Transcript The Problem Resident Program Director Workshop University of Mississippi Medical Center February 2009

The Problem Resident
Program Director Workshop
University of Mississippi Medical Center
February 2009
The Agenda
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Identifying the Problem Resident
Probation and Remediation Processes
Outcomes for Problem Residents
Documentation and Future Credentialing
TOOLS for Success
Assumptions:
• Written Curriculum with Defined Goals and
Objectives
• Outcomes and Competency based Evaluations
completed regularly
• Multi-evaluator In-put (360*)
• At LEAST semi-annual performance evaluation
meetings with residents!
“Competence”
• Professional competence is the habitual and
judicious use of communication, knowledge,
technical skills, reasoning, emotions, values,
and reflection in daily practice for the benefit
of the individual and community being served
(knowledge, skills, attitudes)
“Competency”
• Main Entry: com·pe·tent
1 : proper or rightly pertinent
2 : having requisite or adequate ability or qualities : FIT
3 : legally qualified or adequate
4 : having the capacity to function or develop in a
particular way; specifically : having the capacity to
respond (as by producing an antibody) to an antigenic
determinant
• synonym see SUFFICIENT
Competency In GME
• Historically like pornography? (“know it when you see
it…”)
• Ad hoc local standards, assessment tools
• Traditionally defined around “Knowledge, Skills,
Attitudes”
• National and LOCAL focus on “accountability,” patient
safety, quality of medical care
• 2001 ACGME and ABMS defined 6 domains of
“competency”
• ALL physicians completing graduate medical training
must be competent in all 6 areas
Competence Problems May be
Reflected in:
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Lack of knowledge
Inadequate clinical skills, patient care
Deficient Technical or Procedural skills
Poor Judgment
Ineffective Communication skills
Inability and/or unwillingness to acquire and integrate
professional standards into one’s repertoire of
professional behavior
• Lack of personal insight or self-awareness
• Inability to control personal stress or emotional
reactions that interfere with professional functioning
(conduct or emotional problem) and participation in
teams
Red Flags:
• A disproportionate amount of attention by
training personnel is required
• Grumbling from peers
• The trainee’s behavior does not change as a
function of feedback, remediation efforts, and
/ or time invested (by trainee or program
director!!!)
Developmentally Normative Issues to
be Ruled Out:
• Transition issues
• Mild performance anxiety
• Mild discomfort with diverse patient groups or
multi-disciplinary team members
• Initial lack of understanding of the facility’s or
institution’s norms
• Lack of certain skills sets, but an openness and
readiness to acquire them
Context Issues to be Considered:
• Separation from support systems
• Adjustment issues to new setting both
personally and professionally
• Changes in status (finances or power)
• Impact of Significant life events
• Personal Risk Factors (substance abuse, ADD,
other psychiatric disorders, etc.)
“Secondary” Causes of Poor
Performance:
• Depression: Major, minor, situational
• Distraction: Concerns about children,
relationships; need to manage family or
personal illness
• Deprivation: sleep, food, social interaction,
money?
• Drugs: Alcohol, prescription, illicit
• Disordered personality: OCD, borderline, etc.
OK, So you think there’s a problem:
• Inadequate knowledge base
• Can’t keep up with patient care “pace”
expected for training level
• Constantly late for everything
• Patient management is algorithmic and misses
the subtle stuff
• Irritates everyone s/he comes in contact with
Helpful to Categorize the Problem:
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Factual Knowledge
Judgment
Motor Skills
Communication Skills
Responsibility
Efficiency
Organization
Self-Confidence
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Attitude / motivation
Humanism
Multi-tasking
Problem Solving
Stress Response
Well-being
Substance Abuse
Behavioral Disorder
USE
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COMPETENCIES
!!!!!!!!!!
Obtain OBJECTIVE data
– Written examples of sub-optimal
performance in patient care
– Medical Knowledge assessment scores
– Evaluations from faculty, peers, nurses,
program administrators, etc.
– Output measures (numbers of procedures;
volume of patients seen in clinic, films read,
etc.) compared to peer group
Opportunities for Documentation:
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Direct observation in clinical setting
Critical incident
Monthly evals (written and verbal)
Chart review / medical record audit
Reports from nurses or patients
Videotaped patient encounters
Standardized patients
Clinical Evaluation Exercise (CEX)
In-training exams
Presentations at morning report or conferences
Resident self-assessment
Faculty Challenges:
• Expected outcomes and objective measures of
competence often poorly defined
• Inadequate oversight of actual trainee
performance at bedside or in “working”
clinical settings (poor data collection!)
• Apprehension about defending evaluations
• Concern regarding potential repercussions
from trainee including litigation
• Laziness!!!
• “Nice-guy” syndrome
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Provide Feedback to the Resident
(EARLY!!!)
Chief Resident could be first step
Mentor or Program Director Meeting next
Ask for trainee self-assessment
Outline problems identified by program leaders
Group by competency area
Optimally identify areas of concern orally and in
writing
• Require development of a Performance
Improvement plan with measurable outcomes
The Unpleasant Meeting:
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Thank resident for coming to the meeting
Always act in a respectful manner
Explain the purpose of the meeting
Assume likelihood of miscommunication and paraphrase frequently
Ask the resident to hear you out first
Start by communicating the physician’s value and worth
State in detail and very specifically concerns about performance
Make it clear performance must change
Provide opportunity for resident to respond
Do not become angry
If pertinent, indicate that no retribution will be tolerated
Develop a corrective action plan
Summarize meeting and define consequences of NO performance change
Write a summary of the meeting and ask the resident to sign the summary
reflecting accuracy of content as a report of the meeting.
Institutional Resources
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Student Employee Health
Academic Affairs / Learning Resources
Simulation Center
Clinical Psychologists
Multi-Cultural Affairs
Human Resources / EEO
GME Office
Mississippi Health Professional’s Program
Remediation Considerations:
• Increasing Supervision, either with the same
or new supervisors
• Changing the format of supervision
• Reducing or shifting the trainee’s workload
• Requiring specific academic review
(completion of study guides, text reviews,
question reviews)
• Consider when appropriate a leave of absence
Proposed Stages of Unresolved
Problem Management:
• Notice of inadequate performance and
development of Performance Improvement
Plan (informal)
• Formal Warning in writing & PIP revision
• Notice of Probation (reportable in credentialing
paperwork) & PIP revision (due process
opportunity)
• Prolongation of training OR Termination
Continue close monitoring & f/u throughout!!!
At EVERY Intervention Stage:
• Specify problem behaviors
• Require articulation of expected behavior
changes
• Define MEASURABLE outcomes, goals,
benchmarks
• Hold trainee accountable for plans (sign-off)
• Continue DATA collection from various sources
• FOLLOW THROUGH as promised
Formal Probation
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“Reportable” in future credentialing documents
Defined time frame (Usually 3-6 months)
At least monthly evals (multi-source)
Close scrutiny of trainee behavior
Resident should sign written document which
outlines terms of probation, goals for
improvement
• Optimally provide monthly feedback to trainee
Probation
• Notify GME Office of Trainees placed on Formal
Probation
• Have written probation documents reviewed by
GME and legal prior to presentation to resident
(provide copy to trainee)
• Provide Grievance / Due Process Policy to trainee
• If performance goals not achieved in specified
time, 3 options:
– Extend Probation
– Extend training time
– Terminate trainee, usually at end of contract
Termination
• Offer trainee option of resignation
• Include career counseling regarding future
options
• Review documentation with GME, Legal, and HR
• Written notification to trainee reiterating
probationary conditions, trainee’s response,
reason for dismissal
• Determine time frame for termination
(immediate versus non-renewal of contract)
• Prepare statement to be attached to future
credentialing requests and provide copy to
trainee
Due Process & Legal Requirements
• Academic Due Process
• Employee / HR Due Process
• Academic Problems
• Behavior / Employment Issues
We are never expected or required to leave a
DANGEROUS trainee active in a training program!!!
Academic Due Process
Schools are free to dismiss, or fail to promote students, as long
as they assure students:
• Notice of performance problems, competence
deficits
• Opportunity to demonstrate improvement to
expected level of performance
• A reasoned and thoughtful decision regarding
termination, extension of training, or other
adverse consequence.
• Opportunity for appeal
Employment Due Process
• Notice of performance problems, policy or
expectation violations
• Opportunity to explain behavior or
performance
• Reasonable decision-making process regarding
adverse action (can not be “arbitrary and
capricious”)
• Opportunity for appeal
Legal Requirements for Misconduct
Cases
• Schools (and Employers) are not
required to give Residents an
Opportunity to repeat
Misconduct.
The ACGME Requirements
• Fair and Reasonable Written Grievance and
Due Process policies and procedures that
address:
– academic or other disciplinary actions taken
against residents that could result in nonrenewal
or other action that could significantly threaten a
resident’s intended career development; AND
The ACGME Requirements
– Adjudication of Resident Complaints and
Grievances related to work environment or issues
related to the program or faculty; AND
– Protect Resident from Retaliation; AND
– Allow Resident to address concerns in a
Confidential and Protected Manner.
– Written contracts for each year of training.
Long Term Implications:
• Prior to a problem trainee’s graduation
– Determine what is appropriate to report in future
referencing and credentialing documents
– All Formal Probation will likely require report
– Prepare a document out-lining the problems and
their resolutions
– What will you, and will you not, recommend the
resident for?
– Discuss fully with the trainee and provide a copy of
your summary document
– Emphasize importance of disclosure to trainee!!!
If trainee requires termination:
• Provide or refer for career counseling
• Are they likely to transition successfully to
another residency training program? Same
specialty? Different specialty?
• Utilize institutional resources including other
program directors, counselors
Fears and Myths:
• Fear of compromised rapport or hostility from
other trainees
• Concern for damaging resident’s career
• Fear of being “sued”
• Fear of adverse institutional publicity
• Concern for impact on the applicant pool
• Potential for loss of budgeted spots (with
extension of training)
A Comment on Disability &
“Reasonable Accommodation”:
• Does not lower academic standards
• Does not require substantial program
alterations
• Does not entail undue financial burden
• The resident must STILL meet ALL of the
program’s requirements
Hints for Success:
• Make expectations CLEAR
• Develop evaluation tools which provide OBJECTIVE
data
• Involve faculty mentor or develop mentorship
program
• Actively involve faculty / education committee
• Begin remediation processes early
• NEVER assume a problem will resolve itself!!!
• Develop a realistic and targeted remediation plan
• Ask for help (other PD’s, HR, DIO)
• Respect resident confidentiality
Frames
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Model Behavior
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Energetic
Responsible
Reads / studies regularly
Punctual, strong foundation in professional
behavior and personal integrity
• Communicates confidently and appropriately
• Takes on more responsibilities than expected with
excellent follow through
• Looks for ways to increase their skills and is
appreciative of training experience and
opportunities
Less than Desirable Behavior
• Slacker, does less than expected
• Hides important information
• Never volunteers for important tasks or to
assist colleagues at crunch times
• Criticizes experience, shifts blame, feels they
are asked to do too much
• Lack of competence in any of the defined
ACGME domains
Disruptive Behavior
• Mildly manipulative behavior (“forgets”
conversations, gets others to do their work)
• Shows up late for assigned activities
• Unprepared for rounds or didactics
• Encourages divisiveness among colleagues and /
or ancillary health care professionals
• Interpersonal difficulties, poor team player
• Anger management issues
• “Axis” disorders