Remediation in Practice: A Polarity to be Managed.

ABSTRACT: Originally developed in the business literature, a polarity is a concept where 2 distinctive and opposing characteristics (poles), each presenting advantages and disadvantages or opportunities and pitfalls, must both be taken into account to ensure effective management of a challenging problem. Managing a polarity is a thorny endeavor because it entails striving to maximize the benefits of both poles while simultaneously minimizing or controlling the downsides of each. Previous investigations into stakeholder conceptualizations of remediation led us to suggest that remediation is framed in stakeholders' minds simultaneously as an educational endeavor (ie, the remediatee needs educational support to regain full competence) and a regulatory act (ie, the revocation of the individual's professional right to self-regulate their practice and learning). In this article, we argue that viewing remediation for practicing physicians as a polarity to be managed offers a framework that can further the conversation about how to address some of remediation's challenges.

Strangers in a strange land: The experience of physicians undergoing remediation.

INTRODUCTION: The experience of remediation in practising physicians has not been widely studied. Remediatees frequently present negative emotions, but observers can only infer the underlying reasons behind these. Understanding remediatees' perspectives may help those mandating and organising remediation to structure the process in ways that improve the experience for all concerned parties and maximise chances of a successful outcome for remediatees. METHODS: Seventeen physicians who had undergone remediation for clinical competence concerns were interviewed via telephone. Participant data were first iteratively analysed thematically and then reanalysed using a narrative mode of analysis for each participant in order to understand the stories as wholes. Figured worlds (FW) theory was used as a lens for analysing the data for this constructivist research study. RESULTS: Participants entering the FW of remediation perceived that their position as a 'good doctor' was threatened. Lacking experience with this world and with little available support to help them navigate it, participants used their agency to draw on various discursive threads within the FW to construct a narrative account of their remediation. In their narratives, participants tended to position themselves either as victims of regulatory bodies or as resilient individuals who could make the best of a difficult situation. In both cases, the chosen discursive threads enabled them to maintain their self-identity as 'good doctor'. CONCLUSION: Remediation poses a threat to a physician's professional and personal identity. Focusing mainly on the educational aspect of remediation-that is, the improvement in knowledge and skills-risks missing its impact on physician identity. We need to ensure not only that we support physicians in dealing with this identity threat but that our assessment and remediation processes do not inadvertently encourage remediatees to draw on discursive threads that lead them to see themselves as victims.

Experiential learning, collaboration and reflection: key ingredients in longitudinal faculty development.

BACKGROUND: Longitudinal faculty development (LFD) may allow for increased uptake of teaching skills, especially in a forum where teachers can reflect individually and collectively on the new skills. However, the exact processes by which such interventions are effective need further exploration. METHODS: This qualitative study examined an LFD initiative teaching a novel feedback approach attended by five family practice physicians. The initiative began with two 1.5-hour workshops: Goal-Oriented Feedback (as the teaching skill to be developed) and Narrative Reflection (as the tool to support personal reflection on the skill being learned). Over the subsequent six-months, the five participants iteratively applied the feedback approach in their teaching and engaged in narrative reflection at four 1-hour group sessions. Transcripts from the group discussions and exit interviews were analyzed using thematic analysis. RESULTS: Iteratively trialing, individually reflecting on, and collectively exploring efforts to implement the new feedback approach resulted in the development of a learning community among the group. This sense of community created a safe space for reflection, while motivating ongoing efforts to learn the skill. Individual pre-reflection prepared individuals for group co-reflection; however, written narratives were not essential. CONCLUSION: LFD initiatives should include an emphasis on ensuring opportunities for iterative attempts of teaching skills, guided self-reflection, and collaborative group reflection and learning to ensure sustainable change to teaching practices.

CONTEXTE: La formation professorale longitudinale (FPL) peut faciliter l'acquisition d'habiletés pédagogiques, surtout dans le cadre d'un forum où les enseignants peuvent réfléchir individuellement et collectivement à ces nouvelles habiletés. Cependant, les processus exacts qui rendent ces interventions efficaces doivent être explorés davantage. MÉTHODES: Cette étude qualitative examine une initiative de FPL qui comprend l'enseignement d'une nouvelle approche de rétroaction à laquelle ont participé cinq médecins de famille. L'initiative a commencé avec la tenue de deux ateliers d'une heure et demie, le premier sur la rétroaction axée sur les objectifs (l'habileté d'enseignement à développer) et le deuxième sur la réflexion narrative (comme outil pour soutenir la réflexion personnelle sur cette habileté en apprentissage). Au cours des six mois suivants, les cinq participants ont appliqué de manière itérative l'approche de la rétroaction dans leur enseignement et se sont livrés à une réflexion narrative lors de quatre séances de groupe d'une heure. Des transcriptions des discussions de groupe et des entretiens de clôture ont fait l'objet d'une analyse thématique. RÉSULTATS: L'expérimentation itérative, la réflexion individuelle et l'exploration collective des efforts de mise en œuvre de la nouvelle approche de rétroaction ont permis de développer une communauté d'apprentissage au sein du groupe. Ce sentiment de communauté a créé un environnement sûr pour la réflexion, tout en motivant les efforts continus pour apprendre l'habileté. La préréflexion individuelle préparait les participants à la co-réflexion de groupe; cependant, les récits écrits n'étaient pas essentiels. CONCLUSION: Les initiatives de FPL devraient mettre l'emphase sur les occasions de mise en application itérative des habiletés d'enseignement, d'autoréflexion guidée et de réflexion et d'apprentissage collaboratifs en groupe pour assurer un changement durable des pratiques d'enseignement.

Educator, judge, public defender: Conflicting roles for remediators of practising physicians.

CONTEXT: Practising physicians who remediate their peers face unique challenges. Recent research suggests that leaders of regulatory and educational institutions (ie, those who might be seen as responsible for overseeing remediation programmes for practising physicians) view remediation as a duality: education and regulation. Research has yet to study the perspectives of remediators; therefore, to address that gap we asked: What is the nature of remediation as experienced by remediators? METHODS: We used a theory-informing inductive data analysis study design with positioning theory as a sensitising concept. We interviewed nine remediators from five Canadian provinces, asking them to narrate particularly memorable remediation experiences, then exploring the stories in more depth by asking probing questions around topics related to the research question. We used a hermeneutic analytic approach to explore the meanings that participants gave to their remediation work by iteratively reading their stories, examining the sense making that participants achieved through these narratives, and identifying the positions and responsibilities they described. RESULTS: In their remediation narratives, participants variably position themselves in three different ways: (a) educator; (b) judge, and (c) public defender. For each position, remediators in turn framed the remediatee in a particular way. Participants shifted between educator, judge and public defender in response to evolving experiences with the remediatee, but they expressed preference for the educator position. However, they sometimes encountered serious obstacles to enacting that educator position. Those obstacles were imposed both by regulators and by remediatees. CONCLUSIONS: This study suggests that the duality of remediation as both education and regulation may be contributing to the challenges faced by those working one to one with remediatees. Understanding the dual nature of remediation and equipping remediators with the tools to manage this duality might contribute to improving the experience for both remediators and remediatees, and ultimately to a greater number of successful remediation outcomes.

Attitudes Towards Physicians Requiring Remediation: One-of-Us or Not-Like-Us?

PURPOSE: The data for this paper were collected as part of a larger project exploring how the medical profession conceptualizes the task of supporting physicians struggling with clinical competency issues. In this paper, the authors focus on a topic that has been absent in the literature thus far-how physicians requiring remediation are perceived by those responsible for organizing remediation and by their peers in general. METHOD: Using a constructivist grounded theory approach, the authors conducted semistructured interviews with 17 remediation stakeholders across Canada. Given that in Canada health is a provincial responsibility, the authors purposively sampled stakeholders from across provincial and language borders and across the full range of organizations that could be considered as participating in the remediation of practicing physicians. RESULTS: Interviewees expressed mixed, sometimes contradictory, emotions toward and perceptions of physicians requiring remediation. They also noted that their colleagues, including physicians in training, were not always sympathetic to their struggling peers. CONCLUSIONS: The medical profession's attitude toward those who struggle with clinical competency-as individuals and as a whole-is ambivalent at best. This ambivalence grows out of psychological and cultural factors and may be an undiscussed factor in the profession's struggle to deal adequately with underperforming members. To contend with the challenge of remediating practicing physicians, the profession needs to address this ambivalence and its underlying causes.

Your Goals, My Goals, Our Goals: The Complexity of Coconstructing Goals with Learners in Medical Education.

Phenomenon: Despite a long-standing recognition of the importance of learning goals in feedback, there has been relatively little research on how to address mismatches between learner goals and preceptor goals in medical education. Our study addresses this gap by reporting on challenges and strategies around goal coconstruction as identified by clinical educators who were learning and attempting to implement a goal-oriented feedback approach in their own teaching contexts. Approach: We employed a qualitative, design-based research methodology to study how 5 clinician educators incorporated goal-oriented feedback into their teaching practice. Participants attended workshops on goal-oriented feedback and reflective writing. They then narratively reflected over a 6-month period on their attempts with goal-oriented feedback and shared these reflections in periodic facilitated group discussions. Themes were developed using iterative thematic analysis of group discussions and individual exit interviews. Findings: Participants identified several benefits of goal setting in all environments. They perceived improved rapport with learners and developed empathy for the vastness of learner goals. However, they experienced several struggles especially when learner and preceptor goals did not match. These included (a) how to address learner goals that were not easily amenable to a coconstruction, (b) how to coconstruct goals while actively running a clinical practice, and (c) how to remain learner centered while raising preceptor goals based on perceived gaps. Insights: Mismatches between learner and preceptor goals are inevitable and frequent. Preceptors must find ways to coconstruct goals with learners in various learning environments. That said, in enacting goal-oriented feedback, preceptors are effectively using feedback throughout the teaching and learning interaction to coconstruct the learning environment, resulting in improved rapport with learners and emphasizing why it is important to focus feedback around goals.

Education or regulation? Exploring our underlying conceptualisations of remediation for practising physicians.

CONTEXT: The remediation of practising physicians is coming to the fore in several countries in response to increasing demands for physician accountability and quality improvement initiatives in health care. However, the profession continues to grapple with the concepts and processes of remediation, particularly for physicians in practice who struggle with performance issues related to clinical competence. This suggests that current conceptualisations of remediation might be contributing to this situation. This study therefore, explored how various administration-level stakeholders conceptualise remediation in order to construct a description of the nature and meaning of remediation. METHODS: Semi-structured interviews were conducted using purposive sampling across the range of Canadian stakeholders involved in the remediation of practising physicians, including regulatory authorities, universities, national certifying bodies and medical organisations. With the use of constructivist grounded theory processes, analysis proceeded apace with data collection in an iterative process, with initial insights guiding subsequent interviews. RESULTS: Participants often simultaneously held two different conceptualisations of remediation: (i) remediation as part of an educational continuum involving different degrees of support, and (ii) remediation as a regulatory process removing an individual's educational autonomy. Interviewees moved between these two conceptualisations but did not always appear to be aware of doing so. These conceptualisations each had different implications regarding the degree to which remediation can be incorporated into professional processes of maintaining competence. CONCLUSIONS: Understanding that stakeholders frequently approach the complex issue of remediation with two different perspectives without conscious awareness of doing so may help to explain several challenges in the field, including the issues of what falls under the umbrella of remediation and who should be responsible for offering remediation support. Our findings suggest the need for conceptual clarity around remediation, both to ensure that we illuminate logistical dilemmas in enacting remediation and to address the stigma of 'de-professionalisation' that the provision of even minor educational supports (such as feedback) might invoke by association.

Remediation in Practicing Physicians: Current and Alternative Conceptualizations.

Suboptimal performance in practicing physicians is a decades-old problem. The lack of a universally accepted definition of remediation, the paucity of research on best remediation practices, and the ongoing controversy regarding the institutional responsibility for enacting and overseeing the remediation of physicians suggest that it is not merely a difficult problem to solve but a problem that the community does not grapple with meaningfully. Undoubtedly, logistical and political considerations contribute to this state of affairs; however, other underlying conceptual issues may also play a role in the medical profession's difficulties in engaging with the challenges around remediation.Through a review of the medical education and other literatures, the authors examined current conceptualizations of both reme-diation itself and the individual being remediated, as well as how the culture of medicine influences these conceptions. The authors explored how conceptualizations of remediation and the surrounding culture might affect not only the medical community's ability to support but also its willingness to engage with physicians in need of remediation.Viewing remediation as a means of supporting practice change-rather than as a means of redressing gaps in knowledge and skill-might be a useful alternative conceptualization, providing a good place to start exploring new avenues of research. However, moving forward will require more than simply a reconceptualization of remediation; it will also necessitate a change in how the community views its struggling members and a change in the medical culture that currently positions professional autonomy as the foundational premise for individual practice improvement.

An autoethnographic exploration of the use of goal oriented feedback to enhance brief clinical teaching encounters.

Supervision in the outpatient context is increasingly in the form of single day interactions between students and preceptors. This creates difficulties for effective feedback, which often depends on a strong relationship of trust between preceptor and student. Building on feedback theories focusing on the relational and dialogic aspects of feedback, this study explored the use of goal-oriented feedback in brief encounters with learners. This study used autoethnography to explore one preceptor's feedback interactions over an eight-month period both in the ambulatory setting and on the wards. Data included written narrative reflections on feedback interactions with twenty-three learners informed by discussions with colleagues and repeated reading of feedback literature. Thematic and narrative analyses of data were performed iteratively. Data analysis emphasized four recurrent themes. (1) Goal discussions were most effective when initiated early and integrated throughout the learning experience. (2) Both learner and preceptor goals were multiple and varied, and feedback needed to reflect this complexity. (3) Negotiation or co-construction of goals was important when considering the focus of feedback discussions in order to create safer, more effective interactions. (4) Goal oriented interactions offer potential benefits to the learner and preceptor. Goal oriented feedback promotes dialogue as it requires both preceptor and learner to acknowledge and negotiate learning goals throughout their interaction. In doing so, feedback becomes an explicit component of the preceptor-learner relationship. This enhances feedback interactions even in relatively brief encounters, and may begin an early educational alliance that can be elaborated with longer interactions.

Autoethnography: introducing 'I' into medical education research.

CONTEXT: Autoethnography is a methodology that allows clinician-educators to research their own cultures, sharing insights about their own teaching and learning journeys in ways that will resonate with others. There are few examples of autoethnographic research in medical education, and many areas would benefit from this methodology to help improve understanding of, for example, teacher-learner interactions, transitions and interprofessional development. OBJECTIVES: We wish to share this methodology so that others may consider it in their own education environments as a viable qualitative research approach to gain new insights and understandings. METHODS: This paper introduces autoethnography, discusses important considerations in terms of data collection and analysis, explores ethical aspects of writing about others and considers the benefits and limitations of conducting research that includes self. RESULTS: Autoethnography allows medical educators to increasingly engage in self-reflective narration while analysing their own cultural biographies. It moves beyond simple autobiography through the inclusion of other voices and the analytical examination of the relationships between self and others. Autoethnography has achieved its goal if it results in new insights and improvements in personal teaching practices, and if it promotes broader reflection amongst readers about their own teaching and learning environments. CONCLUSIONS: Researchers should consider autoethnography as an important methodology to help advance our understanding of the culture and practices of medical education.

A comparison of performance assessment programs for medical practitioners in Canada, Australia, New Zealand, and the United kingdom.

PURPOSE: To compare programs designed to assess the performance of practicing doctors in Canada, Australia, New Zealand, and the United Kingdom. METHODS: Senior representatives of 11 organizations undertaking performance assessments were invited to provide a description of their programs, using a standardized written questionnaire. RESULTS: Collectively, the 11 organizations provide 16 performance assessment programs that operate on three levels: those that screen populations of doctors (Level 1), those that target "at risk" groups (Level 2), and those that assess individuals who may be performing poorly (Level 3). The 16 programs differ in such areas as the number of doctors enrolled, the number of assessments undertaken, the referral mechanisms, the outcomes of assessment, and in the resources provided for the task. They particularly differ in their choice of tools to assess performance. CONCLUSION: Although a uniform international approach to performance assessment may be neither feasible nor desirable, an international comparison of current practice, as provided in this report, should stimulate further debate on the development of better performance assessment processes.