlightening.
Remediation of a resident physician, or any professional,
can often be incredibly challenging, as it may be difcult for
the learner to gain insight into their decits and identify key
motivators for change. It may also require meetings with the
hospital and facility administration to review the consequences of problematic behaviors at various levels of the
health care system, ranging from the residency program to
the hospital credentialing department to the state medical
board. However, this process is extremely important, and it
takes both patience and persistence to guide a resident in
their journey toward creation and demonstrationof professional identify.
Practice-Based Learning andImprovement
While this is an infrequently identied competency in need
of remediation, as well as one that faculty are less familiar
addressing, it may overlap with other competencies with
which residents struggle. Key factors for successful remediation in this domain include insight, self-awareness, and a
willingness to acknowledge one’s decits. Strategies to
remediate problems in practice-based learning and improvement may be to have the residentcomplete a self-assessment
of their strengths and weaknesses, expectations, thoughts
and perspectives about their careeras well as their perceived
willingness to accept feedback from others. Setting specic
times to offer feedback or asking the resident to create aselfdirected system for obtaining feedback should be considered. Moreover, the resident may need to be instructed
on how to ask for feedback. Focusing on specic behaviors, skills, or competencies when framing feedback may
help address identiedgaps and allow the resident to gain
insight into their performance. Self-review of charts to identify errors or decits in clinical care is another method to
address deciencies in the area.
Systems-Based Practice
For remediation, assessing the resident’s perspectives on
interprofessional and multidisciplinary teamwork, the complexity of the healthcare system, stewardship ofresources,
cost-conscious care and quality-based metrics, and how
these variables may inuence their daily work and the care
their patients perceive is important. Clearly outlining
expectations and auditing performance for common tasks,
such as completing documentation in a timely manner,
returning patient messages, and organizing patient
resources, may be other strategies to inform and improve
resident behaviors.
18 Addressing Medical Resident Performance Issues: Strategies forImprovement
181
The Suspension andProbation Process
The suspension and probation process for family medicine
residents is a multifaceted and important aspect of medical
education and training. This process involves formal actions
taken by residency programs to address concerns regarding a
resident’s performance, behavior, or professional conduct.
The literature on suspension and probation outlines various
aspectsof reasons for implementationof suspension or probation, procedures, outcomes, and its potential impact on
residents and training programs. Suspension and probation
may be initiated for a range of issues, including academic
difculties, clinical performance concerns, unprofessional
behavior, patient safety issues, or repeated violations of program policies. These actions are typically intended to provide an opportunity for residents to address deciencies,
learn from their mistakes, and work toward improvement.
Residency programs generally have established policies and
procedures for suspension and probation, outlining the
process for identifying concerns, initiating action, and communicating with the resident. The process often involves a
formal review of the resident’s performance, documentation
of concerns, meetings with the program director, and the
development of a performance improvement plan. Successful
completion of the probationary period can result in the resident’s reinstatement to full training privileges. Failure to
meet the requirements of the probationary period may lead to
further actions, including extension of the probation, remediation, or even termination from the residency program.
Programs may offer support and resources to residents on
probation, such as targeted educational interventions, mentorship, counseling, or referrals to external services.
Ultimately, the aim of any remediation plan is to facilitate
the resident’s growth, learning, and development, leading to
improved performance and professionalism.
Balancing the need for accountability with the goal of
providing a supportive environment can be challenging for
residency programs. Clear communication, due process,
and fairness are crucial to ensure that residents understand
expectations and have a chance to address concerns. The
way suspension and probation processes are handled can
signicantly impact the program’s overall culture, including
the perception of fairness, trust, and support. Establishing
an open and nonpunitive culture encourages residents to
seek help, report concerns, and actively engage in the
improvement process. The development of standardized
approaches and best practices for implementing suspension
and probation can enhance consistency across different programs. By implementing fair and transparent procedures,
offering targeted support and resources, and fostering a cul-
ture of learning and improvement, residency programs can
guide residents toward successful completion of their training while upholding high standards of professionalism and
patient care.
Dismissal/Termination ofaResident
The dismissal or termination of a medical resident is a serious and complex matter within training programs. This process involves the formal removal of a resident from their
training program due to signicant performance, behavioral,
or professional deciencies. The literature on the dismissal
or termination of medical residents addresses various
aspectsof the process, including reasons for dismissal, procedures, outcomes, ethical considerations, and potential
impact on the index resident,residentcolleagues, faculty and
staff, and the overall culture of the training program.
Dismissal may be warranted for a range of reasons, including
repeated failures to meet program requirements, serious
breaches of professionalism, clinical incompetence, patient
safety concerns, or violation of program policies. The decision to dismiss is typically made after careful consideration
and due process. Dismissal procedures vary by program, but
they generally involve a formal review of the resident’s performance, documentation of concerns, meetings with program leadership, and the establishment of a clear timeline for
the dismissal process. Transparency, due process, and adherence to program policies are critical to ensure fairness and
consistency.
Balancing the societal duty to protect patient safety with
the responsibility to support residents’ professional growth
and well-being presents ethical dilemmas. Programs must
weigh the potential impact of dismissal on a resident’s
careers and mental health against the need to maintain high
standards of patient care and professionalism. Dismissal
from a residency program can have signicant consequences
for a resident’s future career, nancial stability, and personal
well-being. It may result in delayed career progression,
reevaluation of training options, and potential barriers to
obtaining a medical license. How dismissal is handled can
impact the overall program culture, including trust, fairness,
and perceptions of support. Providing residents with access
to support resources, counseling, and opportunities for remediation can mitigate the negative impact of dismissal.
Dismissal decisions must adhere to legal guidelines and
avoid potential claims of discrimination, due process violations, or wrongful termination. Consultation with legal
experts and adherence to institutional policies are crucial to
navigate potential legal challenges.