Resident Resident RemediationRemediation

A Case Management ApproachA Case Management Approachmodified frommodified from

AAMC/Group on Resident AAMC/Group on Resident AffairsAffairs

Vancouver, B.C.Vancouver, B.C.Kathryn M. Lane, Ed.D.Kathryn M. Lane, Ed.D.

Vice President, Academic Affairs, Vice President, Academic Affairs, Maimonides Medical Center, Maimonides Medical Center,

Brooklyn, NYBrooklyn, NYMichael Bednarski, Ph.D., Michael Bednarski, Ph.D.,

ConsultantConsultant

Resident Resident RemediationRemediationWebsters – “The act or Websters – “The act or process of correcting a process of correcting a

deficit.”deficit.”

Resident Resident RemediationRemediation

Is it the Institutions Is it the Institutions Responsibility?Responsibility?

Is Remediation the Is Remediation the Institution’s Responsibility? Institution’s Responsibility?

YES. YES. An Educational An Educational

ProcessProcess Commitment to Commitment to

Resident Resident Success/DevelopmenSuccess/Developmentt

We are We are Faculty/Mentors in a Faculty/Mentors in a Teaching InstitutionTeaching Institution

Residents Have Residents Have Different Adaptive Different Adaptive StylesStyles

It’s HumanisticIt’s Humanistic Produces More Produces More

Effective DoctorsEffective Doctors Impacts Future Impacts Future

CaringCaring

Is Remediation the Is Remediation the Institution’s Responsibility? Institution’s Responsibility?

NO. NO. Too ExpensiveToo Expensive ““They’re Adults – Should “Know Better!”They’re Adults – Should “Know Better!” Experience with Remediation – “It Experience with Remediation – “It

Doesn’t Work!”Doesn’t Work!” No Resources/Organized Institutional No Resources/Organized Institutional

ResourcesResources ““Can’t Change Character, Attitude, Can’t Change Character, Attitude,

Motivation.”Motivation.” Natural Selection Theory – “Bad Apples Natural Selection Theory – “Bad Apples

Drop Out.”Drop Out.”

Resident Resident RemediationRemediationWhose Responsibility?Whose Responsibility?

DIO?DIO?Chair?Chair?Program Director?Program Director?Chief Residents?Chief Residents?GMECGMEC

Resident Resident RemediationRemediation

Who, What, When, Where?Who, What, When, Where?

WHO SHOULD BE WHO SHOULD BE REMEDIATED?REMEDIATED?

Are There Residents that Should Not Are There Residents that Should Not be Remediated? Severity of Offense.be Remediated? Severity of Offense.

Should Everyone Else be Remediated? Should Everyone Else be Remediated? If the resident agrees to participate in If the resident agrees to participate in remediation. remediation.

WHEN TO REMEDIATE?WHEN TO REMEDIATE?

First Sign or Expression of Difficulty – First Sign or Expression of Difficulty – Trust Instincts – Unaddressed issues, Trust Instincts – Unaddressed issues, performance, demeanor - can become performance, demeanor - can become bigger problems later.bigger problems later.

Part of Formative Evaluation Process – Part of Formative Evaluation Process – Identify Specific BehaviorsIdentify Specific Behaviors

Link Performance to ACGME Link Performance to ACGME CompetenciesCompetencies

WHAT TO REMEDIATE?WHAT TO REMEDIATE? Proper AssessmentProper Assessment

Evaluated by qualified professional.Evaluated by qualified professional. What is the primary problem?What is the primary problem? Etiology Vs SymptomatologyEtiology Vs Symptomatology

Target Behaviors/SymptomsTarget Behaviors/Symptoms Performance AnxietyPerformance Anxiety

Tests, morning reports, rounds, conference.Tests, morning reports, rounds, conference. Coping Deficits.Coping Deficits. Transitional Adjustments.Transitional Adjustments. Work/Life Balance.Work/Life Balance. Cultural DifferencesCultural Differences Communication/Cognitive StyleCommunication/Cognitive Style

WHERE TO REMEDIATEWHERE TO REMEDIATE

Within an Organized ProcessWithin an Organized Process

On Top of an Recognized/Organized On Top of an Recognized/Organized StructureStructure

AN ORGANIZED AN ORGANIZED STRUCTURESTRUCTURE

Maimonides Medical CenterMaimonides Medical Center

High Functioning, Responsive Alert SystemHigh Functioning, Responsive Alert System Coherent/Understood Policies and ProceduresCoherent/Understood Policies and Procedures Centralized Management (Academic Affairs)Centralized Management (Academic Affairs) Available ResourcesAvailable Resources Elaborated Support Systems for Residents, Elaborated Support Systems for Residents,

Programs, and PD’sPrograms, and PD’s Follow-Through and Communications with Follow-Through and Communications with

ProgramsPrograms Case Management – Using System ResourcesCase Management – Using System Resources Resident Integration/Reintegration with StructureResident Integration/Reintegration with Structure Safe LiaisonSafe Liaison

Remediation is Multi-Remediation is Multi-factorialfactorial

Varied Causes of RemediationVaried Causes of Remediation The need for remediation arises from many different The need for remediation arises from many different

sources outside the resident. External events impact sources outside the resident. External events impact resident performance.resident performance.

Evaluation/Biases of PerformanceEvaluation/Biases of Performance How performance is assessed contributes to How performance is assessed contributes to

remediation determinations.remediation determinations. Conceptual Issues in RemediationConceptual Issues in Remediation

There exists a good deal of controversy on definitions There exists a good deal of controversy on definitions and goals of remediation.and goals of remediation.

Common Causes of Common Causes of RemediationRemediation

Poorly Elaborated/Disseminated PolicyPoorly Elaborated/Disseminated Policy No formal or enforceable policy in place.No formal or enforceable policy in place. Policy inadequately communicated.Policy inadequately communicated. Failure to follow protocolFailure to follow protocol

Performance IssuesPerformance Issues Clinical Knowledge/Skills DeficitsClinical Knowledge/Skills Deficits Communications/Interpersonal Skills DeficitsCommunications/Interpersonal Skills Deficits Coping Deficits-poor help seeking skillsCoping Deficits-poor help seeking skills

Mentoring/Learning Style ConflictsMentoring/Learning Style Conflicts Communication StyleCommunication Style Cognitive Style-sensing vs intuitive, thinking vs Cognitive Style-sensing vs intuitive, thinking vs

feeling, judging vs perceiving-introverted vs feeling, judging vs perceiving-introverted vs extravertedextraverted

Three Components of Three Components of Resident Performance Resident Performance

AssessmentAssessment1)1) Establishing Performance CriteriaEstablishing Performance Criteria Use consensually established criteriaUse consensually established criteria

Establish standards with others (including residents) Establish standards with others (including residents) Determine aspects of performance to be evaluated Determine aspects of performance to be evaluated

Codify-document performance criteriaCodify-document performance criteria Communicate criteria prior to performanceCommunicate criteria prior to performance Establish understanding and compliance of Establish understanding and compliance of

criteria.criteria. Elaborate the grievance (“disagreement”) Elaborate the grievance (“disagreement”)

processprocess

Three Components of Three Components of Resident Performance Resident Performance

AssessmentAssessment2)2) Performance EvaluationPerformance Evaluation Develop objective assessment methodsDevelop objective assessment methods

Use multiple independent rates on Use multiple independent rates on similar established criteria-then similar established criteria-then comparecompare

Use Resident self-ratings.Use Resident self-ratings. Stick to Performance criteria – Avoid Stick to Performance criteria – Avoid

narratives.narratives. Establish and maintain records. Establish and maintain records.

Periodically review. Periodically review.

Three Components of Three Components of Resident Performance Resident Performance

AssessmentAssessment3) Criteria-Based Performance Feedback3) Criteria-Based Performance Feedback

Criterion-referenced tests determine what learners can do and what

they know, not how they compare to others. Criterion-referenced tests

report how well learners are doing relative to a pre-determined performance level

on a specified set of educational goals or outcomes included in the curriculum.

Constructive/FormativeConstructive/Formative Formative evaluation occurs throughout the Formative evaluation occurs throughout the

clinical rotation and allows for revision and clinical rotation and allows for revision and improvementimprovement

Conceptual Issues in Conceptual Issues in RemediationRemediation

Correlate Faculty, Program Director Correlate Faculty, Program Director Evaluations & Resident PerformanceEvaluations & Resident Performance

Define the Goals of RemediationDefine the Goals of Remediation Define Who Should Participate and Define Who Should Participate and

Who is ResponsibleWho is Responsible Evaluate the effectiveness of Evaluate the effectiveness of

Remediation for Immediate and Remediation for Immediate and Lasting ChangeLasting Change

Environmental Factors Environmental Factors Affecting Resident Affecting Resident

PerformancePerformance Structural Issues in the DepartmentStructural Issues in the Department – Work flow, – Work flow,

scheduling, and staffing concerns that directly, negatively scheduling, and staffing concerns that directly, negatively affect resident performance.affect resident performance.

Process Issues in the DepartmentProcess Issues in the Department – Proper flow of – Proper flow of communications. Adequate and effective meetings. communications. Adequate and effective meetings. Established expectations and performance guidelines. Established expectations and performance guidelines. Adequate and timely performance feedback. Peer Adequate and timely performance feedback. Peer relationships and initiatives for morale development. relationships and initiatives for morale development. Effective role-modeling.Effective role-modeling.

Departmental Communications/Interpersonal SkillsDepartmental Communications/Interpersonal Skills – Naturally occurring personality differences between – Naturally occurring personality differences between residents, peers, and mentors which become obstacles to residents, peers, and mentors which become obstacles to resident performanceresident performance

LeadershipLeadership Infighting, Role-Confusion, MoraleInfighting, Role-Confusion, Morale

Resource AllocationResource Allocation Role DiffusionRole Diffusion

Personal Factors Affecting Personal Factors Affecting Resident PerformanceResident Performance

Motivation/AttitudeMotivation/Attitude Coping StyleCoping Style Cognitive StyleCognitive Style Personal History – Personal History –

Schemas/TransferenceSchemas/Transference AnxietyAnxiety

IdiosyncraticIdiosyncratic EnvironmentalEnvironmental

Hierarchy of Resident Hierarchy of Resident Response to RemediationResponse to Remediation

How Remediation is structured and How Remediation is structured and presented to Residents effects presented to Residents effects outcomes. outcomes.

Events, interactions, quality of Events, interactions, quality of feedback and goals influence feedback and goals influence interpretation and response. interpretation and response.

Hierarchy of Resident Hierarchy of Resident Response to RemediationResponse to Remediation

1.1. Corrective/Educational ExperienceCorrective/Educational ExperienceMost AdaptiveMost Adaptive Present as opportunity for growth and Present as opportunity for growth and

learning.learning.Provides opportunities to reassess and Provides opportunities to reassess and adjust adjust

Interpreted as constructive and Interpreted as constructive and developmentaldevelopmentalIncorporate Into Behavior ChangeIncorporate Into Behavior Change

Hierarchy of Resident Hierarchy of Resident Response to RemediationResponse to Remediation

2.2. Situational CrisisSituational CrisisSomewhat AdaptiveSomewhat Adaptive

Evokes positive and negative Evokes positive and negative reactions followed by adjustment reactions followed by adjustment and complianceand compliance

Regroup, Recover, Adapt and Regroup, Recover, Adapt and ComplyComply

Hierarchy of Resident Hierarchy of Resident Response to RemediationResponse to Remediation

3.3. Blow to Self-EsteemBlow to Self-EsteemMaladaptiveMaladaptive

Engages maladaptive coping, defenses, and Engages maladaptive coping, defenses, and erosion of performance. Backfires.erosion of performance. Backfires.Maladaptive Coping skillsMaladaptive Coping skills = Avoidance, = Avoidance, Withdrawal, Engagement (aggression)Withdrawal, Engagement (aggression)Defenses Defenses = Denial, Rationalization, Projection= Denial, Rationalization, ProjectionErosion of PerformanceErosion of Performance

Performance Anxiety Loop – “Under the Performance Anxiety Loop – “Under the microscope.”microscope.”

Promoting Effective Promoting Effective RemediationRemediation

Complimentary ApproachesComplimentary Approaches InstitutionalInstitutional InterpersonalInterpersonal PsychosocialPsychosocial

Promoting Effective Promoting Effective RemediationRemediationInstitutionalInstitutional

Obtain Institutional Buy-InObtain Institutional Buy-In Involve Academic Affairs, DIO.Involve Academic Affairs, DIO.

Conducts/Manages the RemediationConducts/Manages the Remediation Outlines/Serves Interests of All PartiesOutlines/Serves Interests of All Parties

Ensure all Understand Protocol/ProcessEnsure all Understand Protocol/Process Specificity Objectives

Identify Specific/Actionable Problems Identify Specific Interventions

Promoting Effective Promoting Effective RemediationRemediationInterpersonalInterpersonal

Avoid/Stem Character Avoid/Stem Character Judgments/DiagnosingJudgments/Diagnosing Character Judgments – Put learners Character Judgments – Put learners

on the defensive, close down on the defensive, close down learning, increases projectionlearning, increases projection

Frequent Constructive FeedbackFrequent Constructive Feedback Avoid Rumor MillAvoid Rumor Mill Assess/Provide Support SystemAssess/Provide Support System

Promoting Effective Promoting Effective RemediationRemediationPsychosocialPsychosocial

Attends to the psychological needs and Attends to the psychological needs and resources important to resident resources important to resident development in the remediation processdevelopment in the remediation process

Engage StakeholdersEngage Stakeholders Ensure Understanding of:Ensure Understanding of:

Cause & EffectCause & Effect ProcessProcess Desired OutcomesDesired Outcomes RamificationsRamifications

Assess Emotions – Normalize AnxietyAssess Emotions – Normalize Anxiety Engage Ego – Corrective ExperienceEngage Ego – Corrective Experience Assess Cognitive/Communication StylesAssess Cognitive/Communication Styles

Assessing Resident Assessing Resident PerformancePerformance

Take a Good HistoryTake a Good History Find Sources of External ValidationFind Sources of External Validation Avoid BiasesAvoid Biases

Halo EffectHalo Effect Central, Lenient, StrictnessCentral, Lenient, Strictness Contrast EffectContrast Effect

Helping Residents Manage Helping Residents Manage RemediationRemediation

MBTI AssessmentMBTI Assessment Coping StyleCoping Style Communication StyleCommunication Style Cognitive StyleCognitive Style

Strength-Based ApproachStrength-Based Approach Sources of External ValidationSources of External Validation Interdepartmental CollaborationInterdepartmental Collaboration Frequent Constructive FeedbackFrequent Constructive Feedback

CONSRUCTIVE FEEDBACKCONSRUCTIVE FEEDBACKIs a ProcessIs a Process

Given with CareGiven with Care:: Show genuine concern, try Show genuine concern, try not to insult or offend the resident. not to insult or offend the resident.

Directly ExpressedDirectly Expressed:: Express feedback directly Express feedback directly and specifically. Deal clearly with particular and specifically. Deal clearly with particular incidents and behavior. Do not “Tiptoe” incidents and behavior. Do not “Tiptoe” around issues. Be direct, open, and concrete.around issues. Be direct, open, and concrete.

Expresses FeelingsExpresses Feelings:: Express feelings as well Express feelings as well as issues so resident can gauge the full impact as issues so resident can gauge the full impact of his/her behavior.of his/her behavior.

Avoids Evaluative JudgmentsAvoids Evaluative Judgments:: Simply Simply describe the situation as you see it, and let the describe the situation as you see it, and let the person concerned make the evaluation.person concerned make the evaluation.

CONSRUCTIVE FEEDBACKCONSRUCTIVE FEEDBACKIs ConcreteIs Concrete

Involves TimingInvolves Timing:: Give when the resident is more open to it and Give when the resident is more open to it and

not far removed from the particular event(s). not far removed from the particular event(s). Do not let issues build-up and get expressed Do not let issues build-up and get expressed

out of frustration.out of frustration. Performance problems often fester due to Performance problems often fester due to

lack of timely feedback (performance lack of timely feedback (performance difficulties only become problematic after difficulties only become problematic after they have progressed too far). they have progressed too far).

Give feedback on as many occasions as Give feedback on as many occasions as possible.possible.

CONSRUCTIVE FEEDBACKCONSRUCTIVE FEEDBACKIs ActionableIs Actionable

Center on behavior that can be Center on behavior that can be changed, not matters outside the changed, not matters outside the resident’s control. resident’s control.

Suggest alternative ways of Suggest alternative ways of behaving. behaving.

Help him/her to think about new Help him/her to think about new ways of tackling old problems.ways of tackling old problems.

CONSRUCTIVE FEEDBACKCONSRUCTIVE FEEDBACKIs ClarifiedIs Clarified

Check to see if resident Check to see if resident understands feedback understands feedback

Check to see if resident can offer Check to see if resident can offer new approaches to problems. new approaches to problems.

Clarify that you are both “on the Clarify that you are both “on the same page.”same page.”

Cultural Factors Affecting Cultural Factors Affecting Resident PerformanceResident Performance

Language BarriersLanguage Barriers Help-Seeking BehaviorsHelp-Seeking Behaviors CustomsCustoms

DeferenceDeference

Cases You Will EncounterCases You Will Encounter The Culturally Isolated ResidentThe Culturally Isolated Resident The scapegoatThe scapegoat The Difficult Cognitive/Communication StyleThe Difficult Cognitive/Communication Style

Big picture thinkerBig picture thinker The introverted typeThe introverted type The logical typeThe logical type The big-hearted typeThe big-hearted type

The Anxious ResidentThe Anxious Resident The over-achieverThe over-achiever The perfectionistThe perfectionist

The EndThe EndDownload the post test Download the post test questions and return questions and return

completed post test to Dr. completed post test to Dr. Sandra OliverSandra Oliver

Post Test OnePost Test One1.1. Which of the follow is incorrect Which of the follow is incorrect

regarding Resident Remediation?regarding Resident Remediation?1.1. Remediation is HumanisticRemediation is Humanistic2.2. Remediation Produces More Remediation Produces More

Effective DoctorsEffective Doctors3.3. Remediation Impacts Future Remediation Impacts Future

CaringCaring4.4. Remediation is only the Resident’s Remediation is only the Resident’s

responsibilityresponsibility

Post Test TwoPost Test Two2.2. Which of the follow is incorrect?Which of the follow is incorrect?

1.1. All residents should be All residents should be remediated. remediated.

2.2. At the first sign of difficulty At the first sign of difficulty residents should be remediated . residents should be remediated .

3.3. Remediation should be apart of a Remediation should be apart of a formative evaluation process formative evaluation process

4.4. Resident performance should be Resident performance should be linked to ACGME Competencieslinked to ACGME Competencies

Post Test ThreePost Test Three3.3. Components of Resident Components of Resident

Performance Assessment include all Performance Assessment include all the following except:the following except:1. Establishing Performance Criteria1. Establishing Performance Criteria2.2. Performance Evaluation Performance Evaluation3. Criteria-Based Performance 3. Criteria-Based Performance FeedbackFeedback4. Norm Referencing of Resident 4. Norm Referencing of Resident performanceperformance

Post Test FourPost Test Four4.4. Constructive Feedback includes all Constructive Feedback includes all

of the following except:of the following except:1. Given with Care 2. Integrates Evaluative Judgments3. Directly Expressed4.4. Is Clarified. Is Clarified.