Situation: PGY2 in 1-3 program is below peers for the following Milestones: PC1, PC2, PC3, PC4, PC8, ICS2. Resident is somewhat resistant to feedback and now resorts to picking individual sub-competencies on the Milestones to justify his/her own impression of his/her competency.

Background: The resident rotated with us as a medical student and everyone knew that he/she would ‘be a project’ during residency, but was felt that he/she would ‘do anything it takes’ to be successful. The resident has been near the bottom of the class during residency based on Milestone assessments, procedure numbers, and number of patients seen per shift. At the end of intern year was evaluated by the medical school’s Center for Academic Excellence to determine strategies to help the resident, etc, but somehow those evaluations were never completed (it is unclear if the CAE or the resident failed to fully complete the evaluations). Now the Clinical Competency Committee is wondering if the resident is in the correct specialty and if the resident should promote to a PGY3 in 5 months.

Assessment: Resident is behind in numerous Milestones and feels ‘under a microscope’ at all times. The resident has become defensive (not quite argumentative) and wants every evaluation documented down to sub-competency level. The resident has been proactive and now requests a Milestone-based evaluation to be completed after virtually all shifts (we view this as a positive).

Recommendation: We are in need of a Milestone-based remediation plan for PC1, PC2, PC3, PC4, PC8, ICS2. There are lots of resources that can be mobilized to effect this.

RTF Advice:

1. From the description, it sounds like the resident is struggling with basic management of patients, managing the volume, and interactions with other members of the team. Medical knowledge is not listed as a problem, so presumably the resident has the appropriate medical knowledge but is having difficulty applying it at the bedside.
2. The fact that the resident is resistant to feedback is a poor prognostic sign. It sounds like the resident is no longer willing to “do anything it takes”. The fact that the resident is now defensive will not help the remediation process. It would be very helpful to have a sit down with the resident and include someone who the resident trusts, and try to get him/her to understand that you are really on his/her side and want him/her to succeed. Regaining the resident’s trust in the process is crucial to the success of the remediation plan. If you can get the resident to “buy-in”, it will greatly increase the likelihood that the remediation will be successful.
3. We STRONGLY recommend that the resident complete the CAE assessment. This may reveal very useful information that will help you understand how the resident learns and how best to teach and remediate him/her.
4. We agree with your clinical competency committee that the resident should not be promoted to PGY-3. It seems clear that this resident will not be capable of independent practice in one year. Once a resident is in their final year, it is very difficult to hold them back from graduation. So, if he/she is promoted to PGY-3, the proverbial horse is off and running. The time for remediation is now.
5. There are many possible causes for this kind of performance by a resident. However, substance abuse and impairment must be in the differential. Try to get as sense if that is what is going on. (Maybe even ask the resident directly.) If so, the resident may benefit from referral to the Committee on Physician Health (or whatever the equivalent is in your state).
6. The PC and ICS issues are really two separate things, which means there may be a cause-and-effect. Meaning, since he/she is having difficulty and others are perceiving and/or pointing it out to him/her, he/she feels like his/her colleagues are not truly on his/her side. That may be perceived as difficulty with team interaction. The reverse may also be true. He/she may be having difficulties with interpersonal communication and this may be perceived as sub-optimal patient care. It would be helpful to try to figure out which is the cause and which is the effect. Fixing the “cause” may make the “effect” go away as well.
7. On a related note, I would focus on the patient care issues. As those improve, (and perhaps the resident develops more confidence), the multi-tasking should improve as well.
8. If a resident will not be promoted, they must be given 4 month’s notice. So, time is of the essence. Keep a close eye on the calendar.

Recommendations:

1. If not already done so, a formal remediation plan should be initiated immediately.
2. Detailed documentation should be maintained.
3. The DIO should be notified.
4. The resident should be informed that if he/she successfully completes the remediation, it will not be reported to future employers or fellowship directors.
5. A detailed remediation plan should be developed with the resident. It should clearly state the problems, the interventions planned, the expected goals, the timeline for re-assessment, and the consequences of not meeting the goals.
6. A sample remediation plan for this resident is below. You alluded to the availability of resources. One technique that may work very well is to have the resident work several shifts one-on-one with an attending (AKA “shadowing shifts”). Ideally it should be an attending who this resident trusts and respects, and someone who feels comfortable providing directed feedback and can help this resident perform at the expected level. Other suggestions are also included. Some require a lot of resources and time that may not be available. You certainly do not need to implement all of them. They are simply listed as options for you to select the best approach in this particular case.

Core Competency: Patient care

Problem: (Be specific here) The resident has been performing below expected level for stabilization, history and physical, diagnostic studies, diagnosis, and multi-tasking. This is based on documentation in the residents’ evaluations, which state……

Interventions:

1. The resident will work one-on-one with an attending physician for “X” number of shifts. The attending will provide directed feedback and assist the resident in improving his/her patient care (specify the issues).
2. The resident will spend extra time in the simulation lab. After each case, a debrief will take place in which the resident will be given directed feedback on how to improve his/her performance.
3. The resident will undergo oral-board style case review with an attending physician.

Goal: The resident will demonstrate improvement in patient care as evidenced by improved evaluations…..

Re-assessment: The resident’s performance will be re-assessed in 2 months (specify a date).

Consequences: If the resident’s performance is still deemed to be below expected level, the resident will be progressed to probation.

Core competency: Interpersonal and Communication Skills

Problem: (Be specific) The resident is not sufficiently managing the team in the emergency department.

Interventions:

1. The resident will attend a course on crucial conversations.
2. The resident will spend time in the simulation lab working with team members to provide care. The cases will focus on the importance of communication in obtaining the best outcome for the patient.
3. The resident will work one-on-one with an attending physician for “X” number of shifts. The attending will provide directed feedback and assist the resident in improving his/her team management skills (specify the issues).

Goal: The resident will demonstrate improvement in interpersonal communication skills as evidenced by improvement on multi-source evaluations….

Re-assessment: The resident will be re-assessed on his/her performance in 2 months.

Consequences: If the resident’s performance is still deemed to be below expected level, the resident will be progressed to probation.

RTF Consult Recommendations