Remediation Methods 2.0 for Professionalism and Interpersonal and Communication Skills Milestones: An Update

The Next Accreditation System implemented by the Accreditation Council for Graduate Medical Education introduced specialty-specific Milestones for the 6 core competencies in 2013.¹  Recently, a 2.0 version of the Milestones harmonized the subcompetencies across specialties, in part to encourage collaboration and sharing of assessment tools and best practices.²  Specialties created unique subcompetencies for Patient Care and Medical Knowledge, while a standardized framework was used to craft the remaining 4 competencies.²  These harmonized subcompetencies in Milestones 2.0 represent shared language, themes, and goals that are consistent across specialties, decreasing the variability seen in the first iteration.

While the Milestones provide a guide to competency expectations, residency programs across specialties still struggle with remediation—particularly related to Professionalism and Interpersonal and Communication Skills (ICS).^3,4  In 2016, Regan et al analyzed the first iteration of the Professionalism and ICS Milestones and published a toolkit of remediation methods for these core competencies.⁵  With the 2.0 version of harmonized Milestones, the opportunity to share resources and strategies for remediation of Professionalism and ICS across specialties becomes more readily feasible. The objective of this Perspective is to identify the common Milestone 2.0 themes among Professionalism and ICS subcompetencies, to create an updated compilation of remediation tools, and to provide an approach for developing a remediation plan for Professionalism and ICS.

Following the methodology of Regan et al in 2016,⁵  the authors performed a content analysis of the version 2.0 Professionalism and ICS subcompetencies for 13 core specialties: anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, ophthalmology, orthopedics, pathology, pediatrics, psychiatry, radiology, and surgery. All authors independently reviewed each specialty’s subcompetencies and identified themes. Reviewer disagreements were resolved through group review to achieve consensus.

Forty-six individual subcompetency themes were identified (21 Professionalism and 25 ICS). Specialties differed in the number of subcompetencies devoted to Professionalism and ICS, but the authors were able to collate these 46 individual themes into 20 common themes (8 Professionalism and 12 ICS). The group agreed to focus the assessment on levels 1 through 4, as level 5 achievements are not required for graduation but are aspirational and thus do not require remediation if not achieved.⁵  Themes present in most specialties (ie, at least 7 of 13) were deemed to be of greatest value to educators across specialties. One theme (confidence and self awareness of limits) was present in 6 specialties but was included as the authors believed that resources for remediating this subcompetency would be valuable. These 20 themes are included in online supplementary data tables 1 and 2.

To identify remediation methods for deficiencies in the 20 common themes, a professional medical librarian trained in systematic reviews helped create a literature search for relevant English-language articles published between 2000 and 2022. The strategy utilized Boolean operators and keywords, derived from the shared subcompetency themes described in online supplementary data tables 1 and 2, along with the search protocol, also available in the online supplementary data. There were 403 citations for Professionalism and 440 citations for ICS identified. Authors screened the resulting titles and abstracts and extracted full text articles that pertained to the remediation of Professionalism or ICS in medical trainees for review.

Based on this literature review, their experience with remediation in Professionalism and ICS, and the previous toolkit,⁵  the authors aggregated specific methods for remediation in the identified shared subcompetency themes for both Professionalism (online supplementary data Table 1) and ICS (online supplementary data Table 2). These suggested methods are intended for use as a guide, with the understanding that each plan must be tailored for the specific specialty, appropriate for the lapse requiring remediation, and personalized for each trainee. Methods without specific references are drawn from the expert opinion of the authors, who share over 75 years of collective experience in residency program and institutional graduate medical education (GME) leadership. Although there are limited outcome data for the aggregated methods, the authors’ consensus is that the provided references are valuable as potential resources for educators developing remediation plans for learners struggling with Professionalism and ICS.

This toolkit will allow educators to identify resources to incorporate into improvement plans for trainees performing below expectations in Professionalism or ICS. As a critical first step, faculty must explore any mental health or physical illness, alcohol or other substance use disorders, or external stressors that could be contributing to the perceived lapses. If identified, the program director (PD) should refer the trainee for counseling or care, per program and institutional policies. If those issues are not assessed as contributing factors, then a remediation plan that includes input from resident self-reflection can be implemented.

As opposed to the first iteration, the harmonized Milestones allow for sharing of assessment and remediation methods across all specialties. As each trainee is unique and has their own challenges, learning plans may be developed based on individual needs and local availability of resources. Once deficiencies are identified, program leadership may refer to online supplementary data tables 1 and 2 to review strategies and resources corresponding to subcompetency themes and create improvement plans.

For context, we walk through a hypothetical scenario. A PD receives several complaints from consultants that a resident frequently provides unclear consultation requests and does not consistently follow recommendations. Additionally, recent peer and faculty evaluations report that the resident is less engaged with the team, arrives late and unprepared for rounds, appears tired, and is irritable.

The resident’s Milestone performance is reviewed by the PD and Clinical Competency Committee (CCC). It is determined that the resident is below expectations in areas of Professionalism and ICS. Referring to online supplementary data table 1, the PD maps the concerns raised in peer and faculty evaluations to the Self-Awareness and Well-Being subcompetency within Professionalism and identifies “recognizes and promotes personal and professional well-being, including wellness, burnout, fatigue, and stress-recognition and mitigation” as the pertinent Milestone theme. Regarding the consultant communication issue, using online supplementary data table 2, they map the concern to the Interprofessional and Team Communication subcompetency within ICS and identify “requests consults effectively and integrates recommendations” as the pertinent Milestone theme.

After requesting that the resident reflect on the identified Professionalism and ICS concerns, the PD and CCC review the suggested resources for the themes provided in the online supplementary data Tables, and, together with the resident, develop an individualized performance improvement strategy.

For the Professionalism concerns, the resident will:

1. Meet with program leadership to discuss professional appearance, punctuality, and wellness techniques.

2. Use screening tools and the institution’s employee assistance program to assess and monitor progress.

3. Participate in wellness education, including development and presentation of content during a didactic session.

For the ICS concerns:

1. The resident will review selected literature on effective consultation and discuss with the faculty advisor a standard approach that they will utilize.

2. The PD will arrange direct observation and feedback by faculty during consultant interactions.

3. Together, the PD and resident will request consultants’ feedback regarding interactions and will review with a faculty advisor or PD.

For monitoring, the PD schedules monthly check-ins with the resident to track progress and confidentially alerts supervising physicians that their feedback on the consultation issues will be solicited monthly for 2 to 3 months, or until feedback is universally supportive of successful remediation. The resident agrees to this remediation plan, which is enacted immediately.

Harmonizing the Professionalism and ICS Milestones provides educators an opportunity to identify, collate, and share resources for remediation across specialties. With the specific activities and monitoring methods described, program leaders can use our updated recommendations as a guide to remediate Professionalism and ICS. It remains our hope that targeted remediation strategies will be developed for Milestones under other subcompetencies. Collaboration within the GME community to develop assessment tools and remediation strategies for the version 2.0 harmonized Milestone subcompetencies, and to study the efficacy of these strategies, should be the standard.

The authors would like to thank Katie Lobner, MLIS, for her assistance in executing the literature search for this manuscript.

The online supplementary data contains the tables from the study and the literature search protocol.

Disclaimer: Dr. Linda Regan is the current Chair of the Review Committee for Emergency Medicine at the Accreditation Council for Graduate Medical Education (ACGME). Dr. Tiffany Murano is a member of the Review Committee for Emergency Medicine at the ACGME. Drs. Regan and Murano’s contributions here are their own and reflect their work and opinions and should not be viewed as an endorsement from the ACGME.