Remediation of the Struggling Medical Learner · Remediation of the Struggling Medical Learner...

Remediation of the Struggling Medical Learner

Jeannette Guerrasio, MD

Professor of Medicine

Director, Student and Resident Remediation

University of Colorado, School of Medicine

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Remediation

• Limitations: • Rare published evidence to guide best practices in

remediation

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Hauer KE. Acad Med 2009; 84(12):1822-1832.

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Disclosure

Objectives

• Describe a process for identifying the underperforming learner

• Outline a framework for diagnosing learner difficulties

• Employ a methodical approach for remediation based on the identified deficiencies

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What We Know

15%

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Importance

• Time

• Morale

• Reputation

• Patient Safety!

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.

Responsibility

• Low attrition surgery programs • 21.0% versus 6.8%; P<.001

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Schwed AC. JAMA Surgery Aug 16, 2017

Responsibility

• Low attrition surgery programs • 21.0% versus 6.8%; P<.001

were more likely to provide resident remediation

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Schwed AC. JAMA Surgery Aug 16, 2017

10Hauer KE. Acad Med 2009; 84:1822-1832.

Identifiers

• Examinations• Written

• Clinical performance (OSCEs)

• Clinical/Preceptor written evaluations

• Peer assessments

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Identifiers

• Verbal comments

• Reporting system for concerns

• Mid-rotation performance evaluations

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13Hauer KE et al. Acad Med 2009; 84:1822-1832.

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Attendings

Competencies:

• Medical Knowledge

• Patient Care

• Interpersonal Skills and Communication

• Professionalism

• Practice-Based Learning

• Systems-Based Practice

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The Outcomes Project. Accreditation Council for Graduate Medical Education. 1999.

Competencies “Plus”:

• Medical Knowledge

• Patient Care

• Clinical Skills

• Clinical Reasoning

• Organization & Time Management

• Interpersonal Skills and Communication

• Professionalism

• Practice-Based Learning

• Systems-Based Practice

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Competencies “Plus”:

• Medical Knowledge

• Patient Care

• Clinical Skills

• Clinical Reasoning

• Organization & Time Management

• Interpersonal Skills and Communication

• Professionalism

• Practice-Based Learning

• Systems-Based Practice

• Mental Well Being17

Cases #1

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Identify the deficit…

1. Medical Knowledge

2. Clinical Skills

3. Clinical Reasoning and Judgment

4. Time Management and Organization

5. Interpersonal Skills and Communication

6. Professionalism

7. Practice-Based Learning and Improvement

8. Systems-Based Practice

9. Mental Well-Being

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Additional InformationDirect Observation

• Collect a H&P

• Efficiency

• Prioritize tasks

• Responsiveness/Ownership

Presentations/Rounds• Integration of information

• Formulation of ddx, A/P

• Ability to summarize case

• Formulation of questions

Interview the Learner

• Reading materials

• Stressors

• Substance abuse

• Learner’s perspective

Other Sources

• Chart review

• Arrival/departure time

• 360˚ evaluations

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Medical Knowledge

Presentation◦ A history of poor exam scores◦ Unable to answer fact based questions

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Clinical ReasoningPresentation◦ During Presentations Extraneous information Unable to focus Too many tests Difficulty differential diagnosis analyzing diagnoses individualizing protocols/practice guidelines

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Cases #2

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Identify the deficit…

1. Medical Knowledge

2. Clinical Skills

3. Clinical Reasoning and Judgment

4. Time Management and Organization

5. Interpersonal Skills and Communication

6. Professionalism

7. Practice-Based Learning and Improvement

8. Systems-Based Practice

9. Mental Well-Being

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Time Management & Organization

• Presentation• Unprepared for deadlines• Disorganized in appearance• Presentations and notes missing sections and out of

order• Arrival and departure times

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Professionalism

• Presentation• Inappropriately dressed• Frequently late or absent, unreliable • Dishonest• Try to pass off work • Poor patient - doctor relationships• Specific unethical actions may be brought to your

attention

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Who needs to know?

Make sure the learner receives the feedback as soon as possible

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Level of Resident By Expert Assessment

Hodges B Acad Med 2001;76(10 S):S87-9.

Who needs to know?

Make sure the learner receives the feedback as soon as possible

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Level of Resident By Expert Assessment

Hodges B Acad Med 2001;76(10 S):S87-9.

Remediation Team Approach

• Review the learner’s academic record

• Review examples of deficit(s) and confirm deficit(s)

• Look for trends and severity

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30Hauer KE. Acad Med 2009; 84:1822-1832.

Remediation Strategy

The goal of remediation is to target and fix:

the greatest deficit!

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Remediation Strategy

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Feedback

Reflection in Action

Deliberate Practice

Interpersonal Skills• Deliberate Practice

• Check-In with Yourself

• Closed Loop Communication• Emote and Explain

• Nonverbal Language

• Call People by their Name• …say “Thank you”

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Interpersonal Skills• Feedback

• What feedback have you received?

• Have the nurses been interacting with you differently?

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Interpersonal Skills• Reflection

• Who Sounds Like This?

• Apologize• Seek Permission to Learn

...and Try Again.

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• Regan L et al. Remediation methods for milestones related to interpersonal and communication skills and professionalism. JGME 2016;2(1):18-23.

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• Ann Demarais PhD and Valerie White PhD. First Impressions: What you don’t know about how others see you. Bantam Books. New York, NY: 2004.

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Creation of an individualized learning plan

What is different about the way struggling residents learn?

Underperforming Learners

WEAKNESSES

• Lack scaffolding to learning

• Don’t learn from the hidden curriculum

• Trouble identifying feedback

• Can’t actualize feedback

• Large blind spots

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Known To Self Unknown To Self

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BLINDJoHari Window

Underperforming Learners

STRENGTHS

• Are teachable

• Have foundational knowledge

• Great memorizers

• Learn from concrete rather than abstract

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Mismatch

Teaching1. Educational Task

2. Assumption of Framework

3. Unconscious/Abstract Learning

4. Feedback Provided

5. Safe Learning Environment

Learning1. Learner’s Competence

2. Absence of Framework

3. Need for Concrete Learning

4. Not Receiving Feedback

5. Fear of Ridicule

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Small Group Exercise

Cases

• John decides that he wants to go to his friend’s wedding over the weekend.

• At 5pm on Friday, John emails the chief resident to let her know that he will not be available to work his previously scheduled shifts on Saturday and Sunday.

• On Saturday morning, the night resident is looking for John so that he can sign out and go home. The medical team doesn’t know where he is.

Cases

• Lindsay was referred for remediation for poor knowledge. However, she scored in the top 85%tile on the Step exams and in the top 90%tile on the in training exam.

• Further assessment reveals that she struggles to build a relevant differential diagnosis and to prioritize tests and treatments.

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The Data

Unprofessional behavior in medical school

Subsequent disciplinary action by the state medical board

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Papadakis MA, et al. N Engl J Med 2005; 353:2673-82.

Kern DE, et al. Curric Devel for Med Educ. 2009; p 67.

The Data

Unprofessional behavior in medical school

Subsequent disciplinary action by the state medical board

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Papadakis MA, et al. N Engl J Med 2005; 353:2673-82.

Kern DE, et al. Curric Devel for Med Educ. 2009; p 67.

Accountability

• Review adherence to requirements (reporting duty hours, procedure log, assignments)

• Discuss professional appearance, punctuality, and wellness techniques; identify barriers to success.

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Professional Values and Conduct

• Pick a mentor role model of professionalism to shadow

• Solicit specific feedback

• Read specific journal articles regarding professionalism; facilitate small group discussion

• Review dangers of social media, discuss infractions

• Participate in wellness education

• Review current policies of department, institution, or state

• Rebuild broken bridges

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Responsiveness to Unique Characteristics and Needs of Patients

• Meet with patients and summarize reflections of the experience with regards to patients' perspectives

• Shadow a social worker or patient representative

• Participate in written/simulated case scenarios

• Perform a self-reflection analysis regarding perceived difficult patients; develop a plan to care for these patients in an unbiased manner.

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Clinical Reasoning

• Deliberate Practice• Framework for creating a ddx

• Create ddx: age, gender, race/ethnicity, & cc

• Feedback• Use Back-up resources

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Clinical Reasoning

•Reflection• Update list of differential diagnoses• What was missing? What was more or less prevalent?

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Clinical Reasoning

• Deliberate Practice Continued• Compare and contrast diagnoses

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Presenting Symptom: Chest Pain

Symptoms and historical info.

Physical Exam Diagnostic Work-up

Treatment

GERD Subacute, epigastric, burning, supine, relief with antacids

Tenderness to palpation of the epigastrium

History alone, Abnormal EGD

Raise head of bed, change diet, avoid tobacco and alcohol, weight loss, H2 blocker, PPI

Stable Angina Male, advanced age, pressure with radiation to arm or jaw, exertional, +/-SOB, nausea, DM, HTN, HLD, tobacco,+ FmHx

May have murmur, lateral PMI, gallop, paradox split S2, or normal

Abnormal EKG, Dynamic EKG, Stress test, Cath

Modify risk factors such as… weight reduction, DM control, HTN control, smoking cessationASA, statin, +/-ACE-I B-blocker, NTG

Etc.

Blankenburg R. et al.. PAS May 2011. 59

Chest Pain

Cardiac

MI

M>F, >50, DM, HTN, HLD,pressures, radiates to

jaw or arm, exertional, SOB, diaphoresis, NV

High or low BP and HR, tachypnea, listen for MR, diaphoresis

EKG, Trops x3, +/-ECHO, Cath for

STEMI new LBBB

Aspirin, oxygen, B-blocker NTG, Statin, morphine, heparin

gtt

Angina

Similar to MI but intermittent and

accelerating

High or low BP and HR

EKG, trops x3, stress test

Aspirin, oxygen, B-blocker NTG, Statin, morphine, heparin

gtt

MSK GI Pulmonary

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• Deliberate Practice• Review Cases

Exertional Burning PMHxDM 2

AbdominalObesity

No TTP of Epigastrium

GERD -

Angina -

Etc.

Blankenburg R. et al.. PAS May 2011.

Clinical Reasoning

• Feedback

• Re-enforce the use of resources and seniors or consultants for feedback

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Clinical Reasoning

• Reflection

• Reflect on the identifying differences between diagnoses

• What questions would be pertinent while taking a history?

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• Guerrasio J. Aagaard EM. Methods and outcomes for the remediation of poor clinical reasoning. JGIM. 2014:29(12):1607-14.

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DeKosky et al. JGME 2018 in press

DeKosky et al. JGME 2018 in press

DeKosky et al. JGME 2018 in press

Resources:

• Regan L et al. Remediation methods for milestones related to interpersonal and communication skills and professionalism. JGME 2016;2(1):18-23.

• Ann Demarais PhD and Valerie White PhD. First Impressions: What you don’t know about how others see you. Bantam Books. New York, NY: 2004.

• Tasha Eurich. Insight. Crown Business, 2017. • Guerrasio J. Aagaard EM. Methods and outcomes for the remediation of

poor clinical reasoning. JGIM. 2014:29(12):1607-14.• Guerrasio J. et al. Study skills and test taking strategies for coaching

medical learners based on identified areas of struggle. MedEdPORTALPublications. 2017;13:10593.

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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.

Reassessment

• Repeat clerkships/rotations

• Standardized patient encounters & simulation

• Directly observed encounters in clinical environment

• Written or web-based assessments

• Chart reviews & Chart-stimulated recall

• Multi-source evaluations

• Arrival and Departure Times

• Attendance

• Attire

• Responses to self-assessment

• Patient and procedure logs

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Fac

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in H

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Value of Faculty Time?

the odds of probation by 3.1% per hour

negative outcomes by 2.6% per hour

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Graduated Resigned Contract NotRenewed

ImmediateTermination

Currently inPractice

BoardCertification

BoardCitation

Prior to Centralized Remediation

Centralized Remediation Program

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…Passed the clerkship or rotation

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“This learner should never be a doctor”

Summary

Challenge of struggling medical learners exist in all programs

Struggling learners need coaching in

DELIBERATE PRACTICEFEEDBACKREFLECTION IN ACTION

Success for teacher, learner and patients!

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Acknowledgements

My Mentors

• Eva Aagaard, MD

Maureen Garrity, PhD

Carol Rumack, MD

Terri Blevins, EdD

Adina Kalet, MD, MPH

Karen Warburton, MD

Contact: Jeannette.Guerrasio@ucdenver.edu

www.clinicalremediation.com78

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