Submitted by Drs. David Hile (Yale-New Haven Hospital) and Jason Bothwell (Madgan Army Medical Center)

Originally presented at CORD AA 2016

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Objectives

• PREVENT REMEDIATION! (Does anything else matter?)
• Discuss incidence and terminology
• Foundations of prevention
• Suggestions for early identification
• Development of early intervention (pre-remediation) program

 

A Common Tale . . .

• Senior resident requires remediation
• Faculty grumbling
• “Under the radar”
• “Insufficient evidence”
• You’ll soon be signing the dotted line

 

Our Purpose in Life

• “All medical learners struggle at some point along their educational journey
• It’s our role as teachers to help them through this struggle to reach their maximum potential”
  • Guerrasio- Remediation of the Struggling Medical Learner

 

Overview – Terminology

• Pre-remediation
• Remediation
• Probation

 

Overview – Scope of the Problem

• 10% of residents have significant areas of learner difficulty
• Prevalence of remediation
  • 92 residents in 71 programs (1.3/program)
    • 90% of programs in past 3 yrs
      • Silverberg et al. WestJEM 2015
• Should be on remediation but aren’t
  • Additional 68 residents in 71 programs

 

Barriers

• Documentation
• Too Early
• Inconsistent Faculty Support
• Identified Too late
• Previously remediated

 

Overview – Scope of the Problem

• Avg 1.9 deficits per resident on remediation
• About 50% in PGY 2 year
• 8 mos average remediation period
  • Silverberg et al. WestJEM 2015

 

Overview – Deficiencies

• Most common deficiencies – EM
  • Medical Knowledge (63%)
  • Patient Care (47%)
  • Professionalism (32%)
• Predictors of remediation failure?
  • PBLI
  • Professionalissm
    • Silverberg et al. WestJEM 2015

• Most common deficiency – Plastic Surgery
  • Professionalism
    • Derderian and Kenkel J Craniofac Surg 2016

 

Overview – Early Identification

• Chances for success
• Time
• Morale
• Deficiencies don’t resolve
• Patient safety and quality of care
• Fewer resources overall
• Integrity of profession/program reputation

 

Foundations of Prevention

Before I Begin…

• Disclaimers:
  • The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense
• No hard science

 

Fundamental Questions

• When is the best time to identify a problem?
• When are residents most impressionable?
• Who do they want to be like?
• What (besides love of EM) motivates residents?

 

I.  Recruiting

Predictors of success:

• AOA membership
• USMLE step 1 & 2
• Interview scores
• EM rotation grade
• Number of Honors clerkships
• 5+ publications
• LOR’s
  • Bhat et al, J EM, 2015
  • Raman et al, Clin Ortho and Rel Res, 2015

Predictors of probation:

• Transferred in from another residency
• Time off between med school & residency
  • Guerrasio et al, Acad Med, 2015

Predictors of success…

• Participation / Excellence in Team Sports
  • Chole et al, Arch Oto; H & N Surg, 2012
  • Alterman et al, J Surg Ed, 2011
  • Papp et al, Am J Surg, 1997

 

II.  Have Clear Expectations

…About behavior:

• Detailed Code of Conduct
  • Attitude
  • Appearance
  • Punctuality & Attendance
  • Prescribing
  • Social Media
  • Responding to email, pages, and calls
    • Katz et al, Acad EM, 2010

…About performance

• Milestones
• ITE performance
• Research requirements
  • Deadlines

Sanctions

• 1st / 2nd offenses, etc
• Misdemeanors & felonies

Everything discussed & signed annually

 

III.  Invest Heavily in Orientation Block
(EM Boot Camp)

Survey Results:

• 85% “yes”
  • Of those, less than half are a full month
  • Range: 4 days – 6 weeks

 

EM Boot Camp – Concept

• July
• Minimal clinical work
• EM specific
• Core lectures
• Core procedures
• EM Ultrasound course
• Sim Day
• Charting workshop
• EMR shortcuts & templates
• Memorizing supply room & drawers
• Initial assessments

 

EM Boot Camp – Why?

• Builds a strong EM foundation
• Get moved in and settled
• Systems familiarization
• Build relationships

 

IV. Foster a Sense of Community

Force the friendship for 1 month

• Lays the framework for residents who:
  • Motivate each other
  • Don’t want to quit on each other
  • Recognize warning signs
  • Support each other through hardships

• Yao et al, J of Gen Int Med, 2001

 

EM Boot Camp – Again

Make Available Resources…Available

• Legal
• Finance
• Mental health
• Spouse support
• Alcohol and drug referral

Remove any barriers to access

• Walk through the physical location
• Introduce them to the POC’s

 

Have Winners teach Winning Habits

Have your best Seniors teach:

• How to study
• How to move patients
• How to consult

Have your best EM2’s teach:

• How to succeed on off-service rotations

 

Winning Habits

Deliberate Modeling

• Show them good habits…before they learn bad ones

Pair them with the Pro’s

• 2-4 hr block of observation
  • Reflective writing afterwards
    • Keng-yen et al, Med Ed, 2010

 

V:  Assign Advisors Carefully

Faculty advisors

• Criteria for pairing
• Template for meetings
• Minimum frequency

Senior resident advisors – PTA

 

In Part 2 of this series, we will cover “Early Recognition” and “Early Interventions: The ‘Pre-Remediation’ Plan.” Please leave your comments below.