Consult:
R2 with a great USMLE/Clerkship grades/ITE >80% national avg but with poor bedside translation of medical knowledge. There may be a language barrier involved, and he generally has a flat affect, which has not helped with the perception from faculty and colleagues that he is behind on his fund of knowledge. He is an introvert and does not speak much on shift.
Issues that arose include faculty having a tough time engaging him although he will tell you he's having a blast in the ED. Faculty also have commented on his lack of insight or sense of grasp of emergent cases. When probed, he tends to minimize things--"she doesn't have ACS. She just doesn't look like it." On further prompting or when confronted on why he's not able to think out loud his impression, he tells you that he's thinking ahead and planning the next steps; from the faculty's perspective, he appears to just stand there and grapple with management of the case. There was an issue earlier in his intern year when he had a bad outcome, and he apparently did not get to debrief and was very tough on himself fearing contributing to another bad outcome. We've debriefed since, yet have found no improvement on his performance.
The issue now is that he has been labeled by many faculty and residents as "behind" or "should not have gone up to R2 year."
He has gotten formal feedback via medhub evaluations, his orientation and biannual meeting with comments from the CCC with his APD. The biggest issue is that he does not seem to apply the suggestions given to help him succeed in the ED--some examples include: acknowledging to the attending that he tends to be quiet and that he will work on verbalizing his thought process, presenting using the SPIT mnemonic to highlight his fund of knowledge of serious diseases and grasp on the case he's managing, summarizing the shift to get feedback on how he could improve.
He does not seem to remember the feedback from faculty, although, in his defense, faculty may not necessarily have given him direct feedback. Rather, most faculty have just discussed amongst themselves their frustration with his performance.
There was a concern for credibility from 2 faculty where he may have misspoke or misrepresented a finding. He only remembers one faculty giving him feedback, although both faculty were clear about giving him that feedback.
His notes are usually not done, yet he leaves the ED on time, and on occasion, 5-10 minutes before his shift is over. He would sign out many pending studies. Of note, he just had a baby although this problem was apparent even before this event in his life. He denies any negative events at home that is affecting his performance.
I think there is a big disconnect with what he thinks his performance is vs. how he actually performs despite discrete sit-down sessions with the APD's.
In summary, we have a book-smart resident with issues regarding application and translation of knowledge in the clinical setting affecting his H&P, Assessment, Plan, and there is a concern regarding his accountability.
RTF Assessment:
- From the description provided, the resident is struggling with translation of medical knowledge into the clinical setting that affects performance. It also seems as though he is unable to apply feedback and has issues with credibility. We have therefore identified deficiencies related to patient care, medical knowledge, and professionalism.
- You mention that the resident has had multiple feedback sessions with assistant program directors and hopefully he 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 his 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.
- A formal written remediation plan should be initiated if not done already. 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 he 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. The CORD standardized contracts for remediation are available at: https://www.cordem.org/resources/residency-management/remediation-resources/remediation-contracts/
- 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, especially in light of his reported difficulty translating medical knowledge into clinical skills.
- You mentioned that this resident recently had a baby and has a flat affect, and while the clinical issues predated fatherhood, whenever there are substantial remediation issues, substance abuse and impairment must be considered. We strongly suggest a referral to your institution’s “Employee Assistance Program”. A program can mandate this referral as a condition of continued employment, but the resident but the content of that meeting is confidential.
- Engaging faculty to help establish expectations and providing feedback for this resident in real-time will be very helpful and may secondarily lessen the faculty-faculty chatter about the resident. This can be discussed with the faculty during a closed-door faculty meeting. When the faculty realize that they have a significant role to play “saving” this resident from non-promotion/termination, they will likely be more inclined to act in a constructive fashion.
- While it’s still early in the academic year, keep in mind that programs are required to provide written notice of intent for non-promotion or non-renewal of contract. The designated time frame for such notification varies by institution.
Sample Remediation Plan:
Core Competency: Patient Care
- 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. This continuity can aid in the identification and remediation of clinical deficiencies with a consistent, “real-time” approach
- 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.
- We strongly suggest that simulation play an integral role in this resident’s remediation plan in order for him to become more familiar with dealing with time-sensitive complex cases and translating medical knowledge into clinical practice. 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 simulation cases, it may be helpful for the resident to review his own performance as well.
- 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.
- 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 his approach to patient care until this approach becomes more natural.
- Complete follow up logs on 5 critical care, 5 general care admitted, and five discharged patients per week with subsequent analysis of patient care.
Core competency: Medical Knowledge
- While the resident has scored well on the USMLE and in-training examination, improvements in medical knowledge will continue to aid in his ability to deliver appropriate patient care. He can deliver lectures to the medical students on basic EM topics such as “The ABCs of Trauma” or “Surviving Sepsis”. He can also engage in weekly core content review with a senior/chief resident and these sessions can focus on the translation of medical knowledge into its use in the clinical setting.
Core competency: Professionalism
1. Professionalism can be the most challenging core competency to remediate. It is concerning that there have been issues with credibility as well as adherence to professional standards, such as timely completion of documentation and appropriate signouts. Just as the resident may benefit from shadow shifts with a chief resident to learn about appropriate patient care, he may also benefit from a professionalism role model for period meetings and/or shadow shifts.
2. Peer accountability may also help the resident recognize appropriate professional behavior. A simple statement from those taking sign-out can reinforce this code of conduct: “We work until the end of our shift and we tie up loose ends before leaving”.
3. In addition to shadow shifts and peer accountability, the resident can be required to keep a list of all patient encounters for each shift. At the end of each shift, he can review this list with an attending or senior resident to ensure each note is complete. The resident should also be required to clock in and out of each shift. If you have a GME timekeeping swipe system, this can be helpful, otherwise the attending can serve as the time-keeper and report each shift to program leadership.
4. Assign reading of specific journal articles regarding professionalism or medical humanism books and then facilitate small group discussion or reflective writing.
5. In order to address accountability, review administrative expectations concerning documentation and signout and identify any barriers to success.
6. Perform a monthly self-assessment of documentation and identify those needing improvement. He may also benefit from reviewing the literature on acceptable documentation practices and present a didactic or participate in peer-review documentation audits.