Resident Remediation

Transcription

1 Resident Remediation Sarah A. Stahmer MD Residency Program Director Cooper University Hospital I. Rules of the Road What are your performance goals? How are you going to determine if they achieve these goals? What are the consequences if they don t? What recourse does the resident have? II. Make Your Expectations Very Clear From the Beginning Non-Negotiable Departmental Requirements 1. Compliance with Duty Hours: Be aware when making shifts changes! Failure to comply after warning: An extra shift for each violation made up during elective month. 2. Conference Attendance: You are required to attend 70% of conferences, excluding vacations. If you are unable to make a conference, you must the PD as to the reason why, except if you are on vacation. Failure to comply after warning: A summary of material covered in lectures missed with a list of resources used to review information. 3. Procedure log: Keep up with it! Failure to comply after warning: I will assume that you have not done the procedures and you cannot graduate until you have demonstrated competency ( and numbers) comparable to your peers. 4. Follow-up log: 20 follow-ups/month in the ED Failure to comply after warning: In addition to completing follow-ups, a brief write up of an interesting follow-up for each EM month. These will all be checked at your mentor review meetings (unofficially) and then officially at your bi-annual review. If you do not comply with these requirements a

2 letter of warning will be placed in your file, and there will be a specific plan of remediation. I have read the above and will comply. I will notify the program director immediately if I anticipate any problems with compliance before it becomes a problem. Resident Name: III. The Process 1. There is a problem 2. Obtain objective data 3. Provide feedback to the resident Mentor meetings Bi-annual meetings Develop a performance improvement plan 4. Reevaluate issue within a defined time period 5. If there is no improvement or resolution, then the issue is discussed at the departmental education subcommittee Departmental warning Departmental probation 6. Probation: a period of closer scrutiny, for a specified length of time, and not greater than 3 consecutive months presented in writing by the Departmental Chair/Chief or designee goals for improvement clearly specified resident must sign monthly evaluations faculty mentor to meet monthly with resident 7. Reassessment Further probation if greater than 6 months then year is repeated or dismissal Off probation 8. Dismissal IV. Know Your GME policies Notice of probationary status goes to GME Due Process Meet with the Senior Vice President of AA and myself Decision made within 5 days

3 Request for a hearing Hearing Committee Hearing Committee decision V. Identification of Problem Resident The program coordinator is often the first one to have a suspicion! Common Problems Doesn t have the requisite fund of knowledge (MK, EBM) Can t keep up with ED flow ( PC) Constantly late for everything shifts, deadlines, conferences. Doesn t comply with departmental requirements (Prof) Patient management is algorithmic, and misses the subtle stuff (EBM, Prof) Irritates everyone he comes in contact with (IP) Formally Categorize the Problem Factual knowledge Problem solving Motor skills Communication skills Responsibility Efficiency Multi-tasking Self-Confidence Attitude/motivation Organization Judgment Humanism Stress Response Well-being Substance-abuse Behavioral disorder Lets start with the easy ones 1. Sexually inappropriate contact with a patient(s) Witnessed Repetitive episodes 2. Routinely came to work armed Violated hospital policy

4 Suspended 3. Arrest record for dealing kilos of marijuana State licensing issue 4. Came to work drunk/high repeatedly Failed to consent to urine drug tests as per hospital policy Repetitive lying What s Not So Easy Problem Resident #1: Extremely nice PGYII who could not move into role as a senior resident Could not apply knowledge in the context of clinical care Could not multitask Clearly had some component of OCD What tools do you have to objectify the problem? 1. Application of knowledge in clinical context Patient care component in rotation evaluations 2. Multitasking Numbers of patients seen/shift Nursing evaluations ED management assessment on evaluation 3. OCD Is it a characteristic or problem? Assessment phase 1. Patient care PGY I At expected level PGY II At expected level 2. Multitasking PGY I At expected level (1.5 patients/hr) PGYII At expected level (2.0 patients/hr) Faculty complain when they re on an overnight shift with him! Need more data Faculty Education make your evaluations mean something!

5 SDOT ( every shift) ED evaluation 1 month later for patient care is 2.0/5.0 Now I have something I can work with! Departmental Letter of Warning This is a departmental letter of warning for inadequate performance in the area of patient care in the ED. This is based on departmental faculty evaluations indicating that your clinical performance in the ED is below the expected level for a PGYIII in EM. Specific issues that have been noted are: 1. Inability to integrate findings on history and physical examination with medical knowledge to formulate a targeted and accurate working diagnosis; particularly with sick and/or complicated patients 2. Inappropriate focus on the procedural component of patient care without consideration of the whole picture indication, safety, contraindications, risk of complications. 3. Failure to follow-up on loose ends disposition, plans of actions based on study findings when volume increases 4. Tendency to focus on isolated aspects of patient care and losing the big picture. This applies to single patients in addition to the ED as a whole These issues have been discussed at length with you, in meetings with your mentor and myself. I have expressed the concern that you may not be able to demonstrate satisfactory competency in this area by the end of this year if you continue to perform at this level. If you do not show competency in the area of patient care by the completion of this year, I cannot state that you finished the residency satisfactorily, nor can I ascertain that you have met the requirements to take the ABEM certification exam. You have indicated that you are willing to commit to a two-month plan of remediation as outlined below. A faculty member will shadow you during your ED shifts for 6 hours/week. The goal is to help direct and focus your assessments and assist in your ability to prioritize tasks specific to patient care. You will receive feedback throughout this period. You will arrange weekly meetings with Dr. C to review cases. You will bring select cases that you have managed in the ED, and ideally were problematic due to inadequacies in patient assessment or treatment plans.

6 You will continue to attend all required conferences in the ED. At the completion of this 2-month period, we will review your progress based on the faculty evaluations of your performance for November and December. If there is no improvement, then you will be place on departmental probation. By signing this letter, you indicate that you have been made aware of the observed deficiencies in your clinical performance and you are agreeing to the plan of remediation. In addition, you are fully aware of the potential consequences if your performance does not improve over the next 2 months. 2 Months Later Resident complied with all of the above. Monthly evaluations continue to show the following: Patient care: 2.17/5.0 Does well with non-emergent, repetitive type patients Not able to think out of the box Patient care is unsatisfactory I am unable to trust him with any scenario beyond a simple non-urgent/fast track type presentation Something is not clicking; in spite of the remediation and counseling/feedback provided Then he FAILED the PICU! Probation A letter of probation was sent to him that stated: At the completion of this 2 month period, we will review your progress based on the faculty evaluations of your performance. One of the following actions will be taken: No improvement dismissal from the program Continued probation if there is some improvement Removal from probation if your patient care is at expected level for a PGYIII Behind the Scenes An actively involved mentor Realistic discussions Not everyone can be an ER doc You re good at many things lets focus on those Alternative career options

7 Letter from Resident S Thank you for all your help. Ever since the concerns over my performance were identified, I have had nothing but support and help from all of you I have been unable to perform at the level expected of me as a PGY-3 I do not want to put my patient s in harms way. I was called by Dr. W this evening and he offered me the open PGY-2 position in family medicine. I accepted it. Thank you very much for all of your support and guidance through all of this. It was greatly appreciated. I would also like to thank you for allowing me to stay on at. until I can start over there. Problem Resident #2: EM resident with ADD Issues: Functions in a different time zone Late for shifts Late for submission of paperwork Otherwise bright and personable Document Problem Attendance sheets - < 70% attendance Rotation evaluations Prof, PC Habitually late, no-show for one shift. Terrible chart documentation Nursing evaluations Nice, but Program coordinator nag register Provide Feedback Departmental Letter of Warning One of the requirements of the residency is demonstration of competency in the area of Professionalism. A critical element of this competency is compliance with departmental regulations. You have failed to meet this requirement by 1) showing up late or not at all for ED shifts, 2) Suboptimal conference attendance and 3) failing to complete your module exams on time. This letter serves a departmental letter of warning, which requires that you demonstrate 100% compliance in these areas over the next three months. Failure to do so will result in being placed on probation, which will become part of your permanent record. This has been discussed with you, and remediation will include the following: Changed advisors prior one was too nice Frequent contact and/or meetings with you advisor to review your weekly/monthly schedule Actually ed the PD her schedule every Sunday.

8 Development of an organizational system that will ensure timely compliance with all departmental requirements with respect to clinical time and paperwork. Fiancee was a computer programmer got her a palm. Your performance in this area will be reviewed in three months, and I anticipate no further difficulties in this area. Follow-up review: Significantly better Problem resident #3 Older resident who was just plain obnoxious Issues: Fights over every little issue Irritates everyone he comes in contact with Multiple complaints from consultants, staff, nurses Obtain Objective Data Rotation evaluations IP skills Nursing evaluations Whenever there was a verbal complaint put it in writing or I never heard it Provide Feedback I. Letter of Warning Following the mid-year review of your portfolio, it was clear that the following areas are in need of improvement. Interpersonal skills: The evaluations continue to show that you have problems communicating effectively with nurses, faculty and often your peers Professionalism: You do not take constructive criticism well and become very defensive. We have discussed these issues, and you will work on improving interpersonal skills. Options discussed include: partnering with a nurse mentor outside counseling peer counseling The effectiveness of your efforts will be monitored through weekly bedside observations during ED shifts and your monthly evaluations. Failure to demonstrate improvement in this area within the next 3 months will require acknowledgement of difficulties in this area as part of your permanent record.

9 Three month follow-up: No improvement. Continuous complaints from nurses, peers and the program coordinator! I have never had this happened to me in the over 25 years of working in Graduate Medical Education, that a resident felt that he could just go on my desk and remove something, make a copy and then try to sneak out of the office without being caught. It is totally unacceptable. It speaks volumes of the lack of professionalism of this resident. This is also not the first time this has happened II Probation: Issue: Lack of improvement in performance in interpersonal skills Requirements: Mandatory counseling Nursing mentor Interactions with the departmental staff must be professional at all times Consequences of lack of improvement: Issue with interpersonal skills will be reflected in all of his letters of recommendations in the future.. The staff has the right to file a complaint with Human Resources if you continue to be abusive to them Follow-up: No real improvement some things you cannot change. Issues reflected in LOR and I have plenty of documentation stating that this is the consequence of his lack of improvement. Only one of my seniors not to have a job Problem resident # 4: PGY 2 resident with limited FOK Issues: Conference attendance : 62% Module exams: <70% Rotational evaluations: 2.2/5 in medical knowldege In-service score 58 Feedback: Letter of Warning: This letter serves as a formal acknowledgement of sub-optimal performance in the areas of medical knowledge and patient care. This is based on the mid-year review of your evaluations covering the period from 7/04 12/04. We have discussed the specifics of your deficiencies in our meeting, which are: 1) Inadequate fund of medical knowledge as demonstrated by your performance on the monthly examinations and on the medical knowledge portion of your clinical evaluations.

10 2) Inconsistent performance in the area of patient care. Most of the deficiencies in clinical performance are failure to consider relevant diagnoses and/or consider alternative treatment plans. Remediation will consist of the following: Delay of the PICU rotation. The PICU rotation is mandatory for graduation, and will be completed at which time you have demonstrated satisfactory clinical performance in the ED. Reduced clinical shift loads in the ED (12-14/month) with protected time for reading Bi-weekly meetings with your Mentor ( Dr. K), during which time you will create a reading schedule, review cases and module exams Follow-up 2 months later! 3.0/5.0 Patient Care 82.5% on module examinations 84% on Inservice exam She s moving on VI. Lessons Learned If you don t have an evaluation tool that will provide objective data; borrow, steal or create one! Actively involve your education committee Actively involve the resident s mentor, and reward them for their help Develop a realistic and targeted remediation plan Ask for help from seasoned program directors and your GME committee Initiate remediation process as soon as you suspect/identify a problem Don t assume the problem will resolve itself Be VERY clear about your concerns RESPECT RESIDENT CONFIDENTIALITY. All discussions should be between the PD and the resident period. If you are directed to involve someone else ask if the resident is aware! VII. Program Coordinator Issues Trust your instinct and/or gut you see and hear everything! Document every interaction that may be controversial If a resident confides something in you that you think should be brought to the PDs attention get their permission to discuss it with the PD, or encourage them to speak with the PD directly

11 Resident Termination The program has failed to do its job Graduating a talented resident is no work The testimony of a good program is the ability to graduate the weaker resident! When all else fails - not everyone is cut out to be an ER doc and that doesn t mean they re a failure