Optimizing Success for the Underperforming Resident

Abstract

The authors outline steps in identifying, clarifying, and addressing deficiencies in resident performance. Performance issues are most commonly identified via direct observation of clinical skills, standardized cognitive or clinical assessments, and critical incidents or complaints. When underperformance is identified, an educational formulation should include the nature and extent of the deficiencies and any contributing factors. A remediation plan should be targeted to the deficits and clearly outline the expected performance outcomes, as well as the prescribed learning activities and any adjustments to the resident’s regular schedule, the process for monitoring and feedback, timetable and criteria for reassessment, and consequences for not achieving the expected standards. The authors review the parameters of a good learning climate that include clear expectations and performance standards, consistent and accurate feedback, and perceived accuracy and fairness of performance feedback and assessment and discuss the challenges of the nonreflective learner. Lastly, the authors discuss the legal context of underperformance and recommendations for sound due process.

Appendix A

Remediation Plan: Sample 1

This is an initial remediation for a PGY1 resident with a discrete deficit in medical knowledge and good insight. This is a program-level remediation. The resident is not being placed on official academic deficiency or probation status.

Dear Merle,

As we discussed last week in your semiannual review meeting, it is the consensus of the faculty that you have a deficiency in the ACGME competency domain of medical knowledge. As you know from our discussion, we are concerned that you are not learning to your ability. You identified time management and lack of reading as your primary challenge. You and I discussed the options and activities that you thought would be useful. These were very helpful as I worked with the Clinical Competency Committee to outline a sensible remediation plan for you.

This letter is to formally outline your remediation plan to improve your level of medical knowledge.

We encourage you to take the following steps:

• Schedule a short time for focused reading and reflection every day.

• Take a self-assessment examination at least monthly. Let these guide your focused reading.

• At the beginning of each rotation, review the goals and objectives for medical knowledge. Talk with your attending at the beginning of each rotation to get input on the most appropriate learning resources for those objectives.

• Every patient is an opportunity for specific reading. If your knowledge is pegged to patient, you will never forget.

It is ultimately your responsibility to take the steps necessary to your improve your level of knowledge. To assist you, the following help will be organized:

• Dr. Nelson has agreed to be your advisor. We recommend you meet with her at least monthly.

• You have access to our Specialty Question Bank and Self-Assessment Program.

• Dr. Cash and Dr. Owens are trained Board Examiners – they have agreed to give you periodic mini-oral exams upon request.

This remediation plan will be in place until next February. Your regular semiannual review will occur midway through this plan, and Dr. Nelson will review individual evaluations with you as they come in. The parameters the CCC will use to assess your progress will include:

• Faculty ratings and comments regarding medical knowledge on your evaluations, with emphasis on the final few months.

• Oral examination assessment cards from the final 3 months of this plan.

• Your in-service exam score. (This exam is just one piece of information, but scores are predictive of eventual success in board certification exam for our specialty. Improvement up to at least the 35th percentile for your PGY group should be a goal).

You will be promoted to your PGY2 year. Despite the knowledge deficits, your clinical skills are very good, and we trust you to assume PGY2 clinical and supervisory responsibilities. We do not plan any alterations to your regular schedule, but if at any point you feel like you need that, we can revisit. If you meet your learning goals in February, we will consider the remediation completed. If you have not met your learning goals by then despite active participation in the plan, we will either continue or modify it. In most instances, a plan that requires extension includes a more formal letter of deficiency.

We are all aware that the birth of your twins created some significant time management challenges for you. I’m pleased to hear that they are now sleeping through the night! Every faculty member is invested in your success and is devoted to helping you become the great doctor we know you can be.

Sincerely,

Signed by Program Director and Resident

Remediation Plan: Sample 2

This is a PGY2 resident with significant, ongoing deficits in multiple domains, with limited insight. Deficits have persisted despite several months of a program level remediation plan. This Sponsoring Institution uses a “letter of deficiency” process in lieu of a traditional probation process.

Dear Jamie,

I. Notice of Deficiency

This letter is to notify you that you are being given a letter of deficiency due to insufficient progress in the competency areas of medical knowledge, patient care, professionalism and practice-based learning, and improvement. Your faculty recognizes that you have been working very hard to improve your performance. However, your performance remains significantly below your level of training. These concerns have been discussed with you on numerous occasions over the past several months, both in your rotation feedback sessions and in monthly progress meetings with your advisor and myself. To review, the assessment of your progress is based on the following:

• Continued variability and unpredictability in performance.

• Reporting of patient data without processing or interpreting it.

• Continued instances of missing details in patient care or presenting wrong information.

• Continued instances of medication errors.

• Faculty continues to have concerns that you respond to feedback in a defensive manner or with excuses.

• Continued tardiness to conferences, clinical obligations, responding to pages, and completing medical records.

• Marked decrease in your ITE score.

At your level of training, you should be able to:

• Consistently demonstrate a predictable clinical performance on a day-to-day basis.

• Demonstrate an appropriate level of medical knowledge as demonstrated on evaluations and ITE.

• Attend to detail in caring for patients. Information presented should be accurate and correct.

• Be able to accurately order medications in the inpatient and outpatient setting.

• Accept feedback professionally and use self-reflection to analyze your own performance and areas for improvement.

• Respond to pages promptly, and keep current with medical records.

II. Opportunity to Correct Deficiency

It is ultimately your responsibility to take the steps necessary to meet expectations. To assist you in meeting the expectations, the following help will be organized:

Dr. Patel will continue as your advisor. Dr. Johnson will be your preceptor in the clinic.

We have made time available in your schedule for your meetings with our academic coach.

We will continue to limit the number of patients that you care for. The faculty does not believe that you are ready to assume a supervisory role.

You have identified EHR fluency as a time management problem. You now have Dragon access for the terminals both on the ward and in the outpatient clinic.

Jamie, your faculty is very worried about your health and wellness. We are concerned that you may have other issues in your personal life that are interfering with your ability to perform to your full potential. When you appear anxious and overwhelmed, your memory, performance, and organization are all markedly below average. We would once again strongly encourage you to utilize the employee assistance program.

In addition to your monthly evaluation review with Dr. Patel, your performance will be reviewed quarterly by the CCC with updates provided to you. Your progress in this letter of deficiency will be reassessed at the end of April. If you have demonstrated significant improvement at that time, this letter of deficiency may be rescinded or continued. If you are not achieving standards by then, we will have to consider either having you repeat all or part of your PGY2 year or termination.

Your faculty stands ready to help you, and we want to see you reach your potential as a physician. We encourage you to make use of all the resources available to you.

Sincerely,

Signed by Program Director, Resident, and DIO

Remediation Plan: Sample 3

This is an example of a last chance agreement with a resident who had unprofessional behavior related to substance misuse. It is more of a contract than a traditional remediation plan and is therefore between the resident and the employing hospital.

Last Chance Agreement

This agreement is made this day of, 20, by and between [Name of Hospital] Hospital (“Hospital”) and, M.D. (“Dr.”).

WHEREAS, Dr. __________, who is enrolled in Hospital Graduate Medical Education program and subsequently employed by Hospital, was referred for a full medical assessment and evaluation of fit for duty following documented substance abuse on (date). Dr. __________ was subsequently referred to (Treatment Center) for a professional evaluation. Dr. __________ has been cleared to return to the residency program under the conditions set forth in this Last Chance Agreement. In addition, Dr. __________ has admitted to several instances of unprofessional conduct that will not be tolerated.

WHEREAS, Dr. __________ desires to enter into this agreement with Hospital, allowing Hospital to provide continued monitoring and oversight, and WHEREAS, Dr. __________ understands and agrees that he would not be allowed to re-enroll in the residency program, but for his agreement to and compliance with these terms, and further understands and agrees that this is his last chance to demonstrate that he is capable of meeting all professional expectations and curricular requirements and completing his residency training program at Hospital.

THEREFORE, IN CONSIDERATION of the mutual covenants and promises contained in this Agreement, the Parties do hereby agree as follows:

• 1. Professional Conduct. Dr. __________ affirms his understanding that his strict compliance with the terms of this Agreement is necessary as a condition of his enrollment in the residency and his employment at Hospital. He further affirms his understanding that non-compliance with this Agreement and non-compliance with the Hospital GME House Staff Manual Policies, and Hospital Policies, will lead to immediate dismissal from the residency training program and termination of his employment.

• 2. Conditions of Employment and Training:

  • (a) Dr. __________ shall submit to ongoing compliance with therapy as recommended by his provider and the Hospital Physician Health and Wellness Committee.

  • (b) Dr. __________ agrees to be monitored by the Hospital Physician Health and Wellness Committee for the remainder of his residency training and will submit to any required activities or treatment as directed by the Committee.

  • (c) Dr. __________ agrees to random drug and alcohol monitoring by Hospital Occupational Health for the duration of his employment.

  • (d) Dr. __________ agrees to be an active participant in various Hospital programs, as requested by the institution, to share his personal experiences with other residents to assist with their learning and professional development.

  • (e) Dr. __________ agrees to meet with faculty mentor, Dr., at least monthly, to discuss and receive direction on his performance.

• 3. Abstinence from Improper Behavior. Dr. __________ agrees to maintain total abstinence from any outbursts, improper behavior, improper or poor communications, or other behavioral issues that are not supportive of a Just Culture, and Hospital’s commitment to clinical quality and patient safety.

• 4. Job Performance Standards. Dr. __________ agrees and understands that he is expected to comply with all residency and job performance standards and requirements and with Hospital/department policies, practices, and procedures. He is expected to report on time for all work shifts, meetings, appointments, patient procedures/consultations, and other work-related requirements. Dr. __________ acknowledges that he will be subject to the appropriate disciplinary action for his non-compliance with this Paragraph 4, including dismissal from the residency program.

• 5. Notice to Management and Human Resources. Dr. __________ acknowledges and agrees that Hospital’s GME Office has the right to provide his management staff, the Hospital VPMA and Chief Medical Officer, and anyone else with a need to know with notice that he is working under this mandatory Agreement and of his compliance or non-compliance with its terms and conditions.

• 6. Binding Agreement. The parties acknowledge that the terms of this Agreement are lawful and binding. Dr. __________ further acknowledges and agrees that any violation of the terms of this Agreement will result in his immediate termination from employment and dismissal from his fellowship training program and render him ineligible for employment at any other System Health facility. A violation of this Agreement will be reported to Dr. __________’s immediate supervisor, GME, and the Hospital VPMA/CMO, as well as the State Board of Medicine.

• 7. Term of Agreement. The parties agree that this Agreement will remain in force during Dr. __________’s employment.

I, __________, MD, acknowledge that I have read and understand the terms and conditions of this Agreement. I agree to abide by all terms of this Agreement without exception. I understand and acknowledge that my employment with Hospital will be terminated due to my non-compliance with this Agreement and/or with the policies and procedures of Hospital. I further acknowledge that I had the opportunity to ask questions and receive appropriate answers to clarify any portion of this Agreement and that I fully understand the terms and implications of the Agreement. I enter into this Agreement voluntarily, willingly, and without duress or coercion.

Signed by Resident and DIO/Hospital Representative