Resident Remediation A Case Management Approach modified from

1. Resident RemediationA Case Management Approachmodified from AAMC/Group on Resident Affairs Vancouver, B.C. Kathryn M. Lane, Ed.D. Vice President, Academic Affairs, Maimonides Medical Center, Brooklyn, NY Michael Bednarski, Ph.D., Consultant

2. Resident Remediation Websters – “The act or process of correcting a deficit.”

3. Resident Remediation Is it the Institutions Responsibility?

4. An Educational Process Commitment to Resident Success/Development We are Faculty/Mentors in a Teaching Institution Residents Have Different Adaptive Styles It’s Humanistic Produces More Effective Doctors Impacts Future Caring Is Remediation the Institution’s Responsibility? YES.

5. Too Expensive “They’re Adults – Should “Know Better!” Experience with Remediation – “It Doesn’t Work!” No Resources/Organized Institutional Resources “Can’t Change Character, Attitude, Motivation.” Natural Selection Theory – “Bad Apples Drop Out.” Is Remediation the Institution’s Responsibility? NO.

6. Resident Remediation Whose Responsibility? DIO? Chair? Program Director? Chief Residents? GMEC

7. Resident Remediation Who, What, When, Where?

8. Are There Residents that Should Not be Remediated? Severity of Offense. Should Everyone Else be Remediated? If the resident agrees to participate in remediation. WHO SHOULD BE REMEDIATED?

9. First Sign or Expression of Difficulty – Trust Instincts – Unaddressed issues, performance, demeanor - can become bigger problems later. Part of Formative Evaluation Process – Identify Specific Behaviors Link Performance to ACGME Competencies WHEN TO REMEDIATE?

10. Proper Assessment Evaluated by qualified professional. What is the primary problem? Etiology Vs Symptomatology Target Behaviors/Symptoms Performance Anxiety Tests, morning reports, rounds, conference. Coping Deficits. Transitional Adjustments. Work/Life Balance. Cultural Differences Communication/Cognitive Style WHAT TO REMEDIATE?

11. Within an Organized Process On Top of an Recognized/Organized Structure WHERE TO REMEDIATE

12. High Functioning, Responsive Alert System Coherent/Understood Policies and Procedures Centralized Management (Academic Affairs) Available Resources Elaborated Support Systems for Residents, Programs, and PD’s Follow-Through and Communications with Programs Case Management – Using System Resources Resident Integration/Reintegration with Structure Safe Liaison AN ORGANIZED STRUCTUREMaimonides Medical Center

13. Remediation is Multi-factorial • Varied Causes of Remediation • The need for remediation arises from many different sources outside the resident. External events impact resident performance. • Evaluation/Biases of Performance • How performance is assessed contributes to remediation determinations. • Conceptual Issues in Remediation • There exists a good deal of controversy on definitions and goals of remediation.

14. Common Causes of Remediation • Poorly Elaborated/Disseminated Policy • No formal or enforceable policy in place. • Policy inadequately communicated. • Failure to follow protocol • Performance Issues • Clinical Knowledge/Skills Deficits • Communications/Interpersonal Skills Deficits • Coping Deficits-poor help seeking skills • Mentoring/Learning Style Conflicts • Communication Style • Cognitive Style-sensing vs intuitive, thinking vs feeling, judging vs perceiving-introverted vs extraverted

15. Three Components of Resident Performance Assessment • Establishing Performance Criteria • Use consensually established criteria • Establish standards with others (including residents) • Determine aspects of performance to be evaluated • Codify-document performance criteria • Communicate criteria prior to performance • Establish understanding and compliance of criteria. • Elaborate the grievance (“disagreement”) process

16. Three Components of Resident Performance Assessment 2)Performance Evaluation • Develop objective assessment methods • Use multiple independent rates on similar established criteria-then compare • Use Resident self-ratings. • Stick to Performance criteria – Avoid narratives. • Establish and maintain records. Periodically review.

17. Three Components of Resident Performance Assessment 3) 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/Formative • Formative evaluation occurs throughout the clinical rotation and allows for revision and improvement

18. Conceptual Issues in Remediation • Correlate Faculty, Program Director Evaluations & Resident Performance • Define the Goals of Remediation • Define Who Should Participate and Who is Responsible • Evaluate the effectiveness of Remediation for Immediate and Lasting Change

19. Environmental Factors Affecting Resident Performance • Structural Issues in the Department – Work flow, scheduling, and staffing concerns that directly, negatively affect resident performance. • Process Issues in the Department – Proper flow of communications. Adequate and effective meetings. Established expectations and performance guidelines. Adequate and timely performance feedback. Peer relationships and initiatives for morale development. Effective role-modeling. • Departmental Communications/Interpersonal Skills – Naturally occurring personality differences between residents, peers, and mentors which become obstacles to resident performance • Leadership • Infighting, Role-Confusion, Morale • Resource Allocation • Role Diffusion

20. Personal Factors Affecting Resident Performance • Motivation/Attitude • Coping Style • Cognitive Style • Personal History – Schemas/Transference • Anxiety • Idiosyncratic • Environmental

21. Hierarchy of Resident Response to Remediation How Remediation is structured and presented to Residents effects outcomes. Events, interactions, quality of feedback and goals influence interpretation and response.

22. Hierarchy of Resident Response to Remediation • Corrective/Educational Experience Most Adaptive Present as opportunity for growth and learning. Provides opportunities to reassess and adjust Interpreted as constructive and developmental Incorporate Into Behavior Change

23. Hierarchy of Resident Response to Remediation • Situational Crisis Somewhat Adaptive Evokes positive and negative reactions followed by adjustment and compliance Regroup, Recover, Adapt and Comply

24. Hierarchy of Resident Response to Remediation • Blow to Self-Esteem Maladaptive Engages maladaptive coping, defenses, and erosion of performance. Backfires. Maladaptive Coping skills = Avoidance, Withdrawal, Engagement (aggression) Defenses = Denial, Rationalization, Projection Erosion of Performance • Performance Anxiety Loop – “Under the microscope.”

25. Promoting Effective RemediationComplimentary Approaches • Institutional • Interpersonal • Psychosocial

26. Promoting Effective RemediationInstitutional • Obtain Institutional Buy-In • Involve Academic Affairs, DIO. • Conducts/Manages the Remediation • Outlines/Serves Interests of All Parties • Ensure all Understand Protocol/Process • Specificity Objectives • Identify Specific/Actionable Problems • Identify Specific Interventions

27. Promoting Effective RemediationInterpersonal • Avoid/Stem Character Judgments/Diagnosing • Character Judgments – Put learners on the defensive, close down learning, increases projection • Frequent Constructive Feedback • Avoid Rumor Mill • Assess/Provide Support System

28. Promoting Effective RemediationPsychosocial Attends to the psychological needs and resources important to resident development in the remediation process • Engage Stakeholders • Ensure Understanding of: • Cause & Effect • Process • Desired Outcomes • Ramifications • Assess Emotions – Normalize Anxiety • Engage Ego – Corrective Experience • Assess Cognitive/Communication Styles

29. Assessing Resident Performance • Take a Good History • Find Sources of External Validation • Avoid Biases • Halo Effect • Central, Lenient, Strictness • Contrast Effect

30. Helping Residents Manage Remediation • MBTI Assessment • Coping Style • Communication Style • Cognitive Style • Strength-Based Approach • Sources of External Validation • Interdepartmental Collaboration • Frequent Constructive Feedback

31. CONSRUCTIVE FEEDBACKIs a Process • Given with Care: Show genuine concern, try not to insult or offend the resident. • Directly Expressed: Express feedback directly and specifically. Deal clearly with particular incidents and behavior. Do not “Tiptoe” around issues. Be direct, open, and concrete. • Expresses Feelings: Express feelings as well as issues so resident can gauge the full impact of his/her behavior. • Avoids Evaluative Judgments: Simply describe the situation as you see it, and let the person concerned make the evaluation.

32. CONSRUCTIVE FEEDBACKIs Concrete • Involves Timing: • Give when the resident is more open to it and not far removed from the particular event(s). • Do not let issues build-up and get expressed out of frustration. • Performance problems often fester due to lack of timely feedback (performance difficulties only become problematic after they have progressed too far). • Give feedback on as many occasions as possible.

33. CONSRUCTIVE FEEDBACKIs Actionable • Center on behavior that can be changed, not matters outside the resident’s control. • Suggest alternative ways of behaving. • Help him/her to think about new ways of tackling old problems.

34. CONSRUCTIVE FEEDBACKIs Clarified • Check to see if resident understands feedback • Check to see if resident can offer new approaches to problems. • Clarify that you are both “on the same page.”

35. Cultural Factors Affecting Resident Performance • Language Barriers • Help-Seeking Behaviors • Customs • Deference

36. Cases You Will Encounter • The Culturally Isolated Resident • The scapegoat • The Difficult Cognitive/Communication Style • Big picture thinker • The introverted type • The logical type • The big-hearted type • The Anxious Resident • The over-achiever • The perfectionist

37. The EndDownload the post test questions and return completed post test to Dr. Sandra Oliver

38. Post Test One • Which of the follow is incorrect regarding Resident Remediation? • Remediation is Humanistic • Remediation Produces More Effective Doctors • Remediation Impacts Future Caring • Remediation is only the Resident’s responsibility

39. Post Test Two • Which of the follow is incorrect? • All residents should be remediated. • At the first sign of difficulty residents should be remediated . • Remediation should be apart of a formative evaluation process • Resident performance should be linked to ACGME Competencies

40. Post Test Three • Components of Resident Performance Assessment include all the following except: 1. Establishing Performance Criteria 2. Performance Evaluation 3. Criteria-Based Performance Feedback 4. Norm Referencing of Resident performance

41. Post Test Four • Constructive Feedback includes all of the following except: • Given with Care • Integrates Evaluative Judgments • Directly Expressed • Is Clarified.