Editor's Note: The online version of this article contains vignettes in emergency medicine, family medicine, obstetrics and gynecology, and psychiatry, as well as remediation approaches by proficiency level for Emergency Medicine Interpersonal and Communication Skills and Professionalism Milestones.
A program director receives the following complaint from 2 members of the faculty: a postgraduate year (PGY) 3 resident seems argumentative during patient handoffs and is neither receptive to discussions about patient care concerns nor to feedback about their interactions. Under these circumstances, how should the program director approach this problem, which reflects deficiencies in interpersonal and communication skills (ICS) and professionalism competencies? What remediation strategies should be considered and can the milestones guide the remediation? Are there any best practice recommendations that can serve as a template across specialties for professionalism and ICS that program directors can use for their residents?
As part of the new accreditation system, the Accreditation Council for Graduate Medical Education developed the Milestone Project, which includes specialty-specific subcompetencies and milestones under each of the 6 competencies.1–3 The milestones allow programs to determine the progression of each resident's knowledge, skills, and attitudes during the course of training.4 With the understanding that subcompetencies and milestones for competencies, such as patient care and medical knowledge, might vary significantly among specialties, we posed the question as to whether or not those for ICS and professionalism share common content themes. If unifying standards for the house of medicine for these competencies did exist, it should follow that suggested approaches to remediation could be applicable across specialties.
It is the authors' hope that the best practice recommendations to follow will allow a program director to expand his or her toolbox for remediation of these competencies, while also developing a broader understanding of approaches to successful remediation. In addition, a remediation approach using targeted strategies mapped to subcompetency proficiency levels is presented for the authors' specialty of emergency medicine (provided as online supplemental material).
The Problem
Despite the importance of professionalism and ICS to the training of future physicians, residency programs often struggle with educating residents in these areas, as well as providing effective remediation for those who fail to meet expectations.5,–7 In a survey, pediatrics program directors reported that residents terminated after failed remediation were significantly more likely to have deficiencies in ICS and professionalism,8 while neurology program directors noted that the most prevalent issue for “problem neurology residents” was professionalism, as demonstrated by inappropriate interactions with colleagues and staff.9 Among program directors in emergency medicine, 80% noted that deficiencies in professionalism were harder to remediate than deficiencies in other core competencies.10 Clinical skills examination scores for Canadian medical students showed a predictive relationship between students who scored poorly on communication and future complaints in their medical practice, with students in the bottom quartile accounting for a significantly higher percentage of patient complaints.11
Program directors face multiple challenges in striving to effect successful remediation of residents failing to meet milestone achievements.12 While some specialties (such as emergency medicine, radiology, pathology, and ophthalmology)1,3 list suggested assessment methods for the competencies, many provide no guidance to program directors with regard to how to assess trainees in their progression on milestone achievements, and there are few specific recommendations for remediation when residents fail to meet expectations. While the Milestone Project provides programs with concrete achievements that residents must meet for each core competency and may aid programs in identifying residents who are not meeting expectations,1,–4,27,–29 the transition from identification to remediation requires knowledge of available resources and expertise in remediation and evaluating outcomes of remediation.30,–34
A Remediation Task Force Was Born
A remediation task force was developed for the Council of Residency Directors in Emergency Medicine (CORD-EM) and was charged with developing activities and tools to assist programs with remediation of residents regarding each proficiency level specific to each subcompetency. Our group focused on professionalism and ICS; each member completed an independent literature review regarding methods to remediate professionalism and ICS, and collated relevant literature from all medical specialties. Participants suggested specific methods to address remediation based on (1) a literature review, and (2) previous experience with remediation in professionalism and ICS. When approaching proficiency levels within professionalism and ICS, the group agreed to focus the assessment on levels 1 through 4, as level 5 represented aspirational achievements that may not be achieved during training, and thus did not require remediation. Consensus was obtained on specific methods to address substandard performance for proficiency levels 1 through 4 in each of the emergency medicine subcompetencies (references were used where available and are provided as online supplemental material).
Core Programs' Common Themes Identified for ICS and Professionalism
As the task force work was completed, it became clear that our approach could be easily translated across graduate medical education programs. We then reviewed the subcompetencies for professionalism and ICS for the specialties of anesthesiology, diagnostic radiology, emergency medicine, family medicine, internal medicine, pathology, pediatrics, psychiatry, obstetrics and gynecology, ophthalmology, orthopaedic surgery, and surgery.1,–3 While the specialties differed in the number of subcompetencies devoted to professionalism and ICS, certain fundamental themes were shared.
The task force utilized our previous approach to develop recommendations for these shared themes (boxes 1 and 2). These suggested methods are intended for use as a guide, with the understanding that each remediation plan needs to be individualized for the specific specialty, appropriate for the remediation lapse, and tailored for the trainee. Residency training programs may map the themes and suggested remediation technique to their specialty-specific milestone proficiency levels.
Pick a mentor role model of professionalism to shadow and/or meet with periodically.13
Solicit specific feedback from faculty that addresses areas of professionalism through evaluations.
Read specific journal articles regarding professionalism; facilitate mentored small group discussion and reflection.14
Review dangers of social media, discuss infractions, and develop a plan for removal of certain online material.15
Participate in wellness education, including development and presentation of content during a didactic session.16,17
Review current policies of department, institution, or state and develop a plan for an impaired physician.
Review policies or literature for disclosing errors and help develop an educational session for residents.18
Meet with a set number of patients and summarize reflections of the experience with regards to patients' perspectives, and the physician role in the patient experience as part of a “patient advocate shift.”
Shadow a social worker or patient representative to learn how to advocate for patients and gain patient perspectives; write a reflection.
Participate in written/simulated case scenarios with emphasis on the impact of physician's beliefs on patient care and experience.21
Perform a self-reflection analysis regarding perceived difficult patients; develop a plan to care for these patients in an unbiased manner.21
Perform a monthly self-assessment of professionalism with examples of cases handled effectively and those in need of improvement.22
Participate in patient case scenarios (standardized patients, simulation, or oral cases); debrief performance using a checklist and develop a performance improvement plan. Follow up with role modeling or self-remediated example.21,23
Obtain and discuss frequent multisource feedback (faculty, nursing, peer, self).24
Participate in patient case scenarios (standardized patient, simulation, or oral cases) with an emphasis on shared decision making.25
Review graduated level of responsibility policies and discuss when to request assistance from senior residents or attending physicians.
Review literature on medical uncertainty and help develop an educational session for residents.26
Document a complex patient case log with analysis on care issues.
Read material such as “Martin's Mind Map”; reflect on areas to incorporate into future patient encounters.35
Complete patient evaluations, and reflect on strengths and areas for improvement.36
Utilize a faculty mentor for scheduled meetings or shadowing to discuss patient interactions.
Participate in simulated patient encounters to evaluate general communication skills via checklist and debrief after the interaction.37
Participate in meetings with patient relations with focus on patient complaints related to communication and preventive strategies.
Attend conflict resolution and communication courses, reflect on current practice, and develop a performance improvement plan.
Participate in employee assistance programs and/or emotional intelligence testing.38
Review literature to develop an educational session on aspects of communication, such as breaking bad news, disclosing errors, shared decision making, and against medical advice discharges.39,–42
Participate in simulated scenarios for breaking bad news, disclosing errors, and patient refusal/against medical advice with evaluation and debriefing.39,–42
Utilize a faculty mentor for scheduled meetings or shadowing to discuss interactions with colleagues and staff.
Work in other roles on the health care team (eg, nurse, social worker, physical therapist, pharmacist) to gain perspective on their roles.
Receive feedback through standardized videotaped or simulation scenarios, direct observation, and 360° evaluations to identify specific areas of communication that need improvement.43,–46
Use a reflection exercise about perceived strengths and weaknesses with team communication to then comment on stressors that lead to conflict.
Participate in an observed checklist of transition-of-care experience, both as an observer to offer feedback and a learner to receive feedback.47
Participate in a leadership training course or Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training course.48,49
Participate in mentored reading program (suggested books include How to Win Friends and Influence People or Crucial Conversations).50,51
Evaluate teamwork climate using metrics such as the Care Process Self-Evaluation Tool; identify areas for improvement.52
Present a didactic session regarding conflict resolution strategies, including vignettes as didactics.
Perform monthly self-assessment of documentation and identify those needing improvement.
Review the literature on acceptable documentation practices and develop and present a didactic.
Participate in peer-review documentation audits.
In the following section, we continue the vignette with an example of how a program director might utilize this work to identify substandard performance, develop and implement a remediation plan, and assess the effect. Additional vignettes in emergency medicine, family medicine, obstetrics and gynecology, and psychiatry are available as online supplemental material.
Implementation
Now reconsider the following: a program director receives a complaint from 2 faculty members that a PGY-3 resident seems argumentative during handoffs and not receptive to discussion about faculty concerns. The program director then maps this issue to the specialty-specific milestone subcompetency ICS-2 (communication with other professionals), proficiency level 2: “effectively communicates relevant patient issues during transitions or transfers of care” and to subcompetency Prof-4 (receiving and giving feedback), proficiency level 2: “accepts feedback from faculty members and incorporates suggestions into practice.”
For remediation, the program director chooses the following methods for ICS: (1) participate in an observed checklist of transition-of-care experience, both as an observer to offer feedback and as a learner to receive feedback, and (2) use a reflection exercise about perceived strengths and weaknesses with team communication to then comment on stressors that lead to conflict. For professionalism, the program director uses (1) a monthly self-assessment of professionalism with examples of cases handled effectively and those needing improvement, as well as (2) frequent multisource feedback (faculty, nursing, peer, self).
For monitoring, the program director alerts faculty members that their feedback will be solicited monthly for 2 to 3 months or until feedback is universally positive.
Next Steps
With the specific remediation activities and monitoring methods described, residency and fellowship programs can use our recommendations as a guide to remediate residents in professionalism and ICS. It is our hope that targeted remediation strategies will be developed for milestones under the remaining core subcompetencies. Collaboration within the graduate medical education community to develop both assessment tools and remediation strategies for the milestone subcompetencies should be the standard.
References
Author notes
The authors would like to thank the Council of Emergency Medicine Residency Directors for their support.
