REMEDIATION PROGRAM SUCCESSES

1. REMEDIATION PROGRAM SUCCESSES Jeannette Guerrasio, MD University of Colorado 2012

2. Disclosure Information The presenter has no disclosures.

3. Objectives • Describe the Impact of Struggling Medical Learners • Identify a Programmatic Approach to a Struggling Learner • Identification • Diagnosis • Remediation • Reflect on Program Outcomes • Plan for the Future through Lessons Learned

4. Magnitude • Medical Students • Up to 15% struggle during during the clinical years • Residents • Point prevalence in need of remediation 7-15% • Attendings • 17% of physicians were aware of and have encountered impaired or incompetent colleagues within the past 3 years Paul G, Teaching and Learning in Medicine. 2009: 21(3):254-60. Yao DC and Wright SM. JAMA 2000; 284;1099-104. DesRoches CM et al. JAMA 2010; 304(2) 187-193.

5. Time Morale Reputation Importance . Lavin, B et al. Acad Med 1998;73(9):998-1002.

6. Importance . .

7. Identification • Processes that identified struggling learners: Direct Observation Critical Incident Poor Performance Neglecting Patient Care Responsibilities Yao, DC & Wright, SM. JAMA. 2000;284:1099-1104.

8. Identifiers Formal evaluations of competencies Written examinations Clinical performance examinations Global assessments During group review or grading session

9. Identifiers Formal evaluations of competencies Written examinations Clinical performance examinations Global assessments During group review or grading session

10. Identifiers Verbal comments Reporting system for concerns Midterm clinical performance evaluations

11. Identifiers Verbal comments Reporting system for concerns Midterm clinical performance evaluations

12. Minor Lapses Behavior that is unwanted, but does notinterfere significantly with learning, the physician-patient relationship, or functioning of the health care team.

13. Major Lapses Behavior that is unwanted, and doessignificantly interfere with learning, the physician-patient relationship, or functioning of the health care team.

14. EDUCAT I ON

15. E D U C A T I O N

16. Accessing Remediation Services

17. Percentage with deficit

18. Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.

19. Competencies: • Medical Knowledge • Patient Care • Interpersonal Skills and Communication • Professionalism • Practice-Based Learning • Systems-Based Practice

20. Competencies “Plus”: • Medical Knowledge • Patient Care • Clinical Skills • Clinical Reasoning • Organization & Time Management • Interpersonal Skills and Communication • Professionalism • Practice-Based Learning • Systems-Based Practice

21. Competencies “Plus”: • Medical Knowledge • Patient Care • Clinical Skills • Clinical Reasoning • Organization & Time Management • Interpersonal Skills and Communication • Professionalism • Practice-Based Learning • Systems-Based Practice • Mental Well-being

23. Why might a reasonable person do this? Adapted from Ledford, CH How to address unprofessional behavior of faculty. Workshop UCD 2009.

24. The Data Unprofessional behavior in medical school Subsequent disciplinary action by the state medical board Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.

25. The Data Unprofessional behavior in medical school Subsequent disciplinary action by the state medical board Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.

26. Who Needs to Know?

27. Problem Identified • Make sure the learner receives the feedback as soon as possible Z-Score Assessment Relative to Standard Level of Resident By Expert Assessment Hodges B Acad Med 2001

28. Problem Identified • Documentation of the Problem • With examples • Committee Decision Making • Warning, Focused Review and Probation • When to Notifying Evaluating Faculty • Know Your Resources • Policies and Procedures

29. Remediation Strategy • The goal of remediation is to target and fixthegreatest deficit! • Choose ONE problem with the greatest return for the efforts • If mental well-being or professionalism deficiency, consider starting there!

30. Remediation • Limits: • Methods are not standardized • Paucity of data on reliable, valid, practical assessment tools • Few small, single institution studies on remediation • Lack of evidence to guide best practices in remediation

31. Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.

32. Remediation Strategy • Deliberate Practice • Receive Feedback • Reflection in Action

33. Clinical Reasoning • Deliberate Practice • Review remediation plan • Review Cases • Highlighter Method • Create a Chart Blankenburg R. et al.. PAS May 2011.

34. Clinical Reasoning • Deliberate Practice Continued • Framework for creating a ddx • Create ddx: age, gender, race/ethnicity, and cc

35. Clinical Reasoning • Deliberate Practice Continued • Collect H&P • Create a problem list and reorganize the ddx. • COMPARE AND CONTRAST! • Framework for choosing the diagnostic plan and treatment • Receiving Feedback • Re-enforce the use of resources and seniors or consultants for feedback

36. Clinical Reasoning • Reflection in Action • SNAPPS • S- summarize history and findings, • N- narrow the differential to 2-3 most likely, • A-analyze the differential by comparing and contrasting, • P-plan treatment and further work-up, • P-probe the preceptor about uncertainties and alternatives, • S-select an issue related to the care for self-directed learning. Wolpaw TM et al. Acad Med 2003;78(9):893-8.

37. Professionalism • Deliberate Practice • Review the remediation plan • Set strict behavioral guidelines, including what is not acceptable behavior • Review examples: perspectives and perceptions, and future suggestions • Have the learner identify a role model that they would like to emulate • Mental health evaluation/referral with drug testing • Receiving Feedback • Discuss academic and career consequences • Increased supervision with feedback • Reflection in Action • Insight is essential! Ask them to write.

38. Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.

39. Measuring Success • Define Success: 1. Has the individual showed significant improvement and caught up to his or her level of training in the previously deficient competency? 2. Is the improvement sustainable?

40. Reassessment • Repeat exposure • Standardized patient & simulation • Directly observed encounters • Written or web-based assessments • Chart reviews & chart-stimulated recall • Patient and procedure logs • Multisource evaluations • Arrival and Departure Times • Attendance • Attire • Responses to self-assessment

43. Let’s talk...

44. “This learner should never be a doctor” • Passed the rotation

46. Planning for the Future • Dissemination and sharing of ideas • Publish methods • Publish more specific outcomes • Reproduce at other institutions • Disseminate program

47. Summary • Challenge of struggling learners exist in all programs • IDENTIFY • DIAGNOSE • REMEDIATE with • DELIBERATE PRACTICE • FEEDBACK • REFLECTION IN ACTION • Measure and document your remediation efforts • Share your results

48. Contact Information • Jeannette.Guerrasio@ucdenver.edu • www.clinicalremediation.com