Preventing Resident Remediation: Part 2

Submitted by Drs. David Hile (Yale-New Haven Hospital) and Jason Bothwell (Madgan Army Medical Center)

Originally presented at CORD AA 2016


Objectives

  • PREVENT REMEDIATION! (Does anything else matter?)
  • Discuss incidence and terminology
  • Foundations of prevention
  • Suggestions for early identification
  • Development of early intervention (pre-remediation) program

 

Early Recognition

“The CORD Remediation Task Force strongly recommends early assessment of interns…”

  • Katz et al, Acad EM 2010

 

I.  Do an Initial Assessment

Survey Results:

  • 29% of programs have one
    • ½ Medical knowledge
      • Mock ITE, Rosh, NBME tests
    • ½ Milestones
      • Entire Level 1 Milestones assessment
      • Simulation cases & standardized patients

 

Initial Assessment

50-100 questions, 1st week of residency

  • Starting point of their MK
  • Early distribution of their talent
  • Sets an academic tone

Intern Sim day

  • 6-8 cases, Core EM

 

Homework Assignment

  • Welcome letter
  • Need-to-know ER drugs to memorize
    • Quiz on arrival
      • Simultaneous glimpse of MK, professionalism & PBLI

 

II.  Assess Early & Often

Assessment Tools Survey

  • 2 Questions
    • What tools are you using?
    • What are most effective in early identification?

 

Assessment Tools:  Most Used

  • Oral Boards
  • Simulation
  • Procedure log review
  • Multisource feedback
  • Observed resuscitations

 

Assessment Tools:  Most Useful

  • Video review
  • Observed resuscitation
  • CORD Airway tool
  • Multisource feedback
  • Checklist task analysis

 

Assessments – Conclusions

  • Oral boards overused?
  • 360 degree evals – popular and useful
  • Video review is useful and underutilized
  • Rosh Review – write in
  • No substitute for observation
    • SDOT on 2nd EM Block each year
    • Senior SDOT on 3rd EM Block

 

III.  Structure Leadership for Detection

Chain of Command: 1 APD per class

  • Class advisor, motivator, 1st line of defense
  • Dedicated eyes on each class
  • Breakout sessions
  • Ease of evals & CCC
  • Spreads the wealth

Consider for your CCC:

  • Dedicated faculty who “specializes” in remediation
    • Guerrasio et al, Acad Med, Feb 2014
  • Dedicated faculty champion by competency
    • Ketteler et al – J of Surg Ed, 2014

 

IV.  Rank Performance Relative to Peers

rankperformance.png

Potential benefits

  • Provides context to a raw score
  • Recognize lesser performers earlier
  • Objective documentation for remediation programs
  • Motivate the left side of the bell curve

 

V.  De-Mystify “Remediation”

  • Reactions are often very negative
  • Make “Remediation” less devastating
  • Change the expectation
  • Change the name
  • Change the tone:
    • A positive step towards improvement
      • (not a negative step towards termination)
  • Encourage self-referral

 

Early Interventions: The ‘Pre-Remediation’ Plan

Diagnostic Studies – Triggers

Current triggers used

  • ITE – 68% of programs use ITE cutoffs
  • Only 25% of programs use other cutoffs
    • Milestone data (very subjective)
    • Other subjective measures (faculty assessment, eval scores, etc.)
  • Suggested triggers for pre-remediation
    • Warning signs
      • History/physical
      • Performance changes
    • Cutoff scores
      • Quiz/tests
      • Sim
    • Standard deviations
      • Evals
      • Other performance measures

 

Treatment Plan

Timing

  • First year assessments
    • Orientation
      • Level 1 milestones generally unhelpful
        • “Recognizes abnormal vital signs”
        • “Manages a single patient amidst distractions”
        • “Places a simple interrupted suture”
  • End of first year
    • Too late?
    • Too difficult – due to multiple rotations, etc.

 

Implementation

Recommendation:

  • End of R1’s 2nd-to last (ie 3rd) EM rotation
  • Combination of assessment methods for all EM1’s
    • SDOT’s
    • Standardized sim cases
    • Oral boards
    • Evaluate in conjunction with written documentation
  • Assess for transition from Level 1 to Level 2
  • Incorporate most useful assessment methods

 

Terminology

Why sweat the semantics?

  • Less stigma
    • Easier to align goals
  • Fewer resources

“Pre-remediation”

  • Focused or Individualized Learning Plan (ILP)
  • Professional Growth Plan
  • Academic Enhancement Plan (AEP)
  • Coaching
  • Warning
    • Esp professionalism

 

Who is responsible for remediation?

  • PD: 46%
  • APD: 26%
  • Faculty Mentor: 7%
  • Dedicated Faculty: 4%
  • Other: 18%

 

Once resident is identified

“Director of Resident Mentoring”

  • Someone on the CCC
  • NOT the PD
  • May be APD if dedicated job

Define goals and duration

  • Communicate objective criteria for passing the individualized learning plan (ILP)
  • Objective goals and outcomes
  • Documentation

Form an alignment with resident (obtaining buy-in)

  • The director of resident mentoring is their advocate
  • Align goals; to help them become a physician who will elevate our specialty
  • Work together to identify the specific issues and achieve the objectives

 

Sample ILP

Core Competency: Patient Care

  • Multiple methods to help focus and improve learning
    • 100% evals
      • Multi-source feedback
    • Video tape review
    • Simulation cases
    • Observed resuscitations
    • Checklist task analysis
    • Oral boards cases

sampleilp.png

Criteria for Success

  • Outcomes
    • Objective and achievable
  • Consider avoiding “relative to peers”
  • Consider alternative scale with defined goal (ie Dreyfus):
    • Novice
    • Advanced Beginner
    • Competent
    • Proficient
    • Expert

eval.png

Take Home Points

Start residency with prevention in mind

  • Recruiting
  • Clear expectations
  • Great orientation block
  • Strong sense of community
  • Deliberate advisor system

Have a system that facilitates early recognition

  • Assess on arrival and 3rd block
  • Consistent feedback
  • Structure leadership for prevention
  • Demystify remediation

Have a committed faculty

Obtain buy-in and have plan with objective outcomes

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