My Trainee is Failing, Now What to Do?

Remediation Cases

This session is designed to discuss different types of remediation cases in a small

group format, emphasizing the difficult to remediate competencies. After this session,
participants will be able to discuss strategies for various types of remediation cases

Why is this individual failing?

• Knowledge
• Skill or Ability (bad hands)
• Application of knowledge and/or skill
• Professionalism or Interpersonal Communication
• Career mismatch - poor "fit"
• Impairment

How can you tell the resident is failing?

• Consensus Opinion
o Stable core faculty
o Frequent reviews of resident performance over time based on
observations
o Balanced opinions
• Documentation
o The good
 Standardized criteria, measurable, accepted benchmark
o The bad
 Vague standard poorly defined, imperfect measurement, vacillating
benchmark
 Inaccurate assessment and documentation
o Evidence trail
 Multiple instances of non compliance
 Documentation of warnings
 Collaborative decision-making
• Data/Testing
o Daily shift evaluations & monthly summary evaluations
o Recurrent exams (In-training exam)
o Nursing/Patient complaints
o Psychological and Learning formal evaluations
o Medical evaluation
o Substance abuse testing

Can the success of remediation be predicted?

• Experienced faculty (including Training Officer)
• Coordination of entire faculty on remediation plan
• Acceptance of the likelihood of success of resident
• Resident characteristics
 • Accepting of their responsibility for improvements
• Willing to put in extra work needed
• Proactive about receiving and using feedback given
• Program characteristics for issues
• Flexibility to allow resident time needed for remediation
• System designed to allow improvement
 Suggested Reading:

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2005 Jul;12(7): 894-900.

2. Brenner AM, Mathai S, Jain S, Mohl PC. Can We Predict “Problem Residents”?
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3. Dudek NL, Marks MB, Regehr G. Failure to fail: the perspectives of clinical
supervisors. Acad Med 2005 Oct ;80(10 Suppl):S84-7

4. Dupras DM et al. “Problem Residents”: Prevalence, Problems and Remediation

in the Era of Core Competencies. Am J Med 2012; 125 (4): 421-425.

5. Gordan MJ. A prerogatives-based model for assessing and managing the resident
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6. Grams GD, Longhurst MF, Whiteside CB. The Faculty Experience with the
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7. Hauer KE, Ciccone A, Henzel TR et al. Remediation of the deficiencies of

physicians across the continuum from medical school to practice: a thematic
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8. Holmboe ES, Fiebach NH, Galaty LA, Hout S. The effectiveness of a focused
educational intervention on resident evaluations from faculty: a randomized,
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9. Irby DM, Milam S. The legal context for evaluating and dismissing medical
students and residents. Acad Med. 1989; 64:639-43.

10. Katz ED, Dahms R, Sadosty AT, Stahmer SA, Goyal D. Guiding Principles for
Resident Remediation: Recommendations of the CORD Remenditaion Task
Force. Acad Emerg Med. 2010: 17(supplement 2): S95-S103.

11. Katz ED, Goyal DG, CharD, Coopersmith CM, Fried ED. A Novel Concept in
Residency Education: Case-based Remediation. J Emerg Med. 2013: 44 (2):
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12. Kissoon N, Lapenta S, Armstron G. Diagnosis and Therapy for the Disruptive
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Difficulty” Med J Austr Nov 2005: 183: 475-476.
14. Ling FW, Grosswald SJ, Laube DW, Carpentieri AM. Education. The in-training
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clinical clerkships. J of Med Educ. 1987;62:353-355.

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Hodgson C. Disciplinary Action by Medical Boards and Prior Behavior in
Medical Schools. NEJM 2005;3535;25: 2673-2682.

17. Ratan R, Pica A, Berkowitz R. A Model for Instituting a Comprehensive

Program of Remediation for At-Risk Residents. Obstet Gynecol 2008:112:1155-
1159.

18. Reamy BV, Harman JH. Residents in trouble: an in-depth assessment of the 25-
year experience of a single family medicine residency. Fam Med 2006;38:252–7.

19. Reed DA, West CP, Mueller PS, Ficalora RD, Engstler GJ, Beckman, TJ.
Behaviors of Highly Professional Resident Physicians. JAMA 2008; 300: 1326-
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20. Roberts NK, Williams RG. The Hidden Costs of Failing to Fail Residents.
JGME 2011: 3(2): 127-129.

21. Rosebraugh CJ. Learning disabilities and medical schools. Med Educ. 2000;34:
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22. Rosenblatt MA, Schartel SA. The problem resident – Probation and Remediation
in American Anesthesiology Training Programs. Anesth Analg. 1998;86:180S.

23. Sanfey H et al. Pursuing Professional Accountability: An Evidence-based

approach to addressing Residents with Behavioral Problems. Arch Surg. 2012;
147 (7): 642-647.

24. Smith CS, Stevens NG, Servis M. A general framework for approaching residents
in difficulty. Fam Med 2007;39:331–6.

25. Sowden D, Hinshaw K. The trainee in difficulty: a viewpoint from the UK. TOG.
2011;13:239-246.

26. Steinert Y, Levitt C. Working the “Problem” Resident: Guidelines for Definition
and Intervention. Fam Med . 1993;25:627-632.
 27. Toth EL, Collinson K, Ryder C, Goldsand G. Committee to Prevent and
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Physicians. Acad Med. 2000; 75:177-181.

29. Wilkinson TJ, Harris P. The transition out of medical school – a qualitative study
of descriptions of borderline trainee interns. Med Educ. 2002;36: 466-471.

30. Williams BW. The prevalence and special educational requirements of

dyscompetent physicians. J Contin Ed Health Prof. 2006; 26: 173-191.

31. Williams RG, Roberts NK, Schwind CJ, Dunnington GL. The nature of general
surgery resident performance problems. Surgery. 2009 Jun; 145 (6): 6511-8.

32. Wu JS, Siewert B, Boiselle PM. Resident Evaluation and Remediation: A

Comprehensive Approach. JGME. 2010: 2 (2): 242-245.

33. Yaghoubian A, et al. General surgery resident remediation and attrition: a multi-
instiutional study. Arch Surg 2012: 147 (9): 829-33.

34. Yao DC, Wright SM. National Survey of Internal Medicine Residency Program
Directors Regarding Problem Residents. JAMA. 2000; 284: 1099-1104.

35. Yao DC, Wright SM. The Challenge of Problem Residents. J Gen Intern Med.
2001;16:486-492.

36. Youssi MD. JCAHO Standards Help Address Disruptive Physician

Behavior. Physician Exec. 2002;28:12-13

Other resources:

Guerrasio J. Remediation of the Struggling Medical Learner. Association for Hospital

Medical Education, Irvin, PA: 2013.

Life Curriculum - www.lifecurriculum.info – Free (for now) case-based curriculum to

“prevent, identify, and manage resident fatigue and impairment” - From Duke University
School of Medicine & Josiah Macy, Jr. Foundation.

Residency Program Alert – monthly newsletter includes many issues of resident

remediation and wellness issues. (www.hcmarketplace.com)

Sagin T. A practical guide to preventing and solving disruptive physician behavior.

HCpro Inc., Marblehead, MA: 2004.