The Evolution of Resident Remedial Teaching at One Institution.

Residency program directors and teaching faculty invest an enormous amount of time, energy, and resources in providing underperforming at-risk learners with remedial teaching. A remediation program was created and centralized at the University of Colorado School of Medicine in 2006 and 2012, respectively, that consolidated expertise in and resources for learner assessment and individualized teaching for struggling learners, particularly those placed on probation or receiving letters of warning (called focused review letters) from their residency programs. Since the implementation of the program, the authors have observed a decrease in the number of residents being placed on probation, and, of those on probation, more are graduating and obtaining board certification. In this Article, the authors aim to describe the development and outcomes of the program and to explore possible reasons for the improved outcomes.

Long-Term Outcomes of a Simulation-Based Remediation for Residents and Faculty With Unprofessional Behavior.

BACKGROUND: There are few studies describing remediation for unprofessional behavior in residents and faculty and none that assess the long-term impact of remediation. OBJECTIVE: We implemented a simulation-based personalized remediation program for unprofessional behavior in residents and faculty and collected assessments from participants and referring supervisors. METHODS: Residents and faculty were referred for unprofessional behaviors, including aggressive, condescending, and argumentative communication styles as well as an inability to read social cues. We had standardized patients recreate the scenarios that triggered the unprofessional behavior. After each scenario, participants reviewed a videotape of their performance, participated in guided self-reflection and feedback, and then iteratively practiced skills. In 2017, about 2 to 4 years after the intervention, we conducted structured phenomenological qualitative interviews until thematic saturation was reached. Transcripts were analyzed inductively for themes by 2 reviewers (J.G. and research assistant). RESULTS: Requests for interviews were sent to 16 residents, 8 faculty members, and 24 supervisors, including program directors. Nine remediation participants (38%) and 19 referring supervisors (79%) were interviewed. Sixteen supervisors reported no recurrence of unprofessional behavior in participants 2 to 4 years after the intervention, and participants identified behavioral strategies to reduce unprofessional behavior. Participants and respective supervisors reported similar themes of behavior changes that resulted in improved professional interaction with others. CONCLUSIONS: A simulation-based personalized remediation program for unprofessional behavior, where faculty and residents practice behaviors with guided feedback, can lead to sustained positive behavior change in participants.

Defining Medical Student Patient Care Responsibilities Before Intern Year: Results of a National Survey.

OBJECTIVES: Program directors have noted that first-year residents struggle with many of the patient care responsibilities they assume as they enter the US graduate medical education system. A national description of medical students' patient care experience in advance of graduation has not been published. We sought to describe the experience of US medical students during their clinical training by surveying the student representatives of each school. METHODS: We developed a mixed-methods survey that was delivered to representatives of 82 schools via an e-mail link to an online survey. RESULTS: Our response rate was 54% (44/82). Of those responding, 28% reported that students do not write any patient care orders at their institution and 34% reported not receiving pages related to patient care. Only 26% of institutions provide an increased patient load to students during their final year of training. Students identified many areas to improve the role of fourth-year medical students, including writing patient care orders, answering pages, increasing autonomy, defining their role better, and providing them with a longer subinternship experience. CONCLUSIONS: Our survey suggests that students are graduating from the undergraduate medical education system and moving to the graduate medical education system in the United States without a guarantee of having answered a page related to patient care or having placed a patient care order. Further studies of students' experiences should be conducted to explore whether exposure to these skills improves first-year resident performance.

A qualitative study of medical educators' perspectives on remediation: Adopting a holistic approach to struggling residents.

INTRODUCTION: During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation. METHODS: We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis. RESULTS: Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation. CONCLUSIONS: The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

Academic Remediation: Why Early Identification and Intervention Matters.

At our institution, we have developed a remediation team of strong, focused experts who help us with struggling learners in making the diagnosis and then coaching on their milestone deficits. It is key for all program directors to recognize struggling residents because early recognition and intervention gives the resident the best chance of success.

Study Skills and Test Taking Strategies for Coaching Medical Learners Based on Identified Areas of Struggle.

INTRODUCTION: Learners in high-performing contexts such as medical school and residency are presumed to have appropriate study skills to be successful. However, for those learners in academic difficulty who are identified as having weak study skills and poor test taking skills, faculty need tools to use to lead these struggling learners to academic success. In coaching learners on study skills, we frequently found that the study skills that helped them get into medical school or residency were no longer sufficient to make them successful in their new program. Given that there are multiple study strategies available, faculty coaches need mechanisms to first tease out which skills are the issue and then provide targeted strategies specific to each learner. METHODS: In meeting with a faculty coach, learners are briefly interviewed, complete a self-assessment to explore all possible root weaknesses in their study skills, and then read strategic solutions and review with faculty how they may be implemented. This tool has been offered to 52 students, 76 residents, and 20 fellows and faculty between 2010 and 2015. RESULTS: One hundred forty-eight individuals participated in this innovation, with more than 91% of all individuals going on to pass the exam that they had either failed or, in the case of the in-training exam, scored below the 30th percentile on. CONCLUSION: A self-assessment tool is key to individualized insight and action plans for improving study skills. Implementation must be supported with concurrent in-person coaching.

Twelve tips for developing and maintaining a remediation program in medical education.

Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors' three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

Heuristic errors in clinical reasoning.

PURPOSE: Errors in clinical reasoning contribute to patient morbidity and mortality. The purpose of this study was to determine the types of heuristic errors made by third-year medical students and first-year residents. METHODS: This study surveyed approximately 150 clinical educators inquiring about the types of heuristic errors they observed in third-year medical students and first-year residents. RESULTS: Anchoring and premature closure were the two most common errors observed amongst third-year medical students and first-year residents. There was no difference in the types of errors observed in the two groups. Errors in clinical reasoning contribute to patient morbidity and mortality CONCLUSIONS: Clinical educators perceived that both third-year medical students and first-year residents committed similar heuristic errors, implying that additional medical knowledge and clinical experience do not affect the types of heuristic errors made. Further work is needed to help identify methods that can be used to reduce heuristic errors early in a clinician's education.

Association of Characteristics, Deficits, and Outcomes of Residents Placed on Probation at One Institution, 2002-2012.

PURPOSE: To describe the population of residents placed on probation, identify learner characteristics associated with being placed on probation, and describe immediate and long-term career outcomes for those placed on probation as compared with matched controls. METHOD: The authors collected data for residents at the University of Colorado School of Medicine placed on probation from July 2002 to June 2012, including postgraduate year placed on probation, deficits identified, mandated evaluation for physical and mental health, duration of probation, disability accommodations requested, and number of additional training months required. They were retrospectively compared with 102 controls matched for specialty, matriculation, and postgraduate year. Variables assessed included demographics, academic performance, license status, specialty, state board certification, and board citations. RESULTS: Of 3,091 residents, 3.3% were placed on probation (88 residents; 14 fellows). Compared with controls, those on probation were more likely to be international medical graduates, married, not Caucasian, older (all P < .001), male (P = .01), to have transferred from another graduate medical education training program, and to have taken time off between medical school and residency (all P < .001). Among those currently in practice, 53 (63.9%) were board certified compared with 93 (100%) of the controls. Placement on probation was associated with failure to graduate and lack of board certification. All 7 graduates cited by state medical boards were in the probation group. CONCLUSIONS: Further research is needed to understand these associations and to determine whether changes in curricula or remediation programs may alter these outcomes.

Methods and outcomes for the remediation of clinical reasoning.

INTRODUCTION: There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills. AIM: To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training. SETTING: Learners enrolled in the University of Colorado School of Medicine Remediation Program. PROGRAM DESCRIPTION: From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked. PROGRAM EVALUATION: Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p = 0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD = 29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fifty-one of the 53 (96%) passed the post remediation reassessment. Thirty-eight (72%) learners either graduated from their original program or continue to practice in good standing. Four (8%) additional residents who were placed on probation and five (9%) who transferred to another program have since graduated. DISCUSSION: The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.

Failure to fail: the institutional perspective.

PURPOSE: To determine institutional barriers to placing failing students on probation, dismissing students. METHODS: An online survey study was distributed to Student Affairs Deans or the equivalent at allopathic (MD) and osteopathic (DO) medical schools, and physician assistant (PA) and nurse practitioner (NP) schools across the United States. Nineteen (40%) of the 48 schools responded: six MD, four DO, five PA and four NP. The survey contained demographic questions and questions regarding probation and dismissal. Themes were independently coded and combined via consensus based on grounded theory. The survey was distributed until saturation of qualitative responses were achieved. RESULTS: Respondents identified variations in the use of probation and dismissal and a wide range of barriers, with the greatest emphasis on legal concerns. Respondents felt that students were graduating who should not be allowed to graduate, and that the likelihood of a student being placed on probation or being terminated was highly variable. DISCUSSION: Our results suggest that institution culture at heath professions schools across the United States may represent an obstacle in placing failing learners on probation and dismissing learners who should not graduate. Additional studies are needed to prove if these concerns are founded or merely fears.

Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012.

PURPOSE: To identify deficit types and predictors of poor academic outcomes among students, residents, fellows, and physicians referred to the University of Colorado School of Medicine's remediation program. METHOD: During 2006-2012, 151 learners were referred. After a standardized assessment process, program faculty developed individualized learning plans that incorporated deliberate practice, feedback, and reflection, followed by independent reassessment. The authors collected data on training levels, identified deficits, remediation plan details, outcomes, and faculty time invested. They examined relationships between gender, training level, and specific deficits. They analyzed faculty time by deficit and explored predictors of negative outcomes. RESULTS: Most learners had more than one deficit; medical knowledge, clinical reasoning, and professionalism were most common. Medical students were more likely than others to have mental well-being issues (P = .03), whereas the prevalence of professionalism deficits increased steadily as training level increased. Men struggled more than women with communication (P = .01) and mental well-being. Poor professionalism was the only predictor of probationary status (P < .001), and probation was a predictor of other negative outcomes (P < .0001). Remediation of clinical reasoning and mental well-being deficits required significantly more faculty time (P < .001 and P = .03, respectively). Per hour, faculty face time reduced the odds of probation by 3.1% (95% CI, 0.09-0.63) and all negative outcomes by 2.6% (95% CI, 0.96-0.99). CONCLUSIONS: Remediation required substantial resources but was successful for 90% of learners. Future studies should compare remediation strategies and assess how to optimize faculty time.

Determining need for remediation through postrotation evaluations.

INTRODUCTION: Postrotation evaluations are frequently used by residency program directors for early detection of residents with academic difficulties; however, the accuracy of these evaluations in assessing resident performance has been questioned. METHODS: This retrospective case-control study examines the ability of postrotation evaluation characteristics to predict the need for remediation. We compared the evaluations of 17 residents who were placed on academic warning or probation, from 2000 to 2007, with those for a group of peers matched on sex, postgraduate year (PGY), and entering class. RESULTS: The presence of an outlier evaluation, the number of words written in the comments section, and the percentage of evaluations with negative or ambiguous comments were all associated with the need for remediation (P  =  .01, P  =  .001, P  =  .002, P  =  < .001, respectively). In contrast, United States Medical Licensing Examination step 1 and step 2 scores, total number of evaluations received, and percentage of positive comments on the evaluations were not associated with the need for remediation (P  =  .06, P  =  .87, P  =  .55, respectively). DISCUSSION: Despite ambiguous evaluation comments, the length and percentage of ambiguous or negative comments did indicate future need for remediation. CONCLUSIONS: Our study demonstrates that postrotation evaluation characteristics can be used to identify residents as risk. However, larger prospective studies, encompassing multiple institutions, are needed to validate various evaluation methods in measuring resident performance and to accurately predict the need for remediation.

Evaluation of a hospitalist-run acute care for the elderly service.

BACKGROUND: Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm. OBJECTIVE: To evaluate a Hospitalist-run Acute Care for the Elderly (Hospitalist-ACE) service. DESIGN: Quasi-randomized, controlled trial. SETTING: Urban academic medical center. PATIENTS: Medical inpatients age ≥70 years. INTERVENTION: Hospitalist-ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum. MEASURES: The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls. RESULTS: One hundred twenty-two Hospitalist-ACE patients were compared to 95 usual care patients. Hospitalist-ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of "Do Not Attempt Resuscitation" orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist-ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30-day readmission rates (12% vs 10%, P = 0.50). CONCLUSIONS: A Hospitalist-ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed.

Creutzfeldt-Jacob disease presenting as severe depression: a case report.

BACKGROUND: An 81 year old female presented with altered mental status after new onset of severe depression and suicidal ideation with recent psychiatric hospitalization. CASE PRESENTATION: Key clinical features included muscle rigidity, prominent startle reflex, and rapidly progressing cognitive decline. Initial working hypothesis was serotonin syndrome or neuroleptic malignant syndrome but continued deterioration after medication removal prompted evaluation for alternative etiology. Work-up revealed elevated 14-3-3 CSF protein which suggested the prion disorder which was confirmed on post-mortem examination of brain tissue. CONCLUSION: While the degree of depression was unusually severe, the case highlights the behavioral and psychiatric manifestations which frequently accompany Creutzfeldt-Jacob disease.