The Problem Resident

Program Director WorkshopUniversity of Mississippi Medical Center

February 2009

The Agenda

• Identifying the Problem Resident• Probation and Remediation Processes• Outcomes for Problem Residents• Documentation and Future Credentialing

TOOLS for Success

Assumptions:

• Written Curriculum with Defined Goals and Objectives

• Outcomes and Competency based Evaluations completed regularly

• Multi-evaluator In-put (360*)• At LEAST semi-annual performance evaluation

meetings with residents!

“Competence”

• Professional competence is the habitual and judicious use of communication, knowledge, technical skills, reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served (knowledge, skills, attitudes)

“Competency”• Main Entry: com·pe·tent

1 : proper or rightly pertinent2 : having requisite or adequate ability or qualities : FIT

3 : legally qualified or adequate 4 : having the capacity to function or develop in a particular way; specifically : having the capacity to respond (as by producing an antibody) to an antigenic determinant

• synonym see SUFFICIENT

Competency In GME• Historically like pornography? (“know it when you see

it…”)• Ad hoc local standards, assessment tools• Traditionally defined around “Knowledge, Skills,

Attitudes”• National and LOCAL focus on “accountability,” patient

safety, quality of medical care• 2001 ACGME and ABMS defined 6 domains of

“competency”• ALL physicians completing graduate medical training

must be competent in all 6 areas

Competence Problems May be Reflected in:

• Lack of knowledge• Inadequate clinical skills, patient care• Deficient Technical or Procedural skills• Poor Judgment• Ineffective Communication skills• Inability and/or unwillingness to acquire and integrate

professional standards into one’s repertoire of professional behavior

• Lack of personal insight or self-awareness• Inability to control personal stress or emotional

reactions that interfere with professional functioning (conduct or emotional problem) and participation in teams

Red Flags:

• A disproportionate amount of attention by training personnel is required

• Grumbling from peers• The trainee’s behavior does not change as a

function of feedback, remediation efforts, and / or time invested (by trainee or program director!!!)

Developmentally Normative Issues to be Ruled Out:

• Transition issues• Mild performance anxiety• Mild discomfort with diverse patient groups or

multi-disciplinary team members• Initial lack of understanding of the facility’s or

institution’s norms• Lack of certain skills sets, but an openness and

readiness to acquire them

Context Issues to be Considered:

• Separation from support systems• Adjustment issues to new setting both

personally and professionally• Changes in status (finances or power)• Impact of Significant life events• Personal Risk Factors (substance abuse, ADD,

other psychiatric disorders, etc.)

“Secondary” Causes of Poor Performance:

• Depression: Major, minor, situational• Distraction: Concerns about children,

relationships; need to manage family or personal illness

• Deprivation: sleep, food, social interaction, money?

• Drugs: Alcohol, prescription, illicit• Disordered personality: OCD, borderline, etc.

OK, So you think there’s a problem:

• Inadequate knowledge base• Can’t keep up with patient care “pace”

expected for training level• Constantly late for everything• Patient management is algorithmic and misses

the subtle stuff• Irritates everyone s/he comes in contact with

Helpful to Categorize the Problem:

• Factual Knowledge• Judgment • Motor Skills• Communication Skills• Responsibility• Efficiency• Organization • Self-Confidence

• Attitude / motivation• Humanism• Multi-tasking• Problem Solving• Stress Response• Well-being• Substance Abuse• Behavioral Disorder

USE

THE

COMPETENCIES

!!!!!!!!!!

Obtain OBJECTIVE data– Written examples of sub-optimal

performance in patient care– Medical Knowledge assessment scores– Evaluations from faculty, peers, nurses,

program administrators, etc.– Output measures (numbers of procedures;

volume of patients seen in clinic, films read, etc.) compared to peer group

Opportunities for Documentation:• Direct observation in clinical setting• Critical incident• Monthly evals (written and verbal)• Chart review / medical record audit• Reports from nurses or patients• Videotaped patient encounters• Standardized patients• Clinical Evaluation Exercise (CEX)• In-training exams• Presentations at morning report or conferences• Resident self-assessment

Faculty Challenges:• Expected outcomes and objective measures of

competence often poorly defined• Inadequate oversight of actual trainee

performance at bedside or in “working” clinical settings (poor data collection!)

• Apprehension about defending evaluations• Concern regarding potential repercussions

from trainee including litigation• Laziness!!!• “Nice-guy” syndrome

Provide Feedback to the Resident (EARLY!!!)

• Chief Resident could be first step• Mentor or Program Director Meeting next• Ask for trainee self-assessment• Outline problems identified by program leaders• Group by competency area• Optimally identify areas of concern orally and in

writing• Require development of a Performance

Improvement plan with measurable outcomes

The Unpleasant Meeting:• Thank resident for coming to the meeting• Always act in a respectful manner• Explain the purpose of the meeting• Assume likelihood of miscommunication and paraphrase frequently• Ask the resident to hear you out first• Start by communicating the physician’s value and worth• State in detail and very specifically concerns about performance• Make it clear performance must change• Provide opportunity for resident to respond• Do not become angry• If pertinent, indicate that no retribution will be tolerated• Develop a corrective action plan • Summarize meeting and define consequences of NO performance change• Write a summary of the meeting and ask the resident to sign the summary

reflecting accuracy of content as a report of the meeting.

Institutional Resources

• Student Employee Health• Academic Affairs / Learning Resources• Simulation Center• Clinical Psychologists• Multi-Cultural Affairs• Human Resources / EEO • GME Office• Mississippi Health Professional’s Program

Remediation Considerations:

• Increasing Supervision, either with the same or new supervisors

• Changing the format of supervision• Reducing or shifting the trainee’s workload• Requiring specific academic review

(completion of study guides, text reviews, question reviews)

• Consider when appropriate a leave of absence

Proposed Stages of Unresolved Problem Management:

• Notice of inadequate performance and development of Performance Improvement Plan (informal)

• Formal Warning in writing & PIP revision• Notice of Probation (reportable in credentialing

paperwork) & PIP revision (due process opportunity)

• Prolongation of training OR TerminationContinue close monitoring & f/u throughout!!!

At EVERY Intervention Stage:• Specify problem behaviors• Require articulation of expected behavior

changes• Define MEASURABLE outcomes, goals,

benchmarks• Hold trainee accountable for plans (sign-off)• Continue DATA collection from various sources• FOLLOW THROUGH as promised

Formal Probation• “Reportable” in future credentialing documents• Defined time frame (Usually 3-6 months)• At least monthly evals (multi-source)• Close scrutiny of trainee behavior• Resident should sign written document which

outlines terms of probation, goals for improvement

• Optimally provide monthly feedback to trainee

Probation• Notify GME Office of Trainees placed on Formal

Probation• Have written probation documents reviewed by

GME and legal prior to presentation to resident (provide copy to trainee)

• Provide Grievance / Due Process Policy to trainee• If performance goals not achieved in specified

time, 3 options:– Extend Probation– Extend training time– Terminate trainee, usually at end of contract

Termination• Offer trainee option of resignation• Include career counseling regarding future

options• Review documentation with GME, Legal, and HR• Written notification to trainee reiterating

probationary conditions, trainee’s response, reason for dismissal

• Determine time frame for termination (immediate versus non-renewal of contract)

• Prepare statement to be attached to future credentialing requests and provide copy to trainee

Due Process & Legal Requirements

• Academic Due Process• Employee / HR Due Process

• Academic Problems• Behavior / Employment Issues

We are never expected or required to leave a DANGEROUS trainee active in a training program!!!

Academic Due ProcessSchools are free to dismiss, or fail to promote students, as long as they

assure students:

• Notice of performance problems, competence deficits

• Opportunity to demonstrate improvement to expected level of performance

• A reasoned and thoughtful decision regarding termination, extension of training, or other adverse consequence.

• Opportunity for appeal

Employment Due Process

• Notice of performance problems, policy or expectation violations

• Opportunity to explain behavior or performance

• Reasonable decision-making process regarding adverse action (can not be “arbitrary and capricious”)

• Opportunity for appeal

Legal Requirements for Misconduct Cases

• Schools (and Employers) are not required to give Residents an

Opportunity to repeat Misconduct.

The ACGME Requirements

• Fair and Reasonable Written Grievance and Due Process policies and procedures that address:– academic or other disciplinary actions taken

against residents that could result in nonrenewal or other action that could significantly threaten a resident’s intended career development; AND

The ACGME Requirements

– Adjudication of Resident Complaints and Grievances related to work environment or issues related to the program or faculty; AND

– Protect Resident from Retaliation; AND– Allow Resident to address concerns in a

Confidential and Protected Manner. – Written contracts for each year of training.

Long Term Implications:• Prior to a problem trainee’s graduation

– Determine what is appropriate to report in future referencing and credentialing documents

– All Formal Probation will likely require report– Prepare a document out-lining the problems and

their resolutions– What will you, and will you not, recommend the

resident for?– Discuss fully with the trainee and provide a copy of

your summary document– Emphasize importance of disclosure to trainee!!!

If trainee requires termination:

• Provide or refer for career counseling• Are they likely to transition successfully to

another residency training program? Same specialty? Different specialty?

• Utilize institutional resources including other program directors, counselors

Fears and Myths:

• Fear of compromised rapport or hostility from other trainees

• Concern for damaging resident’s career• Fear of being “sued”• Fear of adverse institutional publicity• Concern for impact on the applicant pool• Potential for loss of budgeted spots (with

extension of training)

A Comment on Disability & “Reasonable Accommodation”:

• Does not lower academic standards• Does not require substantial program

alterations• Does not entail undue financial burden• The resident must STILL meet ALL of the

program’s requirements

Hints for Success:• Make expectations CLEAR• Develop evaluation tools which provide OBJECTIVE

data• Involve faculty mentor or develop mentorship

program• Actively involve faculty / education committee• Begin remediation processes early• NEVER assume a problem will resolve itself!!!• Develop a realistic and targeted remediation plan• Ask for help (other PD’s, HR, DIO)• Respect resident confidentiality

Frames

of

Reference…

Model Behavior• Energetic• Responsible• Reads / studies regularly• Punctual, strong foundation in professional

behavior and personal integrity• Communicates confidently and appropriately• Takes on more responsibilities than expected

with excellent follow through• Looks for ways to increase their skills and is

appreciative of training experience and opportunities

Less than Desirable Behavior

• Slacker, does less than expected• Hides important information• Never volunteers for important tasks or to

assist colleagues at crunch times• Criticizes experience, shifts blame, feels they

are asked to do too much• Lack of competence in any of the defined

ACGME domains

Disruptive Behavior

• Mildly manipulative behavior (“forgets” conversations, gets others to do their work)

• Shows up late for assigned activities• Unprepared for rounds or didactics• Encourages divisiveness among colleagues and /

or ancillary health care professionals• Interpersonal difficulties, poor team player• Anger management issues• “Axis” disorders