Resident Remediation A Case Management Approach modified 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 Resident Remediation Websters – “The act or process of correcting a deficit.” Resident Remediation Is it the Institutions Responsibility? Is Remediation the Institution’s Responsibility? YES. 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? NO. 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.” Resident Remediation Whose Responsibility? DIO? Chair? Program Director? Chief Residents? GMEC Resident Remediation Who, What, When, Where? WHO SHOULD BE REMEDIATED? Are There Residents that Should Not be Remediated? Severity of Offense. Should Everyone Else be Remediated? If the resident agrees to participate in remediation. WHEN TO REMEDIATE? 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 WHAT TO REMEDIATE? 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 WHERE TO REMEDIATE Within an Organized Process On Top of an Recognized/Organized Structure AN ORGANIZED STRUCTURE Maimonides Medical Center 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 Remediation is Multi-factorial Varied Causes of Remediation Evaluation/Biases of Performance The need for remediation arises from many different sources outside the resident. External events impact resident 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. 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 Three Components of Resident Performance Assessment 1) 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”) proce 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. 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. Criterionreferenced tests report how well learners are doing relative to a predetermined 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 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 Environmental Factors Affecting Resident Performance Structural Issues in the Department – Work flow, scheduling, and Leadership 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 Infighting, Role-Confusion, Morale Resource Allocation Role Diffusion Personal Factors Affecting Resident Performance Motivation/Attitude Coping Style Cognitive Style Personal History – Schemas/Transference Anxiety Idiosyncratic Environmental 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. Hierarchy of Resident Response to Remediation 1. 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 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 2. 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 3. Performance Anxiety Loop – “Under the microscope.” Promoting Effective Remediation Complimentary Approaches Institutional Interpersonal Psychosocial Promoting Effective Remediation Institutional 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 Promoting Effective Remediation Interpersonal 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 Promoting Effective Remediation Psychosocial 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 Assessing Resident Performance Take a Good History Find Sources of External Validation Avoid Biases Halo Effect Central, Lenient, Strictness Contrast Effect Helping Residents Manage Remediation MBTI Assessment Coping Style Communication Style Cognitive Style Strength-Based Approach Sources of External Validation Interdepartmental Collaboration Frequent Constructive Feedback CONSRUCTIVE FEEDBACK Is 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. CONSRUCTIVE FEEDBACK Is 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. CONSRUCTIVE FEEDBACK Is 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. CONSRUCTIVE FEEDBACK Is 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.” Cultural Factors Affecting Resident Performance Language Barriers Help-Seeking Behaviors Customs Deference 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 The End Download the post test questions and return completed post test to Dr. Sandra Oliver Post Test One 1. Which of the follow is incorrect regarding Resident Remediation? 1. 2. 3. 4. Remediation is Humanistic Remediation Produces More Effective Doctors Remediation Impacts Future Caring Remediation is only the Resident’s responsibility Post Test Two 2. Which of the follow is incorrect? 1. 2. 3. 4. 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 Post Test Three 3. 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 Post Test Four 4. Constructive Feedback includes all of the following except: 1. 2. 3. 4. Given with Care Integrates Evaluative Judgments Directly Expressed Is Clarified.