Situation: PGY2 in a 1-3 program is below peers for the following Milestones: PC1, PC2, PC4, and PC8. Resident has been in a formal remediation program for PC1, PC9, PC10, PC12, ICS1, PROF1, PROF2, and MK. Resident’s initial remediation plan included double-covered ED shifts to reduce need for multi-tasking, increased individual simulation experiences, and more direct observation.  She was also assigned 100 Ross review questions per month and a reflection piece on her communication style as compared to faculty role models. She has made some progress over the initial three months of remediation, but the patient care concerns continue.

 Assessment: The resident has made some progress in the ICS, Professional, and Medical Knowledge competencies which is encouraging as related to the potential for an overall successful remediation. While the resident is thought to be doing well with straight forward cases, she has much more difficulty dealing with complex patient care issues, especially when time-sensitive. There also appears to be documentation of resident responding to potential patient safety issues by ignoring them or focusing on other tasks. Based on the information provided the resident has not demonstrated that she is capable of caring for critically ill patients or of safely performing resuscitation procedures.

RTF Assessment:

1. From the description and identified Milestones, the resident is struggling with emergency stabilization, focused history and physical exam, diagnosis, and multi-tasking in complex patient care situations and likely still suffers from underlying medical knowledge deficiencies.
2. Given that the resident has made some progress towards successful remediation, hopefully she still trusts the process and understands the work and dedication required to be successful. If not already performed, it would helpful to have the resident identify a faculty member (distinct from the residency leadership) to be her advocate and mentor during the process. The resident must plan and complete meetings with this faculty member on a monthly basis. It should be the responsibility of the resident to arrange these meetings.
3. A formal remediation plan should be continued. It should clearly state the problems, the interventions planned, the defined requirements, the expected goals, the timeline for re-assessment, and the consequences of not meeting the goals. The resident should be informed that if she successfully completes the remediation, it will not be reported to future employers or fellowship directors if this has been decided by your program. Consequences of not successfully completing the remediation are either extension of training or non-renewal/dismissal. If the latter is a possibility (for failure to meet the educational objectives of the program), then it must be explicitly stated at this time in the remediation process and the resident must attest to understanding. The DIO and legal should be notified of this remediation plan.
4. We strongly suggest that the resident complete the CAE assessment, as it may reveal useful information about how the resident learns and the best ways to teach and remediate. An alternative would be neuro-psychiatric testing if offered by your university.
5. You mentioned that this resident is an international trainee and may not have a lot of social support. Whenever there are substantial remediation issues, substance abuse and impairment must considered. The resident may benefit from referral to the Committee on Physician Health (or equivalent in your state). An alternative would be a meeting with a resident wellness liaison if available at your institution.
6. While it’s still early in the academic year, keep in mind that if the resident will not be promoted, she must be given 4 month’s notice.

 Sample Remediation Plan: 

Core Competency: Patient Care

1. The resident will work one-on-one with an attending physician for “X” (recommend 5-10) number of shifts. The attending will observe encounters, provide directed feedback, and assist the resident in improving patient care.
2. In addition to one-on-one shifts with an attending physician, the resident may benefit from 4 hour shadow shifts with a chief resident to observe appropriate decision-making and multitasking.
3. You mentioned that the resident has already been involved in additional simulation cases, but we strongly suggest that simulation play an integral role in this resident’s remediation plan in order for her to become more familiar with dealing with time-sensitive complex cases. After each case, a debrief can take place during which the resident can receive directed feedback on performance improvement. If you have the capability to video-tape the simultation cases, it may be helpful for the resident to review her own performance as well.
4. Oral-board style cases (both single cases as well as triples) led by an attending physician are an additional opportunity for the resident to practice dealing with complicated time-sensitive cases and receive directed feedback on performance.
5. We recommend a standardized approach to all patient care interactions. While many EM residents are able to do this on a subconscious basis, this resident can develop a checklist for the critical part of all encounters (vital signs, history, physical, orders, documentation, re-evaluation, etc) in order to organize her approach to patient care until this approach becomes more natural.
6. Consider targeted elective time to areas of deficiency (ICU, pharmacy, ultrasound, anesthesia).
7. Complete follow up logs on 5 critical care, 5 general care admitted, and five discharged patients per week.
8. Whether through simulation or observation the resident will need to demonstrate continued competency in basic airway management, bag valve mask ventilation, and central venous access.

 Core competency: Medical Knowledge

1. The resident must comply with the residency conference attendance policy. A pattern of further unexcused absences will be grounds to consider termination of training.
2. Improvements in medical knowledge will continue to aid in her ability to deliver appropriate patient care. She can deliver lectures to the medical students on basic EM topics such as “The ABCs of Trauma” or “Surviving Sepsis”. She can also engage in weekly core content review with a senior/chief resident.