15. Identifying and supporting the resident in difficulty (including remediation)

Introduction

The vast majority of residents spend their time in their program without any issues. They will be successful in achieving all of the objectives of their rotations, or will be on track for achieving EPAs as expected, and will be promoted along with their peers and will eventually complete training and be successful in their specialty examinations. There will be a small percentage, however, who will experience some difficulties. Others in your program (e.g., PA, supervisor, resident colleague) may help you in identifying a trainee in difficulty, but the difficult task of speaking to the resident about the issue(s), and coming up with a plan, will be up to you, the program director.

Very often, the first indication of a problem will come to you by word of mouth. In fact, very often, you won’t have any written documentation to guide you, but rather you will have heard a “story” from individuals who either were involved or observed something that concerned them. As a program director, it’s critical that you try first to get as much “fact” (versus “story”) as you can, and second, that you encourage the individual reporter(s) to document their concerns as accurately as possible. Once you have the information you need, you then need to bring the concerns forward to the resident in a supportive fashion to allow them the opportunity to provide their perspective. In some circumstances, it may be best to invite the individual who raised the concern (e.g., supervisor) to a meeting with the resident so that an open discussion can occur.

You will also want to be sensitive to and aware of the training reality of some residents from underrepresented minorities (URMs) in your program. Not only are URM learners a minority in many medical training programs, but they often face barriers to advancement, bias and harassment from colleagues, leadership and even patients during their training years.¹

It is also important to recognize that there is often stigma associated with struggling or experiencing difficulty in the culture of medical education. As a leader and someone whom residents and faculty look up to, you have a role to play to decrease stigma, normalize vulnerability and encourage help-seeking.

Residents who are from URMs may face racial biases, which can result in additional stigma. Black residents may experience racial microaggressions from their program’s faculty or their peers or they may have to contend with implicit biases, which can lead others to believe that they are less qualified than their peers or that they had matched at their residency program to fulfill a diversity quota.² The stigma associated with their racial identity may trigger “stereotype threat”: residents may worry that they will behave in ways that confirm a negative stereotype that members of their racial group are less qualified, which may in turn affect their performance in ways that perpetuate the stereotype. This cycle ultimately affects residents’ perceived self-worth and their motivation to persevere in this environment, potentially threatening their retention.³ Sense of belonging can also play a role in the performance of URM residents. As program director, you have a role to play in unpacking the impact of racial microaggressions in the learning environment and uncovering biases that may shape the perception of a trainee in difficulty. If you have a URM resident who is struggling, you should discuss these issues with the resident in an open and supportive way while recognizing that the resident may feel more comfortable disclosing their concerns to someone with lived experience of racism and/or discrimination.

Documentation

The key to understanding the nature of any performance issues that you may be concerned about with a resident is to ensure that you have documentation and evidence to support the concerns, and the more documentation, the better. There is a reason that the new accreditation standards of the Royal College of Physicians and Surgeons of Canada mandate a system of assessment that includes a broad range of assessment tools that assess all CanMEDS domains throughout the duration of residency training. Gone are the days where the only information available to program directors regarding assessment was the ITER, which was often completed well after the rotation had ended, leading to issues with recall bias and a failure to provide timely feedback. The era of competency-based medical education is now upon us and this change in educational philosophy encourages and supports frequent low-stakes, timely assessments, which should enable you to identify residents in difficulty more quickly. Early intervention is important to avoid further difficulties or psychological distress.

While it is critical to have robust assessment data to truly understand where your resident might be having difficulty, these data are also critically important to support your recommendation for a plan moving forward. Although your ultimate priority should be the resident’s well-being, you may be embarking on a process that leads to a recommendation of remediation or probation. Such a recommendation could result in an extension of training or even ultimately in dismissal.

It is important to recognize that URM residents are overrepresented in cases of probation and dismissal. When a Black, Indigenous or other racialized resident is experiencing difficulties, it is important to explore whether bias may be a factor in their assessments. American data from the 2015–16 academic year from all medical specialties demonstrated that 20.9% of dismissed trainees were Black, even though Black trainees represented only 4.6% of all trainees in Accreditation Council for Graduate Medical Education programs.³ In one program the Black residents were dismissed at a rate 10 times higher than white residents even though they represented less than 5% of the trainees in the program. These numbers are alarming. Anecdotally, the experiences of Black and Indigenous residents in Canada are similar.⁴

Given the high stakes of remediation and probation decisions, residents may appeal the recommendation. Appeal committees are going to look at the processes that you followed. They want to ensure that there was a fair and transparent process that led to the recommendation and that the data that were used to support the recommendation were adequate (note that appeals committees are in place to ensure that process was followed; they are not there to second guess specific assessments unless there were procedural errors). Be sure that you have taken the time to review your institution’s assessment and evaluation policies and procedures for residents and your institution’s appeals policies.

Meeting with the resident

When you meet with the resident to review your concerns, be sure that you have reviewed all the data in the file. Approach this meeting in a supportive way; avoid making assumptions about what might be affecting their performance. One of the most common reasons for performance issues is a deterioration in a resident’s mental and/or physical well-being. It’s important to recognize that as the program director, it is not always your responsibility to provide wellness support, but it is your responsibility to recognize that it is a common reason that performance may be suboptimal, and you need to know where to refer the resident for support (e.g., your faculty of medicine or postgraduate medical education [PGME] wellness office, provincial resident association, provincial medical association). You should reassure the resident that whatever is discussed with these individuals or groups is confidential unless the resident gives them explicit permission to discuss specific things with you.

Understand the process and relevant policies

If this is the first time that you have encountered a resident in difficulty, even if you have reviewed your local policies, you may have questions about how to proceed or may want additional advice, particularly on the interpretation of your university’s policies. If this is the case, book a meeting with your postgraduate dean to discuss the situation and understand the options that are available. This step is critical as you will need to bring this information back to your residency program committee (RPC); they will need it to determine what their formal recommendation for the resident will be.

Most often, the biggest question you will face is whether the issues that have been identified can be remediated through an informal, rather than a formal, process. In general, an informal process can be managed at the program level, with relatively simple interventions such as a change in the order of rotations or educational experiences, work with a specific supervisor with expertise in an area of weakness, guided reading, additional tutoring sessions or simulated experiences. An informal remediation plan typically won’t alter the duration of time spent in training. It tends to be used when the issues are considered relatively small and you expect that the trainee is only mildly off trajectory. Informal remediation is also generally used if a single aspect of a CanMEDS Role is an issue (e.g., communication within a team) or a small number of EPAs or milestones are problematic. If, however, the issues are of a larger magnitude, if they affect more than one CanMEDS domain or several EPAs, if rotations have been failed or if professionalism issues are involved, a formal period of remediation is required. Formal remediation involves a more formalized process where the recommendation must be reviewed and ratified at the level of the postgraduate dean or delegate, and once ratified, these decisions are subject to appeal. Additionally, as noted above, since these decisions can extend training or lead to dismissal, they can be appealed.

Creating a written plan

The decision to recommend a form of remediation should be made through discussion and review within the program. Depending on the size and structure of your program, this may be done through the RPC, or a subcommittee such as an assessment or remediation committee. Once a decision has been made to undertake either an informal or a formal period of remediation, a written plan needs to be developed. Your committee can help with this. Critical elements of the plan include:

• The specific issue, ideally categorized by CanMEDS Role
  • Note that there can be many issues within a specific CanMEDS Role.
  • Note that a resident may have issues in many CanMEDS Roles (e.g., it is not uncommon for residents to have issues in two or more domains).
• For each issue, a clear outline of the specific objectives or EPAs and milestones that need to be achieved during the remedial period and at what level
• For each issue, a plan or strategy for what the trainee will do and what the program will do to meet the specific objectives or EPAs
  • It should be clearly understood what role each person has to play.
  • It is very important to do this as it lays out accountability.
• An assessment strategy for each issue
  • This is often the most difficult part of creating the plan.
  • The assessment strategy must be specific to the issue. If no published or well-recognized assessment strategy(ies) exist(s), you may need to reconsider the objective or you may need to design your own assessment strategy, although this is not ideal.
  • The assessment strategy must be measurable.
    • Example of a poor assessment strategy:
      • The trainee must get 4/5 on “Communicator” on the ITER.
    • Example of a better assessment strategy:
      • The trainee must achieve a score of 4 or 5 on each of the five Communicator statements on each of the final two blocks of the remediation period.
    • As you develop the assessment strategy and how success will be measured for each of the issues, test the strategy by going through possibilities to see if the strategy actually works.
    • It can be quite frustrating to get to the end of a remedial strategy and try to decide on an outcome when the outcome measures you’ve selected for each of the issues are nebulous. You want assessment strategies that allow you to definitely say that the trainee met the objective or EPA in a clear yes or no fashion.

Although the above points cover the most critical elements to include in the plan, there other pieces of information that must also be included:

• Duration
  • This will depend on how significant the issues are and will be driven to a certain extent by local policies (some universities have identified specific durations in their policies).
• Start and end dates
• Specific blocks and other educational experiences (e.g., simulation sessions) that are to be completed
• Supervisors or other individuals with a specific role in carrying out the plan
• Potential outcomes

Although not required, it is best practice to include a section at the beginning of the plan that outlines the process that was used in establishing the recommendation in addition to a detailed summary of the evidence that the program used in coming to its recommendation.

Resident wellness and accommodations

As mentioned, there is often a wellness component underlying the reason for remediation. It is important to ensure that the resident is indeed well enough to train under remediation. If not, they may be placed on a medical leave of absence by their primary care physician or other health care professional, and you will be informed by those professionals when they are ready to resume training. If wellness issues are a concern, it’s possible that the resident’s provider may request a graduated return to training or some other form of accommodation. You are required under human rights law to accommodate to the point of “undue hardship.” Note that the provider is under no obligation to provide any specific medical information to justify the accommodation and should only do so with the express consent of the resident and where it is believed that sharing of such information is necessary.

Remediation is a stressful and challenging process. Even if the trainee did not have wellness issues before the start of a remedial period, they will often encounter them during this period. Residents may perceive that they are “under the microscope” as the remedial period is often high stakes and therefore increases the amount of pressure that the resident is under. This increased pressure will be particularly felt by racialized residents who already perceive that they are under more scrutiny than their peers when they enter their program.^5,6 In addition to their regular work, residents  also have to do extra remedial activities. As a result, strong consideration should be given to incorporating some time off (e.g., half-day to a full day per week) so that the trainee can focus on reading, work on special projects, work on specific aspects of the remedial plan and attend visits with wellness and other professionals (e.g., mentor). While this may slightly lengthen the remedial period, there is evidence that this has positive outcomes.

Areas of weakness: teaching and assessing specific CanMEDS Roles

The plan strategy outlined above can be used for all seven CanMEDS Roles. Most programs will already have the correct support tools and assessment strategies identified and available. Occasionally, however, programs struggle with how to remediate specific issues, particularly those that are related to non-Medical Expert Roles, which can be challenging to assess. If you face this challenge, there are several ways you can look for guidance. The first is to visit the Royal College website. The Royal College has recently published a toolkit, both online and in textbook format, which includes each of the CanMEDS Roles and has many ideas for how to teach them and how to assess them. The next strategy would be to consult your PGME office, as there is often an expert in PGME who can help. Another option is to consult with other program directors in your discipline across the country or from different disciplines within your own university. Your PGME dean may be able to facilitate a meeting with another PD who has expertise in the area in which you are having challenges or another PD who has remediated similar issues with another trainee and can offer advice.

It should be noted that while the above approach can be used for all CanMEDS Roles, issues pertaining to professionalism can be more challenging to address and may involve different policies and regulations, depending on the university or  province in which your program is located. Oftentimes, professionalism is dealt with under a separate policy at the university and hospital and may require different methods of investigation and remediation. A broader discussion of professionalism is beyond the scope of this chapter, but you are encouraged to review your institution’s specific policies in this regard.

Conclusion

Having a solid understanding of how to approach the issues for residents in difficulty, whether the issues are small or large, and whether they involve the Medical Expert Role or another role, is a critical skill for all program directors, and it is just as important for a program director with one resident as it is for a program director with 100 residents. A robust system of assessment is the cornerstone of the identification of residents who are not on a normal trajectory and will allow you to intervene at an early stage before minor issues become major issues. A written plan to address the issues is strongly recommended for informal remediation, and it is mandatory when formal mediation is required. It is very important that the plan contain enough detail that it can serve as a stand-alone document to both justify the remediation plan and provide the specific details of how it will be carried out and how the outcome will be adjudicated. Awareness of the impact of microaggressions on trainee performance and well-being is critical. It is also critical to identify wellness issues and provide the necessary support throughout the remedial process, and you should anticipate the need for accommodations during remediation. Remember that you are not alone in the process of remediation. Actively seek out the help and advice of others, particularly your postgraduate dean. There are a lot of great resources to help support you through this frequently complicated process.

References

1. Nieblas-Bedolla E, Williams JR, Christophers B, Kweon CY, Williams EJ, Jimenez N. Trends in race/ethnicity among applicants and matriculants to US surgical specialties, 2010–2018. JAMA Netw Open. 2020;3:e2023509.
2. Ode GE, Bradford L, Ross WA Jr, Carson EW, Brooks JT. Achieving a diverse, equitable, and inclusive environment for the Black orthopaedic surgeon: Part 1: Barriers to successful recruitment of Black applicants. J Bone Joint Surg Am.2021;103(3):e9.
3. McDade W, MD PhD, Accreditation Council for Graduate Medical Education, unpublished data, Nov. 30, 2020.
4. Osei-Tutu K, Johnson N, Daodu T  Tripart Focus Groups: Black residents and staff in Calgary. 2021 (unpublished findings)
5. Liebschutz JM, Darko GO, Finley EP, Cawse JM, Bharel M, Orlander JD. In the minority: Black physicians in residency and their experiences. J Natl Med Assoc. 2006;98(9):1441–1448.
6. Osseo-Asare A, Balasuriya L, Huot SJ, Keene D, Berg D, Nunez-Smith M, et al. Minority resident physicians’ views on the role of race/ ethnicity in their training experiences in the workplace. JAMA Netw Open. 2018;1(5):e182723.
7. Wong RL, Sullivan MC, Yeo HL, Roman SA, Bell RH Jr, Sosa JA. Race and surgical residency: results from a national survey of 4339 US general surgery residents. Ann Surg. 2013 Apr;257(4):782-7. doi: 10.1097/SLA.0b013e318269d2d0. PMID: 23001076