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

 

Early Recognition

“The CORD Remediation Task Force strongly recommends early assessment of interns…”

• Katz et al, Acad EM 2010

 

I.  Do an Initial Assessment

Survey Results:

• 29% of programs have one
  • ½ Medical knowledge
    • Mock ITE, Rosh, NBME tests
  • ½ Milestones
    • Entire Level 1 Milestones assessment
    • Simulation cases & standardized patients

 

Initial Assessment

50-100 questions, 1st week of residency

• Starting point of their MK
• Early distribution of their talent
• Sets an academic tone

Intern Sim day

• 6-8 cases, Core EM

 

Homework Assignment

• Welcome letter
• Need-to-know ER drugs to memorize
  • Quiz on arrival
    • Simultaneous glimpse of MK, professionalism & PBLI

 

II.  Assess Early & Often

Assessment Tools Survey

• 2 Questions
  • What tools are you using?
  • What are most effective in early identification?

 

Assessment Tools:  Most Used

• Oral Boards
• Simulation
• Procedure log review
• Multisource feedback
• Observed resuscitations

 

Assessment Tools:  Most Useful

• Video review
• Observed resuscitation
• CORD Airway tool
• Multisource feedback
• Checklist task analysis

 

Assessments – Conclusions

• Oral boards overused?
• 360 degree evals – popular and useful
• Video review is useful and underutilized
• Rosh Review – write in
• No substitute for observation
  • SDOT on 2nd EM Block each year
  • Senior SDOT on 3rd EM Block

 

III.  Structure Leadership for Detection

Chain of Command: 1 APD per class

• Class advisor, motivator, 1st line of defense
• Dedicated eyes on each class
• Breakout sessions
• Ease of evals & CCC
• Spreads the wealth

Consider for your CCC:

• Dedicated faculty who “specializes” in remediation
  • Guerrasio et al, Acad Med, Feb 2014
• Dedicated faculty champion by competency
  • Ketteler et al – J of Surg Ed, 2014

 

IV.  Rank Performance Relative to Peers

Potential benefits

• Provides context to a raw score
• Recognize lesser performers earlier
• Objective documentation for remediation programs
• Motivate the left side of the bell curve

 

V.  De-Mystify “Remediation”

• Reactions are often very negative
• Make “Remediation” less devastating
• Change the expectation
• Change the name
• Change the tone:
  • A positive step towards improvement
    • (not a negative step towards termination)
• Encourage self-referral

 

Early Interventions: The ‘Pre-Remediation’ Plan

Diagnostic Studies – Triggers

Current triggers used

• ITE – 68% of programs use ITE cutoffs
• Only 25% of programs use other cutoffs
  • Milestone data (very subjective)
  • Other subjective measures (faculty assessment, eval scores, etc.)

• Suggested triggers for pre-remediation
  • Warning signs
    • History/physical
    • Performance changes
  • Cutoff scores
    • Quiz/tests
    • Sim
  • Standard deviations
    • Evals
    • Other performance measures

 

Treatment Plan

Timing

• First year assessments
  • Orientation
    • Level 1 milestones generally unhelpful
      • “Recognizes abnormal vital signs”
      • “Manages a single patient amidst distractions”
      • “Places a simple interrupted suture”
• End of first year
  • Too late?
  • Too difficult – due to multiple rotations, etc.

 

Implementation

Recommendation:

• End of R1’s 2nd-to last (ie 3rd) EM rotation
• Combination of assessment methods for all EM1’s
  • SDOT’s
  • Standardized sim cases
  • Oral boards
  • Evaluate in conjunction with written documentation
• Assess for transition from Level 1 to Level 2
• Incorporate most useful assessment methods

 

Terminology

Why sweat the semantics?

• Less stigma
  • Easier to align goals
• Fewer resources

“Pre-remediation”

• Focused or Individualized Learning Plan (ILP)
• Professional Growth Plan
• Academic Enhancement Plan (AEP)
• Coaching
• Warning
  • Esp professionalism

 

Who is responsible for remediation?

• PD: 46%
• APD: 26%
• Faculty Mentor: 7%
• Dedicated Faculty: 4%
• Other: 18%

 

Once resident is identified

“Director of Resident Mentoring”

• Someone on the CCC
• NOT the PD
• May be APD if dedicated job

Define goals and duration

• Communicate objective criteria for passing the individualized learning plan (ILP)
• Objective goals and outcomes
• Documentation

Form an alignment with resident (obtaining buy-in)

• The director of resident mentoring is their advocate
• Align goals; to help them become a physician who will elevate our specialty
• Work together to identify the specific issues and achieve the objectives

 

Sample ILP

Core Competency: Patient Care

• Multiple methods to help focus and improve learning
  • 100% evals
    • Multi-source feedback
  • Video tape review
  • Simulation cases
  • Observed resuscitations
  • Checklist task analysis
  • Oral boards cases

Criteria for Success

• Outcomes
  • Objective and achievable
• Consider avoiding “relative to peers”
• Consider alternative scale with defined goal (ie Dreyfus):
  • Novice
  • Advanced Beginner
  • Competent
  • Proficient
  • Expert

Take Home Points

Start residency with prevention in mind

• Recruiting
• Clear expectations
• Great orientation block
• Strong sense of community
• Deliberate advisor system

Have a system that facilitates early recognition

• Assess on arrival and 3rd block
• Consistent feedback
• Structure leadership for prevention
• Demystify remediation

Have a committed faculty

Obtain buy-in and have plan with objective outcomes