Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012

The Surgical Knowledge "Growth Curve": Predicting ABSITE Scores and Identifying "At-Risk" Residents

OBJECTIVE

Resident performance on the American Board of Surgery In-Training Examination (ABSITE) is used for evaluation of surgical knowledge and guides resident selection for institutional remediation programs. Remediation thresholds have historically been based on ABSITE percentile scores; however, this does not account for predictors that can impact a resident's exam performance. We sought to identify predictors of yearly ABSITE performance to help identify residents "at-risk" for performing below their expected growth trajectory.

DESIGN

The knowledge of the residents, as measured by standardized ABSITE scores, was modeled as a function of the corresponding postgraduate year via a linear mixed effects regression model. Additional model covariates included written USMLE-1-3 examination scores, gender, number of practice questions completed, and percentage correct of practice questions. For each resident, the predicted ABSITE standard score along with a 95% bootstrap prediction interval was obtained. Both resident-specific and population-level predictions for ABSITE standard scores were also estimated.

SETTING

The study was conducted at a single, large academic medical center (Massachusetts General Hospital, Boston, MA).

PARTICIPANTS

Six years of general surgery resident score reports at a single institution between 2014 and 2019 were deidentified and analyzed.

RESULTS

A total of 376 score reports from 130 residents were analyzed. Covariates that had a significant effect on the model included USMLE-1 score (PGY1: p = 0.013; PGY2: p = 0.007; PGY3: p = 0.011), USMLE-2 score (PGY1: p < 0.001; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p < 0.001; PGY5: p = 0.032), male gender (PGY1: p = 0.003; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p = 0.008), and number of practice questions completed (p=0.003). Five residents were identified as having "fallen off" their predicted knowledge curve, including a single resident on 2 occasions. Population prediction curves were obtained at 7 different covariate percentile levels (5%, 10%, 25%, 50%, 75%, 90%, and 95%) that could be used to plot predicted resident knowledge progress.

CONCLUSION

Performance on USMLE-1 and -2 examinations, male gender, and number of practice questions completed were positive predictors of ABSITE performance. Creating residency-wide knowledge growth curves as well as individualized predictive ABSITE performance models allows for more efficient identification of residents potentially at risk for poor ABSITE performance and structured monitoring of surgical knowledge progression.

Remediation and reassessment methods in pharmacy education: A systematic review

BACKGROUND

Colleges of pharmacy are currently required to implement a remediation program within their curricula, but no specifications are provided on the ideal methodology. While the need for successful remediation strategies continues to grow, literature describing positive or negative outcomes of different approaches is significantly lacking. The objective of this literature review was to describe and evaluate remediation methodologies in pharmacy education.

METHODS

This literature review was completed following PRISMA criteria. A search of the PubMed, Cochrane Library, Cumulative Index of Nursing and Allied Health, Academic Search Complete, PsycInfo, Scopus, and ProQuest Central databases was conducted in July 2019. Studies were included if they involved pharmacy student education and described either remediation or reassessment.

RESULTS

The evaluated studies discussed a range of course types being remediated, a large variety of remediation strategies and timeframes, and differing overall outcomes. No studies provided comparison of remediation techniques or provided details on the implementation of their chosen approaches. A consistent finding within the evaluated studies was the inclusion of prevention strategies to attempt to avoid the need for remediation preemptively. Overall outcomes for each remedial program were inconsistent and no clear patterns were evident other than an improvement in student performance following remediation.

IMPLICATIONS

Remediation strategies included course repetition, summer restudy, reassessment, and individualized plans. Outcomes varied significantly between studies, making methodology comparisons difficult. Future studies that include more detail and consistency in the reported outcomes would be beneficial to students and help clarify remediation for colleges of pharmacy.

Mental Health Conditions Among Struggling GME Learners: Results From a Single Center Remediation Program

BACKGROUND

Graduate medical education (GME) learners may struggle with clinical performance during training. A subset of these trainees has mental health conditions (MHCs).

OBJECTIVE

To characterize the MHCs that underlie poor trainee performance and their relationship to specific clinical performance deficit (CPD).

METHODS

At the University of Virginia (UVA), GME learners not meeting appropriate milestones, or who request help, have the option to self-refer or be referred to COACH (Committee on Achieving Competence Through Help). A physician remediation expert assesses the learner and identifies a primary CPD. If there is concern for an MHC, referral is made to a psychologist with expertise in working with trainees. All learners are offered remediation for the CPD. Using descriptive statistics, we tracked the prevalence of MHC and their correlation with specific CPDs.

RESULTS

Between 2016 and 2019, COACH assessed 7% (61 of 820) of GME learners at UVA. Thirty-eight percent (23 of 61) had an MHC associated with the CPD. Anxiety was the most common MHC (48%), followed by depression (17%), cognitive dysfunction (17%), adjustment disorder (13%), and other (4%). Professionalism was the most identified CPD among learners with MHCs (52%). Of remediated learners, 47% have successfully finished remediation, 21% were terminated or voluntarily left their program, and 32% are still being remediated (83% of whom are in good standing).

CONCLUSIONS

MHCs were identified in nearly 40% of struggling learners referred to a centralized remediation program. Professionalism is the most identified CPD among learners with MHCs.

Remediation Through Transformation: Applying Educational Theory to the Struggling Resident

The struggling medical resident is faced with many adaptive challenges that may require change in mindset. However, formal remediation within graduate medical education (GME) often employs overly structured technical solutions to address trainee deficiencies. These strategies may ultimately fail to result in sustained improvement. Transformative learning (TL) is an educational theory that has recently been explored as a teaching modality in health professions education. In 2013, Cranton published a three-part framework for TL. This framework, composed of the cognitive perspective, beyond rational TL, and TL for social change, has potential applications to GME remediation, specifically in helping individuals to overcome adaptive challenges. These strategies may be particularly useful within the traditionally difficult-to-remediate competencies of systems-based practice, practice-based learning and improvement, and professionalism. The authors provide a descriptive overview of each of Cranton's perspectives, introducing concrete examples drawn from the medical literature. This article will contrast current remediation strategies with those using TL theory in order to assist graduate medical educators in applying these principles to the remediation of their own struggling residents.

Seeing but not believing: Insights into the intractability of failure to fail

CONTEXT

Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee.

METHODS

Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place.

RESULTS

Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility.

CONCLUSION

Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.

Role of formative assessment in predicting academic success among GP registrars: a retrospective longitudinal study

OBJECTIVES

The James Cook University General Practice Training (JCU GPT) programme's internal formative exams were compared with the Royal Australian College of General Practitioners (RACGP) pre-entry exams to determine ability to predict final performance in the RACGP fellowship exams.

DESIGN

A retrospective longitudinal study.

SETTING

General Practice (GP) trainees enrolled between 2016 and 2019 at a Registered Training Organisation in regional Queensland, Australia.

PARTICIPANTS

376 GP trainees enrolled in the training programme.

EXPOSURE MEASURES

The pre-entry exams were Multiple-Mini Interviews (MMI), Situational Judgement Test (SJT) and Candidate Assessment and Applied Knowledge Test. The internal formative exams comprised multiple choice questions (MCQ1 and MCQ2), short answer questions, clinical skills and clinical reasoning.

PRIMARY OUTCOME MEASURE

The college exams were Applied Knowledge Test (AKT), Key Feature Problems (KFP) and Objective Structured Clinical Examination (OSCE).

RESULTS

Correlations (r), coefficients of determination (R²) and OR were used as parameters for estimating strength of relationship and precision of predictive accuracy. SJT and MMI were moderately (r=0.13 to 0.31) and MCQ1 and MCQ2 highly (r=0.37 to 0.53) correlated with all college exams (p<0.05 to p<0.01), with R² ranging from 0.070 to 0.376. MCQ1 was predictive of failure in all college exams (AKT: OR=2.32, KFP: OR=3.99; OSCE: OR=3.46); while MCQ2 predicted failure in AKT (OR=2.83) and KFP (OR=3.15).

CONCLUSION

We conclude that the internal MCQ formative exams predict performance in the RACGP fellowship exams. We propose that our formative assessment tools could be used as academic markers for early identification of potentially struggling trainees.

Amant L, Glover Takahashi S. Managing residents in difficulty within CBME residency educational systems: a scoping review

BACKGROUND

Best practices in managing residents in difficulty (RID) in the era of competency-based medical education (CBME) are not well described. This scoping review aimed to inventory the current literature and identify major themes in the articles that address or employ CBME as part of the identification and remediation of residents in difficulty.

METHODS

Articles published between 2011 to 2017 were included if they were about postgraduate medical education, RID, and offered information to inform the structure and/or processes of CBME. All three reviewers performed a primary screening, followed by a secondary screening of abstracts of the chosen articles, and then a final comprehensive sub-analysis of the 11 articles identified as using a CBME framework.

RESULTS

Of 165 articles initially identified, 92 qualified for secondary screening; the 63 remaining articles underwent full-text abstracting. Ten themes were identified from the content analysis with "identification of RID" (41%) and "defining and classifying deficiencies" (30%) being the most frequent. In the CBME article sub-analysis, the most frequent themes were: need to identify RID (64%), improving assessment tools (45%), and roles and responsibilities of players involved in remediation (27%). Almost half of the CBME articles were published in 2016-2017.

CONCLUSIONS

Although CBME programs have been implemented for many years, articles have only recently begun specifically addressing RID within a competency framework. Much work is needed to describe the sequenced progression, tailored learning experiences, and competency-focused instruction. Finally, future research should focus on the outcomes of remediation in CBME programs.

Investigating Learning Challenges from the Perspective of Nursing Students and Educators at a University in Casablanca, Morocco

Background:

Whether in an academic or clinical setting, many students often consider nursing studies to be difficult. Identifying learning challenges could help to improve the quality of the training and students’ skills.

Objective:

This study aimed to identify the main learning challenges of nursing students.

Methods:

The study utilised a two-phase mixed methods design. First, a focus group discussion with nine teachers and tutors was conducted to explore the learning challenges observed by staff. Then, based on the results, a questionnaire was developed for 54 students to explore and estimate the frequency of learning challenges perceived by them.

Results:

The data analysis confirmed 15 major learning challenges, including cognitive challenges, consisting of theoretical gaps, and challenges related to clinical reasoning, and non-cognitive procedural and behavioural challenges. Challenges related to clinical reasoning, such as the difficulty in developing care plans (100%) and choosing care actions (90.2%), remain the most frequent regardless of the level of study.

Conclusion:

Supervisors should consider students’ learning challenges when designing, developing and implementing their educational interventions.

Evaluation of Progress of an ACGME-International Accredited Residency Program in Qatar

Background: The American College of Physicians’ (ACP) Internal Medicine In-Training Examination (IM-ITE) is designed to evaluate the cognitive knowledge of residents to aid them and program directors in evaluating the training experience. Objective: To determine the impact of the curriculum reform accompanied by the Accreditation Council for Graduate Medical Education (ACGME)-I alignment and accreditation on the internal medicine residency program (IMRP) using residents’ performance in the ACP's ITE from 2008 to 2016, and where the IMRP stands in comparison to all ACGME and ACGME-I accredited programs. Methods: This is a descriptive study conducted at a hospital-based IMRP in Doha, Qatar from 2008 to 2016. The study population is 1052 residents at all levels of training in IMRP. The ACP-generated ITE results of all the United States and ACGME-I accredited programs were compared with IM-ITE results in Qatar. These results were expressed in the total program average and the ranking percentile. Results: There is a progressive improvement in resident performance in Qatar as shown by the rise in total average program score from 52% in 2008 to 72% in 2016 and the sharp rise in percentile rank from 3rd percentile in 2008 to 93rd percentile in 2016 with a dramatic increase during the period 2013 to 2014 (from 32nd percentile to 73rd percentile), which represents the period of ACGME-I accreditation. None of the factors (ethnicity, USMLE or year of residency) were statistically significant with a p value >0.05 and standard coefficient ( − 0.017–0.495). There was negligible correlation between the USMLE test scores with the residents’ ITE scores with a p value = 0.023 and a Pearson correlation r = 0.097. Conclusion: The initial ACGME-I alignment followed by the accreditation, together with whole curriculum redesign to a structured, competency-based program starting from 2008, has led to an improvement in the ITE scores in the IMRP. This was further evidenced by the lack of change in the residency entry selection criteria.

How to identify, address and report students' unprofessional behaviour in medical school

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Struggling urology trainee: a qualitative study into causes of underperformance

BACKGROUND

Urological surgical trainees who underperform are difficult to identify, manage and require significant resources in an already stretched system relying on pro bono supervisors that often have no formal training. While there are commentaries on how to manage underperforming surgical trainees, there is a lack of data detailing the complex reasons for underperformance. It is important to understand the complexities contributing to underperformance so that improved remediation plans can be developed which can better help trainees meet expectations and succeed.

METHODS

In this qualitative study, individual semi-structured interviews were conducted with key persons identified as having very high levels of background knowledge and involvement with current underperforming urological surgery trainees. Transcribed interviews were thematically analysed.

RESULTS

Ten interviews were conducted, including nine urology consultants and one educational manager. Five themes were identified: underperformance is a small but profound issue; spiral of failure; the changing trainee; lack of insight and under supported supervisors and posts.

CONCLUSION

Causes of underperformance in urology trainees are complex and multifactorial. Behavioural issues were considered the most likely cause, which are also the most challenging to remedy. However, in addition to trainee factors, causative factors related to supervision and training were identified. Addressing all of these issues is paramount if effective remediation of these trainees is to occur.

Remediating professionalism lapses in medical students and doctors: A systematic review

CONTEXT

A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors.

METHODS

Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist.

RESULTS

A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation.

CONCLUSIONS

The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Convergent Validity of a Novel Clinical Reasoning Tool in Clerkship Medical Students: Pilot Study

Medical student educators have limited tools for standardized clinical reasoning assessment. The clinical reasoning task (CRT) checklist has been shown to identify specific tasks in the diagnostic process among residents and faculty. Authors assessed a novel student think aloud protocol strategy, the CRT, compared with the validated clinical data interpretation (CDI) test in six third-year medical students. The CRT was scored by two independent reviewers (kappa = 0.88). CRT and CDI scores were strongly positively correlated (r = 0.768, p = 0.074, df = 4). CRT provides both a global assessment of clinical reasoning and specific clinical reasoning deficits.

Are workplace-based assessment methods (DOPS and Mini-CEX) effective in nursing students' clinical skills? A single-blind randomized, parallel group, controlled trial

Background: Evaluation of clinical skills is critically important for nursing students. However, the quality of evaluation tools is poor.Objectives: To evaluate the effectiveness of Direct Observation of Procedural Skills (DOPS) and Mini-Clinical Evaluation Exercise (Mini-CEX) on clinical skills of nursing students.Methods: This study was conducted among 108 senior nursing students. Mini-CEX and DOPS were utilized to evaluate clinical skills in the intervention group.Results: The mean of students' scores in all of the five procedures was significantly higher in the intervention group compared to control group.. Students' scores for the procedures significantly raised through the first stage of DOPS and Mini-CEX to the third stage.Conclusions: Utilization of DOPS and Mini-CEX for evaluation of clinical skills in nursing students effectively enhance their learning ability. Implementing of such assessment methods lead to promoting clinical skills of students which eventually help them to provide high quality care for their patients.

The Struggling Infectious Diseases Fellow: Remediation Challenges and Opportunities

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors' Committee focused the 2018 National Fellowship Program Directors' Meeting at IDWeek on "Remediation of the Struggling Fellow." Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges.

Guidelines: The dos, don'ts and don't knows of remediation in medical education

INTRODUCTION

Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies.

METHODS

Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus.

RESULTS

We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline.

CONCLUSIONS

Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

The Evolution of Resident Remedial Teaching at One Institution

Residency program directors and teaching faculty invest an enormous amount of time, energy, and resources in providing underperforming at-risk learners with remedial teaching. A remediation program was created and centralized at the University of Colorado School of Medicine in 2006 and 2012, respectively, that consolidated expertise in and resources for learner assessment and individualized teaching for struggling learners, particularly those placed on probation or receiving letters of warning (called focused review letters) from their residency programs. Since the implementation of the program, the authors have observed a decrease in the number of residents being placed on probation, and, of those on probation, more are graduating and obtaining board certification. In this Article, the authors aim to describe the development and outcomes of the program and to explore possible reasons for the improved outcomes.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review: BEME Guide No. 56

Background: Clinical teachers often struggle to report unsatisfactory trainee performance, partly because of a lack of evidence-based remediation options. Objectives: To identify interventions for undergraduate (UG) and postgraduate (PG) medical learners experiencing academic difficulties, link them to a theory-based framework and provide literature-based recommendations around their use. Methods: This systematic review searched MEDLINE, CINAHL, EMBASE, ERIC, Education Source and PsycINFO (1990-2016) combining these concepts: medical education, professional competence/difficulty and educational support. Original research/innovation reports describing intervention(s) for UG/PG medical learners with academic difficulties were included. Data extraction employed Michie's Behavior Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraisal used the Mixed Methods Appraisal Tool (MMAT). The authors synthesized extracted evidence by adapting the GRADE approach to formulate recommendations. Results: Sixty-eight articles met the inclusion criteria, most commonly addressing knowledge (66.2%), skills (53.9%) and attitudinal problems (26.2%), or learner personal issues (41.5%). The most common BCTs were Shaping knowledge, Feedback/monitoring, and Repetition/substitution. Quality appraisal was variable (MMAT 0-100%). A thematic content analysis identified 109 interventions (UG: n = 84, PG: n = 58), providing 24 strong, 48 moderate, 26 weak and 11 very weak recommendations. Conclusion: This review provides a repertoire of literature-based interventions for teaching/learning, faculty development, and research purposes.

To accept or decline academic remediation: What difference does it make?

Introduction: Academic remediation offered after failure in a knowledge-based progress-test assessment is voluntary and involves student-centered individualized support that helps students to learn most effectively for themselves. This paper explores whether accepting or declining the offer of academic remediation given to struggling students impacts their outcomes both short-term and longitudinally. Method: Data was collated from 2015-16, 2016-17, and 2017-18 and included all students offered academic remediation in the third, fourth, and fifth years of a five-year Dentistry program. Z-scores for each stage and test were calculated and centered on a triggering point; the point at which the offer of remediation was made. These students' average performance post-trigger test and longitudinal performance were analyzed. Results: While performance for both groups significantly improved for the immediate post-trigger test after academic remediation, those that accepted remediation sustained longitudinal improvements across subsequent tests compared to those that declined remediation. Discussion: Through the academic remediation support process students appear to increase their mastery of "learning to learn" and are able to implement sustainable effective learning strategies to carry with them throughout their program. Conclusion: Students who accept academic remediation maintain a more successful academic profile compared to those that do not take advantage of this.

Providing Compassionate Off-Ramps for Medical Students Is a Moral Imperative

It is highly unusual for learners to leave medical training in the United States even though some individuals' goals may change and others may not achieve expected competence. There are a number of possible reasons for this: (1) Students may feel that they have progressed too far into their careers and amassed too much debt to leave medical training; (2) students may be allowed to graduate despite marginal performance; and (3) students may have entered medical training with risk factors for poor performance that were not addressed. As stewards of the educational process, medical educators have an ethical obligation to students and the public to create off-ramps, or points along the educational continuum at which learners can reassess their goals and educators can assess competence, that allow students to leave medicine.Given the nationwide focus on physician health and wellness, the authors believe the creation of options to leave medical training without compromising one's self-esteem or incurring unmanageable debt (i.e., compassionate off-ramps) is a moral imperative. The practice of medicine should not be an exercise in survival; it should allow people to develop and thrive over the course of their careers. Offering students options to make use of the medical competencies they have accumulated in other attractive careers would enable medical educators to behave compassionately toward individual students and fulfill their societal obligation to graduate competent and committed physicians. To this end, the authors present six recommendations for consideration.

Practical Implications of Compassionate Off-Ramps for Medical Students

Attrition from medical school remains uncommon even when a medical student performs poorly, has a change in interests, or experiences an unexpected life event that alters his/her ability to succeed as a physician. In this issue, Bellini and colleagues describe the scope of this problem and make recommendations to support the implementation of compassionate off-ramps for students. These recommendations include enabling ongoing assessment of commitment to career path via a professional identity formation curriculum; implementing competency-based education and training to identify struggling learners; using career advisors and coaches who understand alternative career pathways; providing credit or credentials for competencies already achieved; requiring financial counseling and supporting debt forgiveness; and requiring schools to report on their remediation programs and handling of debt. In this Invited Commentary, the authors describe a representative student-a composite of several students they have counseled whose medical school paths have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues-who may have benefited from these recommendations. The authors elaborate on Bellini and colleagues' recommendations and describe what they think would be necessary to ensure that the recommendations effectively meet the goal of providing compassionate off-ramps for students in need. The authors describe the potential impact of the recommendations on the representative and similar students. Although this impacts a small proportion of students, the recommendations would help schools achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.

Developing a two-dimensional model of unprofessional behaviour profiles in medical students

Standardized narratives or profiles can facilitate identification of poor professional behaviour of medical students. If unprofessional behaviour is identified, educators can help the student to improve their professional performance. In an earlier study, based on opinions of frontline teachers from one institution, the authors identified three profiles of medical students' unprofessional behaviour: (1) Poor reliability, (2) Poor reliability and poor insight, and (3) Poor reliability, poor insight and poor adaptability. The distinguishing variable was Capacity for self-reflection and adaptability. The current study used Nominal Group Technique and thematic analysis to refine these findings by synthesizing experts' opinions from different medical schools, aiming to develop a model of unprofessional behaviour profiles in medical students. Thirty-one experienced faculty, purposively sampled for knowledge and experience in teaching and evaluation of professionalism, participated in five meetings at five medical schools in the Netherlands. In each group, participants generated ideas, discussed them, and independently ranked these ideas by allocating points to them. Experts suggested ten different ideas, from which the top 3 received 60% of all ranking points: (1) Reflectiveness and adaptability are two distinct distinguishing variables (25%), (2) The term reliability is too narrow to describe unprofessional behaviour (22%), and (3) Profiles are dynamic over time (12%). Incorporating these ideas yielded a model consisting of four profiles of medical students' unprofessional behaviour (accidental behaviour, struggling behaviour, gaming-the-system behaviour and disavowing behaviour) and two distinguishing variables (reflectiveness and adaptability). The findings could advance educators' insight into students' unprofessional behaviour, and provide information for future research on professionalism remediation.

A Road Map for Attending to Medical Students' Professionalism Lapses

PURPOSE

To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

METHOD

Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

RESULTS

Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

CONCLUSIONS

An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.

Effects of targeted remediation in anatomy for first year medical students

The aim of this study was to assess the effectiveness of a questionnaire to guide targeted remediation among undergraduate medical students in anatomy. Seventy-five students from a medical college in South India who failed in the first internal theory examination were administered a validated 35-item questionnaire. The total and domain specific questionnaire scores were calculated. Specific weekly interventions for each student based on the questionnaire scores were conducted by appointed academic mentors for three months prior to the second internal examination. The dependent variable was performance in the second internal examination. The students were re-administered the questionnaire after the second internal examination. The independent variables were the marks obtained in the first internal examination, domain specific and total questionnaire scores, sex, and regularity of the student in attending the remedial sessions. Inferential statistical tests used were the chi-square test, independent sample t test, paired t test, multiple regression and binomial logistic regression. Of the 75 students who underwent remediation, 54 (72%) passed in the second internal examination. The scores in the second internal examination among these students was found to be significantly higher as compared to the first internal examination. The total, subject related and study skills questionnaire score were significantly lower after remediation. Students who were irregular had a significantly lower pass rate. The multivariate analysis showed that only the first internal marks added significantly to the prediction about second internal performance. This study provides evidence to show that struggling students perceive a benefit from targeted remediation.

A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity

The relatively new term "Professional Identity Formation" (PIF) complements behavior-based and attitude-based perspectives on professionalism. Unprofessional behavior and its remediation should also be addressed from this perspective. However, a framework is needed to guide discussion and remediation of unprofessional behavior, which can encompass behavior-based, attitude-based, and identity-based perspectives on professionalism. To this end, the authors propose a multi-level professionalism framework which describes, apart from professional behavior, more levels which influence professional performance: environment, competencies, beliefs, values, identity, and mission. The different levels can provide tools for educators to address and discuss unprofessional behavior with their students in a comprehensive way. By reflecting on all the different levels of the framework, educators guard themselves against narrowing the discussion to either professional behavior or professional identity. The multi-level professionalism framework can help educators and students to gain a better understanding of the root of unprofessional behavior, and of remediation strategies that would be appropriate. For despite the recent emphasis on PIF, unprofessional behavior and its remediation will remain important issues in medical education.

The Clinical Competency Committee in Adult Cardiothoracic Anesthesiology-Perspectives From Program Directors Around the United States

The clinical competency committee offers a fellowship program a structured approach to assess the clinical performance of each trainee in a comprehensive fashion This special article examines the structure and function of this important committee in detail. Furthermore, the strategies for the optimal functioning of this committee are also discussed as a way to enhance the overall quality of the fellowship program.

Student response to reports of unprofessional behavior: assessing risk of subsequent professional problems in medical school

BACKGROUND

An early concern note (ECN) program is used by some medical schools to identify, counsel, and intervene when students exhibit unprofessional behavior. Student maturity, insight, propensity for reflection, and receptiveness to feedback have been suggested as predictors of future behavior.

OBJECTIVE

We hypothesized that (a) classifying students with a first ECN based on their response to the report would identify students at risk of repeat ECNs better than the action that prompted it and (b) receipt of multiple ECNs would identify students at risk of adverse academic events.

DESIGN

For this study, 459 ECNs were classified based on students' (1) recognition that their behavior was inappropriate and (2) acceptance of responsibility for the behavior. Student academic progress and receipt of subsequent ECNs were tracked.

RESULTS

Students who recognized their behavior was inappropriate and accepted responsibility after an initial ECN received subsequent ECNs at lower rates (14-19%) than students who disagreed with the significance of their behavior or were resistant to accepting responsibility (36-59%). Students with limited insight and adaptability appeared to be at highest risk. Seventy-one percent of students with three or more ECNs encountered adverse academic events during enrollment.

CONCLUSION

Student reactions to reports of unprofessional behavior may be useful as a tool to help assess risk of recurrent lapses. Students with diminished capacity to recognize behaviors as unprofessional or accept responsibility for them appear to be at highest risk for additional adverse academic and professionalism events while in medical school.

Long-Term Outcomes of a Simulation-Based Remediation for Residents and Faculty With Unprofessional Behavior

BACKGROUND

There are few studies describing remediation for unprofessional behavior in residents and faculty and none that assess the long-term impact of remediation.

OBJECTIVE

We implemented a simulation-based personalized remediation program for unprofessional behavior in residents and faculty and collected assessments from participants and referring supervisors.

METHODS

Residents and faculty were referred for unprofessional behaviors, including aggressive, condescending, and argumentative communication styles as well as an inability to read social cues. We had standardized patients recreate the scenarios that triggered the unprofessional behavior. After each scenario, participants reviewed a videotape of their performance, participated in guided self-reflection and feedback, and then iteratively practiced skills. In 2017, about 2 to 4 years after the intervention, we conducted structured phenomenological qualitative interviews until thematic saturation was reached. Transcripts were analyzed inductively for themes by 2 reviewers (J.G. and research assistant).

RESULTS

Requests for interviews were sent to 16 residents, 8 faculty members, and 24 supervisors, including program directors. Nine remediation participants (38%) and 19 referring supervisors (79%) were interviewed. Sixteen supervisors reported no recurrence of unprofessional behavior in participants 2 to 4 years after the intervention, and participants identified behavioral strategies to reduce unprofessional behavior. Participants and respective supervisors reported similar themes of behavior changes that resulted in improved professional interaction with others.

CONCLUSIONS

A simulation-based personalized remediation program for unprofessional behavior, where faculty and residents practice behaviors with guided feedback, can lead to sustained positive behavior change in participants.

Early predictors of summative assessment performance in general practice post-graduate training: A retrospective cohort study

BACKGROUND

Success in summative general practice (GP) training assessments is one indicator of competence for practice. Early-training factors predictive of outcomes would facilitate targeted interventions aimed at preventing candidate failures.

METHODS

We undertook a retrospective cohort study of Australian GP trainees in two training organizations over five years. Associations of pre-training and early-training predictors with summative examination scores in an Applied Knowledge Test (AKT), Key Features Paper (KFP), and Objective Structured Clinical Examination (OSCE), plus failure on any one of these, were tested via univariate and multivariable regression. Predictors were program-entry selection-score decile, pre-training-commencement multiple choice assessment (MCQA), direct observation of practice performance, and clinical supervisor reports.

RESULTS

On univariate analyses, selection decile and MCQA were associated with all outcomes except AKT. There were no associations of other predictors with any outcomes. On multivariable analysis, selection decile and MCQA performance were predictive of OSCE performance. MCQA performance was also predictive of KFP performance. On multivariable analysis, no predictors were associated with AKT performance or failing any examination.

CONCLUSIONS

Selection decile and pre-commencement MCQA performance were predictive of performance in some summative assessments. These findings could inform selection policies and targeted early interventions for trainees at most risk for exam failure.

Struggling Medical Learners: A Competency-Based Approach to Improving Performance

INTRODUCTION

Faculty must be trained to recognize, analyze, and provide feedback and resources to struggling medical learners. Training programs must be equipped to intervene when necessary with individualized remediation efforts to ensure learner success.

METHODS

This 90-minute interactive faculty development workshop provides a foundational competency-based framework for identifying and assisting the struggling medical learner. The workshop uses a mock academic promotions committee meeting addressing the case of a struggling undergraduate learner. The workshop was presented at two regional conferences, and participants completed an anonymous evaluation form containing 10 items on a 5-point Likert scale and two open-ended questions. Data were analyzed and a subgroup analysis performed using an independent t test and correlation. Qualitative data were read and coded for representative themes by two authors.

RESULTS

Fifty-five participants completed an evaluation form. The quality of the workshop was high (M = 4.5, SD = 0.6); participants agreed that the learning objectives were achieved and relevant to their educational needs (M = 4.4, SD = 0.7). A significant positive correlation existed between perceived quality and the interactive elements (.70, p < .05) as well as the intention to apply learning (.60, p < .05). Written comments revealed six themes: role-play, resources, interaction with colleagues, modeling, relevant content, and the process of learning.

DISCUSSION

The workshop's quality, relevance, and applicability were rated excellent among medical educators. Participants felt the interactive nature of the workshop was its most useful aspect, and a majority intended to apply the learning to their practice.

Simple Frameworks for Daily Work: Innovative Strategies to Coach Residents Struggling With Time Management, Organization, and Efficiency

BACKGROUND

Organization and efficiency are central to success on busy inpatient services and may be relevant to demonstrating certain milestones. Most residents adopt these skills by observing supervisors and peers. For some, this method of emulation and adaptation does not occur, with the potential for a negative effect on patient care and team morale. Information on effective strategies for remediating organization and efficiency deficits is lacking.

OBJECTIVE

We explored the major themes of organization and efficiency referred to the University of Pennsylvania Department of Medicine Early Intervention and Remediation Committee (EIRC), and developed tools for their remediation.

METHODS

Assessments of residents and fellows referred to the EIRC between July 2014 and October 2016 were reviewed for organization and efficiency deficits. Common areas were identified, and an iterative process of learner observations and expert input was used to develop remediation tools.

RESULTS

Over a 2-year period, the EIRC developed remediation plans for 4% of residents (13 of 342 total residents), and for 1 internal medicine subspecialty fellow. Organization and efficiency was the primary or secondary deficit in more than half of those assessed. Most common deficiencies involved admitting a patient efficiently, performing effective prerounding, and composing daily progress notes/presentations. Remediation tools that provided deconstruction of tasks to their most granular and reproducible components were effective in improving performance.

CONCLUSIONS

Deficits in organization and efficiency can disproportionately affect resident performance and delay milestone achievement. Many residents would benefit from detailed frameworks and assistance with new approaches to basic elements of daily work.

Untying the Gordian knot: remediation problems in medical schools that need remediation

This position paper discusses on-going academic remediation challenges within the field of medical education. More specifically, we identify three common contemporary problems and propose four recommendations to strengthen remediation efforts. Selecting or determining what type of remediation is needed for a particular student is akin to analyzing a Gordian knot with individual, institutional and systemic contributors. More emphasis, including multi-institutional projects and research funding is needed. Recommendations regarding language use and marketing of such programs are given.

Learning support interventions for Year 1 medical students: a review of the literature

CONTEXT

The journey through medical school can be challenging, especially for undergraduate medical students who must deal with a demanding curriculum, coupled with the demands of transitioning into adulthood. Despite experiencing learning challenges, most students succeed with appropriate learning support. Many medical schools offer learning support programmes, particularly in the latter years, but it has been suggested that such support could be more beneficial, especially during the initial years.

OBJECTIVES

This review explores learning support intervention programmes used to address learning challenges and deficits in the first year of medical school. Additionally, we propose a potential framework for supporting learning during the first year of medical school.

METHODS

We searched PubMed, Web of Science, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Academic Search Premier and Google Scholar using the search terms 'learning support', 'learning challenge', 'remediation', 'change', 'medical education' and 'first year'. We developed and used a review matrix to record the main elements of each article. We also coded the matrix to identify emerging themes.

RESULTS

The main themes that emerged from the study were 'intervention approaches', 'area of intervention', 'intervention strategies', 'intervention dose' and 'intervention outcomes'.

INTERVENTIONS

(i) used proactive-deficit, reactive-deficit and proactive-developmental approaches; (ii) addressed content knowledge, academic success skills, personal and professional skills and programme-related elements; (iii) utilised faculty staff-facilitated, peer-facilitated, support staff-facilitated, experiential placement, self-study and reduced-load strategies; (iv) varied in length from 5 weeks to 2 years, and (v) generally showed positive results.

CONCLUSIONS

This review has identified the main components of learning support interventions used for Year 1 medical students. Interventions, however, are generally not grounded on empirical assessment that elucidates the nature of the challenges faced by students. Future research should provide empirical understanding of the learning challenges to be addressed.

Situating Remediation: Accommodating Success and Failure in Medical Education Systems

There has been a widespread shift to competency-based medical education (CBME) in the United States and Canada. Much of the CBME discourse has focused on the successful learner, with relatively little attention paid to what happens in CBME systems when learners stumble or fail. Emerging issues, such as the well-documented problem of "failure to fail" and concerns about litigious learners, have highlighted a need for well-defined and integrated frameworks to support and guide strategic approaches to the remediation of struggling medical learners.This Perspective sets out a conceptual review of current practices and an argument for a holistic approach to remediation in the context of their parent medical education systems. The authors propose parameters for integrating remediation into CBME and describe a model based on five zones of practice along with the rules of engagement associated with each zone. The zones are "normal" curriculum, corrective action, remediation, probation, and exclusion.The authors argue that, by linking and integrating theory and practice in remediation with CBME, a more integrated systems-level response to differing degrees of learner difficulty and failure can be developed. The proposed model demonstrates how educational practice in different zones is based on different rules, roles, responsibilities, and thresholds for moving between zones. A model such as this can help medical educators and medical education leaders take a more integrated approach to learners' failures as well as their successes by being more explicit about the rules of engagement that apply in different circumstances across the competency continuum.

Exploring trainer and trainee emotional talk in narratives about workplace-based feedback processes

Emotion characterises learners' feedback experiences. While the failure-to-fail literature suggests that emotion may be important, little is known about the role of emotion for educators. Secondary analyses were therefore conducted on data exploring 110 trainers' and trainees' feedback experiences. Group and individual narrative interviews were conducted across three UK sites. We analysed 333 narratives for emotional talk using textual analysis: Linguistic Inquiry and Word Count. Furthermore, thematic framework analysis was conducted on the trainer narratives to explore aspects of feedback processes that are emotional. An additional in-depth little 'd' discourse analysis was conducted on selected trainer narratives to enable us to explore the complex relationship between the whats (reported events) and the hows (emotional talk). Trainer narratives did not differ significantly in positive or negative emotional talk from trainee narratives. By exploring the interplay of the whats and the hows, several aspects of feedback processes were identified as potentially emotional for trainers including trainers being concerned about upsetting learners and worried about patient safety. This was illustrated through numerous linguistic devices to establish emotional tone such as metaphoric talk and laughter. These findings suggest that feedback processes can be emotional for trainers. It highlights the need to better understand the 'filter' of emotion for trainers but also to better understand how emotion plays a role in feedback as a complex social process.

To fail is human: remediating remediation in medical education

INTRODUCTION

Remediating failing medical learners has traditionally been a craft activity responding to individual learner and remediator circumstances. Although there have been moves towards more systematic approaches to remediation (at least at the institutional level), these changes have tended to focus on due process and defensibility rather than on educational principles. As remediation practice evolves, there is a growing need for common theoretical and systems-based perspectives to guide this work.

METHODS

This paper steps back from the practicalities of remediation practice to take a critical systems perspective on remediation in contemporary medical education. In doing so, the authors acknowledge the complex interactions between institutional, professional, and societal forces that are both facilitators of and barriers to effective remediation practices.

RESULTS

The authors propose a model that situates remediation within the contexts of society as a whole, the medical profession, and medical education institutions. They also outline a number of recommendations to constructively align remediation principles and practices, support a continuum of remediation practices, destigmatize remediation, and develop institutional communities of practice in remediation.

DISCUSSION

Medical educators must embrace a responsible and accountable systems-level approach to remediation if they are to meet their obligations to provide a safe and effective physician workforce.

Comprehensive Assessment of Struggling Learners Referred to a Graduate Medical Education Remediation Program

BACKGROUND

Implementation of the Next Accreditation System has provided a standardized framework for identifying learners not meeting milestones, but there is as yet no corresponding framework for remediation.

OBJECTIVE

We developed a comprehensive assessment process that allows correct diagnosis of a struggling learner's deficit(s) to promote successful remediation.

METHODS

At the University of Pennsylvania, resident learners within the Department of Medicine who are not meeting milestones are referred to the Early Intervention Remediation Committee (EIRC). The EIRC, composed of 14 faculty members with expertise in remediation, uses a standardized process to assess learners' deficits. These faculty members categorize primary deficits as follows: medical knowledge, clinical reasoning, organization and efficiency, professionalism, and communication skills. The standardized process of assessment includes an analysis of the learner's file, direct communication with evaluators, an interview focused on learner perception of the problem, screening for underlying medical or psychosocial issues, and a review of systems for deficits in the 6 core competencies. Participants were surveyed after participating in this process.

RESULTS

Over a 2-year period, the EIRC assessed and developed remediation plans for 4% of learners (14 of a total 342). Following remediation and reassessment, the identified problems were satisfactorily resolved in all cases with no disciplinary action. While the process was time intensive, an average of 45 hours per learner, the majority of faculty and residents rated it as positive and beneficial.

CONCLUSIONS

This structured assessment process identifies targeted areas for remediation and adds to the tools available to Clinical Competency Committees.

A qualitative study of medical educators' perspectives on remediation: Adopting a holistic approach to struggling residents

INTRODUCTION

During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation.

METHODS

We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis.

RESULTS

Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation.

CONCLUSIONS

The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

Diagnosis and management of clinical reasoning difficulties: Part II. Clinical reasoning difficulties: Management and remediation strategies. MEDICAL TEACHER 2017;39:797-801. [PMID: 28587511 DOI: 10.1080/0142159x.2017.1331034]

Part II of this AMEE Guide provides a detailed overview of the main difficulties in clinical reasoning, including the cues to look out for in clinical supervision, the root causes of each difficulty and targeted remediation strategies. Specific challenges and issues related to the management of clinical reasoning difficulties will also be discussed.

Study Skills and Test Taking Strategies for Coaching Medical Learners Based on Identified Areas of Struggle

INTRODUCTION

Learners in high-performing contexts such as medical school and residency are presumed to have appropriate study skills to be successful. However, for those learners in academic difficulty who are identified as having weak study skills and poor test taking skills, faculty need tools to use to lead these struggling learners to academic success. In coaching learners on study skills, we frequently found that the study skills that helped them get into medical school or residency were no longer sufficient to make them successful in their new program. Given that there are multiple study strategies available, faculty coaches need mechanisms to first tease out which skills are the issue and then provide targeted strategies specific to each learner.

METHODS

In meeting with a faculty coach, learners are briefly interviewed, complete a self-assessment to explore all possible root weaknesses in their study skills, and then read strategic solutions and review with faculty how they may be implemented. This tool has been offered to 52 students, 76 residents, and 20 fellows and faculty between 2010 and 2015.

RESULTS

One hundred forty-eight individuals participated in this innovation, with more than 91% of all individuals going on to pass the exam that they had either failed or, in the case of the in-training exam, scored below the 30th percentile on.

CONCLUSION

A self-assessment tool is key to individualized insight and action plans for improving study skills. Implementation must be supported with concurrent in-person coaching.

Effect of Performance Deficiencies on Graduation and Board Certification Rates: A 10-yr Multicenter Study of Anesthesiology Residents

BACKGROUND

This multicenter, retrospective study was conducted to determine how resident performance deficiencies affect graduation and board certification.

METHODS

Primary documents pertaining to resident performance were examined over a 10-yr period at four academic anesthesiology residencies. Residents entering training between 2000 and 2009 were included, with follow-up through February 2016. Residents receiving actions by the programs' Clinical Competency Committee were categorized by the area of deficiency and compared to peers without deficiencies.

RESULTS

A total of 865 residents were studied (range: 127 to 275 per program). Of these, 215 residents received a total of 405 actions from their respective Clinical Competency Committee. Among those who received an action compared to those who did not, the proportion graduating differed (93 vs. 99%, respectively, P < 0.001), as did the proportion achieving board certification (89 vs. 99%, respectively, P < 0.001). When a single deficiency in an Essential Attribute (e.g., ethical, honest, respectful behavior; absence of impairment) was identified, the proportion graduating dropped to 55%. When more than three Accreditation Council for Graduate Medical Education Core Competencies were deficient, the proportion graduating also dropped significantly.

CONCLUSIONS

Overall graduation and board certification rates were consistently high in residents with no, or isolated, deficiencies. Residents deficient in an Essential Attribute, or multiple competencies, are at high risk of not graduating or achieving board certification. More research is needed on the effectiveness and selective deployment of remediation efforts, particularly for high-risk groups.

The Fundamentals of Resident Dismissal

Residents have the rights and responsibilities of both students and employees. Dismissal of a resident from a training program is traumatic and has lasting repercussions for the program director, the faculty, the dismissed resident, and the residency. A review of English language literature was performed using PUBMED and OVID databases, using the search terms, resident dismissal, resident termination, student dismissal, student and resident evaluation, legal aspects of education, and remediation. The references of each publication were also reviewed to identify additional appropriate citations. If the Just Cause threshold has been met, educators have the absolute discretion to evaluate academic and clinical performance. Legal opinion has stated that it is not necessary to wait until a patient is harmed to dismiss a resident. Evaluations should be standard and robust. Negative evaluations are not defamatory as the resident gave consent to be evaluated. Provided departmental and institutional polices have been followed, a resident can be dismissed without a formal hearing. Residencies are entitled to modify academic requirements and dismissal is not considered a breach of contract. Although there is anxiety regarding resident dismissal, the courts have uniformly supported faculty having this role. When indicated, failure to dismiss a resident also places the program director and the faculty at risk for educational malpractice.

Defining Uniform Processes for Remediation, Probation and Termination in Residency Training

It is important that residency programs identify trainees who progress appropriately, as well as identify residents who fail to achieve educational milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications. Informal remediation is initiated when a resident's performance is deficient in one or more of the outcomes-based milestones established by the Accreditation Council for Graduate Medical Education, but not significant enough to trigger formal remediation. Formal remediation occurs when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident's file and notification of the graduate medical education office; however, the documentation is not disclosed if the resident successfully remediates. Probation is initiated when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are significant enough to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and occurs when a resident is unsuccessful in meeting the terms of probation or if initial problems are significant enough to warrant immediate termination.

The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42

BACKGROUND

Many clinical educators feel unprepared and/or unwilling to report unsatisfactory trainee performance. This systematic review consolidates knowledge from medical, nursing, and dental literature on the experiences and perceptions of evaluators or assessors with this failure to fail phenomenon.

METHODS

We searched the English language literature in CINAHL, EMBASE, and MEDLINE from January 2005 to January 2015. Qualitative and quantitative studies were included. Following our review protocol, registered with BEME, reviewers worked in pairs to identify relevant articles. The investigators participated in thematic analysis of the qualitative data reported in these studies. Through several cycles of analysis, discussion and reflection, the team identified the barriers and enablers to failing a trainee.

RESULTS

From 5330 articles, we included 28 publications in the review. The barriers identified were (1) assessor's professional considerations, (2) assessor's personal considerations, (3) trainee related considerations, (4) unsatisfactory evaluator development and evaluation tools, (5) institutional culture and (6) consideration of available remediation for the trainee. The enablers identified were: (1) duty to patients, to society, and to the profession, (2) institutional support such as backing a failing evaluation, support from colleagues, evaluator development, and strong assessment systems, and (3) opportunities for students after failing.

DISCUSSION/CONCLUSIONS

The inhibiting and enabling factors to failing an underperforming trainee were common across the professions included in this study, across the 10 years of data, and across the educational continuum. We suggest that these results can inform efforts aimed at addressing the failure to fail problem.

Describing Failure in a Clinical Clerkship: Implications for Identification, Assessment and Remediation for Struggling Learners

BACKGROUND

In addition to training future members of the profession, medical schools perform the critical role of identifying students who are failing to meet minimum standards in core competencies.

OBJECTIVE

To better understand reasons for failure in an internal medicine clerkship.

DESIGN

A qualitative content analysis of letters describing reasons for students' failure.

PARTICIPANTS

Forty-three students (31 men) who failed the internal medicine clerkship at the University of Minnesota Medical School, 2002-2013.

APPROACH

We conducted a qualitative content analysis of the 43 letters describing reasons for students' failure. We coded critical deficiencies and mapped them to the Physician Competency Reference Set (PCRS) competency domains and classified them into two categories: conduct (unprofessional behaviors) and knowledge and skills specific to the practice of medicine. We then calculated the frequency of each critical deficiency. We statistically tested for relationships between gender and critical deficiencies in each of the competency domains.

KEY RESULTS

We coded 50 critical deficiencies with all codes mapping to a PCRS competency domain. The most frequently cited deficiencies were "insufficient knowledge" (79 % of students) and "inadequate patient presentation skills" (74 %). Students exhibited critical deficiencies in all eight competency domains, with the highest concentrations in Knowledge for Practice (98 %) and Interpersonal and Communication Skills (91 %). All students demonstrated deficiencies in multiple competencies, with 98 % having deficiencies in three or more. All 43 students demonstrated deficits in the knowledge and skills category, and 81 % had concurrent conduct issues. There were no statistically significant relationships between gender and critical deficiencies in any competency domain.

CONCLUSIONS

This study highlights both the diversity and commonality of reasons that students fail a clinical clerkship. Knowing the range of areas where students struggle, as well as the most likely areas of difficulty, may aid faculty in identifying students who are failing and in developing remediation strategies.