Introduction
Remediation in medical education has been defined as “the act of facilitating a correction for trainees who started on the journey toward becoming a physician but have moved off course [1].” Although the prevalence of residents requiring remediation varies among specialties, program directors (PDs) in all specialties are tasked with guiding these trainees back on track [2-7].
Remediation is a challenging endeavor for both residency leadership and trainees. There is variation not only in the practices of remediation among specialties but also in the terminology used to approach struggling trainees [8,9]. Although deficiencies vary among trainees, a significant amount of time, resources, and restructuring of the program's training schedule is required to improve resident performance to the point where it meets minimum standards. In addition, the process may be associated with negative stigma or stereotyping, including the term, “remediation,” itself. Given their high level of prior academic achievement, trainees may struggle to accept that their deficiencies require more work than their peers [10]. They may express strong emotional responses, such as anger, blame, or shame, which further promotes a negative attitude toward the remediation process [4].
To our knowledge, there are few institutions that have created a uniform process for all trainees utilizing faculty and resources across multiple specialties. Although the milestones for patient care and medical knowledge vary among specialties, professionalism (Prof), interpersonal and communication skills (ICS), systems-based practice (SBP), and practice-based learning and improvement (PBLI) are shared values and commonalities that allow for pooling of resources and interdisciplinary mentorship. One other institution-wide remediation program implemented at the University of Colorado School of Medicine was established in 2006 and is focused on the remediation of a spectrum of learners ranging from medical students to faculty across all core competencies [11]. In a perspectives publication, Kalet et al. [1] recommend the creation of a system-level approach to remediation that incorporates constructive alignment, supports a continuum of practices, develops institutional communities of practice of remediation, and destigmatizes remediation.
We sought to change the landscape of remediation with two objectives in mind: (1) Create an institution-wide standardized process for remediation of trainees utilizing institutional resources; and (2) positively rebrand the process by eliminating the term “remediation” and provide institution-wide transparency.
Materials and methods
Creation of the Housestaff Performance Enhancement Program Subcommittee (HPEPSC)
This program was developed and implemented at an academic university-based institution. A group of education leaders across seven specialties (anesthesiology, emergency medicine, internal medicine, neurology, obstetrics/gynecology, surgery, and urology) in our institution formed a graduate medical education subcommittee (HPEPSC). The HPEPSC sought to achieve its goals by investigating current best practices for remediation and creating a program for the competencies that are shared among all specialties: Prof, ICS, SBP, and PBLI. The committee agreed to address Prof and ICS in Phase 1 of the project, with SBP and PBLI to be addressed in the forthcoming Phase 2. We decided to eliminate the term “remediation” to facilitate a more positive perception of the program. The creation of the process, toolkits, and triggers was an iterative expert consensus of the committee and content expert based on our literature search.
Creation of the toolkit and the triggers
Working off the toolkit published by Regan et al. [4], professionalism behaviors were categorized into values and conduct, accountability, responsiveness to unique characteristics/needs of patients, self-awareness and betterment, and adaptability. ICS was categorized into patient-centered communication, healthcare team communication, healthcare team leadership, and documentation in the electronic medical record (EMR).
Triggers for each of the categories were created by consensus of the HPEPSC. Triggers were defined as behaviors or actions that were non-compliant with the established standards of professionalism and ICS for our institution, common milestones, and the medical field. Triggers were identified based on prior behaviors by trainees and were classified as minor, moderate, or major based on the severity of the action/behavior. Mild triggers were actions/behaviors that were present in an isolated or infrequent evaluation and warranted a conversation between the PD and the trainee. Moderate triggers were actions/behaviors that were noted in multiple evaluations or complaints, and required intervention by the residency leadership, but did not negatively impact patient care. Major triggers were actions/behaviors that were repeatedly present in multiple sources (evaluations, complaints, or reports), negatively impacted patient care, or egregiously violated professional and ethical standards (see Appendix B [12-43] and Appendix C).
Standardizing the process
To standardize the terms used within the institution, formal remediation plans created and implemented for trainees within their training programs were termed “program-based improvement plans (PIPs).” PIPs are initiated at the discretion of the individual program and are considered internal methods of improving resident performance. The HPEPSC asks programs to implement a PIP when trainees fail to meet appropriate milestone levels and/or exhibit ≤2 minor triggers despite counseling or a minor trigger in the presence of one moderate trigger. Residency leadership performs wellness/burnout evaluations to identify any external contributing factors or circumstances. All conversations pertaining to the PIP are documented and placed in the trainee’s file, and the GME office is notified for tracking purposes only. Participation in PIP is not disclosed to future employers for trainees who have no further incidents. Trainees are unsuccessful if there are repetitive unprofessional behaviors, there is a failure to correct current behaviors, new or additional triggers are exhibited, or goals for PIP are not achieved. Unsuccessful PIPs are documented in the trainee’s file, and they are referred to the institutional house staff performance enhancement program (HPEP) (see Appendix A).
HPEP process
HPEP is implemented when the trainee is unsuccessful in a PIP, consistently fails to meet appropriate milestone levels, is more than one level below expectation on one or more Prof or ICS milestones, exhibits more than two minor triggers repetitively despite counseling, exhibits two moderate triggers, or exhibits one or more major triggers (see Appendix A). The decision to enroll the trainee in the HPEP is made in collaboration with the trainee’s PD, Clinical Competency Committee, Department Chair, and the Designated Institutional Official (DIO). The trainee is notified in writing by the PD and the HPEPSC Chair and is required to visit the institution’s resident wellness and excellence center to screen for contributing external factors. Faculty mentors are chosen by the subcommittee chair in conjunction with the PD, and focused improvement plans are created utilizing the HPEP Prof/ICS Toolkit (Appendix B [12-43] and Appendix C). All trainees in the HPEP are assigned faculty mentors outside of their department. The plans are documented in an HPEP contract signed by the PD, DIO, faculty mentor, and the trainee. The length of the HPEP cycle is determined by the individual trainee’s needs in conjunction with all participating parties.
Summative evaluations are completed for all trainees at the completion of the HPEP cycle. Trainees are considered to have successfully completed an HPEP cycle if they meet all prescribed goals and complete all required elements of the plan. HPEP participation is not disclosed to future employers for trainees who successfully complete the program. Trainees have the option to maintain contact with his/her faculty mentor following a successful HPEP cycle, but all are encouraged to continue informal monitoring within their program to ensure that there are no further deficient behaviors. Any trainee who does not meet the expectations or goals set forth in the HPEP contract is either referred for an additional HPEP cycle, placed on probation, terminated, or does not have their contract renewed by the institution. Probation, termination, and/or non-renewal are disciplinary actions and disclosed to future employers.
The confidentiality of all trainees is maintained throughout the process. The only individuals aware that a trainee is enrolled in the HPEP are their PD, Department Chair, the HPEPSC Chair, the faculty mentor, and the DIO. PDs were informed only of the number of trainees enrolled in the program on a monthly basis during GME meetings.
Transparency
The HPEP was placed on our GME website including a description of the program, the process, and frequently asked questions.
Evaluation
Evaluations were created via an electronic survey (Survey Monkey®) by the HPEPSC for the trainees, the PDs, and the faculty mentors. Each evaluation was composed of 8-9 questions using a 5-point Likert scale (strongly agree-strongly disagree) with two questions asking for challenges or obstacles that were faced and suggestions for potential improvements to the HPEP process. These electronic evaluations were anonymous and sent to all parties one month, six months, and 12 months after the completion of the HPEP cycle. The timing of the evaluation was chosen to enable longitudinal monitoring. All evaluations were reviewed by the HPEP members and feedback was used to make improvements. Reminders to fill out evaluations were sent to all parties on a biweekly basis.
For the analysis of this program, the Institutional Review Board approved this project.
Results
Our institution sponsors 48 ACGME-accredited residency and fellowship programs with 663 trainees. During the academic years from 2018 to 2021, 12 trainees entered an HPEP cycle for Prof and/or ICS. All 12 trainees completed the HPEP cycle. All trainees enrolled in the HPEP completed one 3-month cycle and 10/12 of the trainees did not exhibit any additional unprofessional behaviors or had any problematic communication issues following the completion of the HPEP cycle. One trainee graduated shortly after completion and the last trainee’s contract was not renewed at the end of the academic year that coincided with the HPEP cycle.
One-month evaluations
There were two trainees who left the institution within one month of completing the HPEP. Therefore, a total of 10 evaluations were sent to the trainees with 7/10 (70%) completed. Evaluations were sent to all 12 PDs and faculty mentors with a response rate of 9/12 (75%) for both. PDs were mostly positive in their responses (Figure 1).
Figure 1
Survey Results for PDs (a), Faculty Mentors (b), and House Staff of the HPEP (c)
HPEP: housestaff performance enhancement program; PEP: performance enhancement program; PD: program director.
Of the seven trainees who responded, 85% (6/7) "strongly agreed" or "agreed" with statements pertaining to the ease and value of the process as well as the mentoring experience. When responding to the statement about whether participation in HPEP would not be used against the trainee by future credentialing requests, four of the seven trainees responded neutrally, while three agreed or strongly agreed.
Most of the faculty mentors responded "agree" or "strongly agree" to statements regarding being paired with the mentee in a fast and efficient manner and working well together with the mentee (8/9, 89%), meeting on a regular basis with the mentee, creation of a streamlined action plan and having appropriate and specific goals and objectives, and PD availability and responsiveness (7/9, 77.8%). Three mentors felt that they had difficulty facilitating meetings with the mentee and three mentors felt that the HPEP process required a significant time commitment.
Six-month evaluations
Of the 12 trainees, five did not receive the six-month evaluation because of non-renewal (1), completion of training (2), and within six months of completion of the HPEP (2). Of the 12 mentors and PDs, two did not receive six-month evaluations because their trainees were within six months of HPEP completion.
Six out of the 10 (60%) PDs responded to the six-month survey. None of the PDs referred their trainees back to the HPEP or thought that the trainees continued to meet with their mentors following the HPEP cycle. Two out of the six PDs felt the trainee continued to use the skills and tools that they learned through the PEP while three were neutral and one disagreed. Two noticed that the trainee’s behavior was and continued to be positively impacted by the HPEP process while four were neutral. Four of the six PDs felt that the trainees continued to believe that the HPEP process contributed positively to their professional development while two remained neutral. Five PDs said that they would very likely refer other trainees to the HPEP and would recommend that other PDs use the HPEP for their trainees while one PD was undecided.
One house staff responded to the six-month evaluation. Their response indicated that they did not continue to meet with the assigned faculty mentor after the HPEP. The responses to all the other statements were agree or strongly agree. Two faculty mentors responded to the six-month survey. Although only one faculty continued to meet with their mentee, both faculty agreed or strongly agreed that the trainee continued to ask for guidance after the HPEP cycle was completed and continued to use the skills and tools learned in the HPEP and their behavior continues to be positively impacted by the HPEP.
Twelve-month evaluations
Of the 12 trainees, five were unable to complete the 12-month evaluation because of non-renewal (1), completion of training (2), and within six months of completion of the HPEP (2). Of the 12 mentors and PDs, two did not receive 12-month evaluations because their trainees were within six months of HPEP completion.
Five of the 10 PDs responded to the 12-month evaluation. Two of the five PDs felt that the trainee continued to use the skills and tools that they learned, the behavior was and continued to be positively impacted, and that the HPEP process positively contributed to their professional development while three PDs were neutral in these domains. All the PDs said that they would use the HPEP if needed in the future for other trainees. All PDs reported that their trainees were not referred to the HPEP for continued professionalism or ICS issues.
Only one trainee responded to the 12-month follow-up survey. The respondent did not meet with their mentor following the HPEP but answered agree or strongly agree to other statements pertaining to altering the way they practice medicine, recommend the program to other trainees if needed, and would volunteer to participate in other areas in need of improvement.
Three of the 10 faculty mentors responded to the 12-month evaluation. One agreed that the trainee continued to meet with them and ask for guidance and feedback following the HPEP. Two positively responded that the trainees continued to use the tools and skills learned in the HPEP. Two of the mentors would recommend other faculty to serve as HPEP mentors and all three agreed or strongly agreed that they would be happy to participate as an HPEP mentor again.
Discussion
Our program is unique in that we created a transparent institution-wide approach to assisting our trainees who did not meet minimum expectations while we positively rebranded and changed the perception of the remediation process. We wanted our trainees and faculty to see remediation as a golden opportunity, rather than a permanent blemish on their record once the trainee has graduated from residency or fellowship. Most United States’ state medical licensing boards do not require that PDs report residents who have been on remediation [44]. However, it was the impression of many PDs at our institution that remediation would negatively impact a trainee’s ability to obtain licensure.
The process, as well as the toolkit, may be helpful in institutions across all specialties to use for education in professionalism and interpersonal communication skills for trainees in their programs. Implementing a transparent process will help to create a standardized mechanism for programs to follow and perhaps allow trainees to see that the institution is committed to their learning and improvement. Jennings and Slavin [45] suggested that programs should strive for transparency whenever possible as a preventative measure to keep residents from having feelings of being treated unfairly or unjustly. In addition, this process may make institutions more attuned to how to best help their trainees and how to best utilize their resources.
Our program incorporates a wellness screen into the process by requiring trainees who are referred to the HPEP to visit the Resident Wellness and Excellence Center (RWEC). The RWEC provides confidential counseling services to the house staff at no charge and is geared toward assisting trainees with stressors that may arise inside or outside of their program. We felt that this was an important step in the process given the significant amounts of stress, burnout, and physician suicide that are affecting the medical profession on so many levels [45-49]. In a systematic review and meta-analysis by Mata et al. [48], it was demonstrated that between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms, respectively. By necessitating this meeting at the RWEC, we hope that external pressures that may be affecting a trainee’s performance begin to be appropriately addressed. We were unable to measure the success of this component due to the confidential nature of these visits.
Overall, Phase 1 of the HPEP was well received by the trainees, mentors, and the PDs. The use of faculty mentors outside of the trainees’ specialty was implemented to allow the trainees to feel like they had a “champion” who was objective and would not be negatively influenced by interactions prior to or following the HPEP. One of the challenges that the participants of the HPEP experienced was finding time for the trainees to meet with their faculty mentors. In one case, this may have been due to the trainee’s attitude toward being in the HPEP, as they were noted by the mentor as being dismissive. However, given the demanding service schedules of both trainees and faculty, it stands to reason that the residency program should make reasonable allowances for these mentoring sessions to occur. As a few of the trainees had reading and reflective essay assignments, it is also reasonable that the training program and institution create a supportive environment to allow the participants to complete these tasks within the constructs of the functioning of the program and their scheduled work hours.
Our study has several limitations. Even though the first phase of our program has been successful in achieving its goals, the evaluation of the effectiveness of our program is limited by the small number of participants. It is also difficult to track trainees once they have graduated from the program, so longitudinal follow-up is limited. We anticipate that obtaining long-term outcomes of our program may be limited by the fact that it is difficult to follow the HPEP trainees’ performance once they have graduated from their training programs and have obtained outside employment as faculty or fellows, which would require continued contact between the program and its graduates. Further, it may be possible to assess for relapses in professionalism by querying medical licensing boards to see if the graduates had any professionalism issues that required disciplinary action. In addition, there are some unprofessional behaviors (such as sexual harassment, sexually inappropriate behavior, and substance abuse) that purposefully were not addressed in the HPEP because they are routinely referred to human resources by institution policy. With respect to the toolkit, the resources that are listed were not based on published literature and have not been proven to be helpful themselves, rather they were created for use based on the published recommendations of simulation-based case discussion. Finally, due to the COVID-19 pandemic, the HPEP process was paused as our institution was in the pandemic emergency stage for two months. The interruption in the HPEP process may have led to breakdowns in communication and loss of any previous progress that was made prior to the pandemic. In addition, six- and 12-month follow-ups may have been poor secondary to the fact that communication was hindered by the patient care demands and challenges with resources during the pandemic.
Conclusions
The HPEP is a standardized process utilizing institution-wide resources that had positive outcomes after one year of enrollment. Rebranding the remediation process by framing it in a positive way, removing the word “remediation,” and providing transparency may eventually shift the attitudes toward remediation.
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