Benjamin T. Jarman MD, FACS Gundersen Lutheran Medical Foundation La Crosse, WI March 21, 2012

Disclosure

• • I have not terminated a resident I have designed successful and unsuccessful remediation plans for senior residents

“10% of residents take 90% of the Program Director’s time” John Potts MD

“10% of residents definitely take 90% of the Program Director’s time” Benjamin Jarman MD

Why?

• • • • • • • • • Medical knowledge Patient care Professionalism Communication Mental health Change of interest/lifestyle concerns Drug/alcohol abuse Technically challenged Failure to meet program requirements

Step back

• • • • Tragic event – 24 th /25 th grade How to predict/associated factors?

Identify problems / DOCUMENT early Role for personality or learning assessments?

• Prevention?

Actions

• • • • • • Remediation - the correction of something bad or defective Repeat year Probation – the condition of being given a chance to redeem failures or misconduct in order to retain an academic classification Suspension – punishment by temporary exclusion from work Contract non-renewal Termination –concluding employment

ACGME Requirements

• IR II.D: Resident Appointment • Contract must contain • • • • Resident responsibilities Duration of appointment Conditions of reappointment Grievance procedures

ACGME Requirements

• IR II.D.4.d(1): Non-renewal of contract • Provision of written notice 4 months prior to end of current contract • Resident must be permitted to implement grievance procedure

Documentation

• Essential

Gundersen Lutheran

Institutional Plan • Written letter to resident from CPC • List deficiency, resources, plan • Resident option to address with CPC • Determination of ongoing deficiency • • • Direct meeting with CPC/resident Resident response (<3 days) CPC recommendation

Gundersen Lutheran

Institutional Plan • Resident response (3 days) • Submit written resignation • • Agree with recommendations Request formal review by DME/GMEC • Review panel • • Meet with resident, CPC, record review Formal decision (30 days)

Remediation

Remediation Resources • Clinical Performance Committee (CPC) • • • • • Employee assistance program: • • • • Free Provide professional, confidential assistance Address personal and/or work related issues Conduit for additional services Human resources department Professional counselors Teaching faculty Residency coordinator

Remediation Performance Improvement Plan (PIP) • • • • Focused plan with endpoints • • • Define the issue(s) – competency based Goals for improvement Action plan with defined interval (3-6 months) Ownership – Establish a mentor(s) Monitoring Follow up

Remediation (PIP) • • • Ramifications/next steps • • • • • Completion of PIP Ongoing remediation Probation/suspension Decision to resign Termination Meet with Human Resources and resident Resident and program director sign the document

Remediation (PIP) • Things to consider while PIP ongoing: • • • • Keep faculty engaged Frequent evaluations/feedback Keep the resident engaged Be quick to comment on accomplishments and challenges • Respond to rumors, word on the street

Resident 1 – Dr. Indecision Problem • • • • Filled PGY II vacancy with prelim. resident Technically behind peers Problem: difficulty making definitive intraoperative decisions, trying to appease different attendings’ practice patterns rather than developing independent approach - paralyzing Now 4 months until graduation

Dr. Indecision Action plan • • • • • Required lab practice Encouraged to perform all operations (no teaching cases) Altered training for terminal 3 months and mandated at least 3 months additional training Contacted ACGME and ABS One on one mentorship with dedicated teaching faculty for 4-6 week intervals – focus of establishing operative plan/expectations and completing all aspects of care plan

Dr. Indecision Result • • • • • • • Significant improvement Developed independent style Improved progress of operations Deemed able to graduate after additional training Successful general surgery practice 3 years later Reasons for success; engaged individual and early acceptance that additional training would be needed To do different; earlier plan of action/alter training earlier in experience

Resident 2: Dr. Mean Problem • • • • Filled PGY II vacancy with prelim. resident Issues: • • • • Professionalism Disrespectful Did not work well with women Protected himself – dumped on other residents Technically/clinically sound All issues became more evident when in leadership roles during the PGY IV year

Dr. Mean Plan • • • • • • Complicating factors • • • Transition of program leadership Inadequate documentation of “events” Action plan Series of meetings/sit downs Made it clear that graduation was not a given Established with Employee assistance plan Strongly recommended professional evaluation Provided resources – educated about perceptions

Dr. Mean Result • • • • Improved behavior with on time graduation Avoidance of some staff Successful in practice – private/solo What to do better? • • • • Better compliance with institutional plan Avoid hiring / Anticipate challenges Documentation Less tolerance with better action plan

Probation

• • • • Similar format as PIP More dire ramifications with termination being more likely May restrict clinical duties or those related to areas of deficiency Permanent record

• • • •

Termination

Reasons • Failure of action plans to remediate clinical or academic performance Moonlighting Substance abuse Theft (skills lab/OR/Hospital) Injuring patients/peers

Termination

Process • • • Must have written protocol Must keep up with documentation Must consult with legal department/human resources

Conclusions

• • • • • Tough situations High stakes with significant implications Identify and manage problems early Rely on CPC Rely on written policies

Thank you

Remediating the Competencies

• Medical Knowledge • • • • Reading plan Establish mentor Regular testing Assess learning ability

Remediating the Competencies

• Patient care • • • • • Mock oral exams Establish mentor Written tests Alter supervision Mandate increased communication with regard to decision making

Remediating the Competencies

• Practice based learning/improvement • • • Require evidence based reviews Establish learning goals Witness resident education of patients

Remediating the Competencies

• Professionalism • • • • “we own the perceptions we create” talk Variety of books Social media education Gender/race/culure dynamics education

Remediating the Competencies

• Interpersonal skills • • • Mandate documentation review Coding review Directly monitor resident with patient with feedback

Remediating the Competencies

• System based practice • • Assign to inter-professional teams Assign to systems improvement projects

Remediating the Competencies

• Technical • • • • • Use skills lab Assure getting into OR Frame future practice Mandate preoperative discussion Provide immediate feedback

Remediation PIP

• Success?

• • • • Based on testing Based on clinical or technical evaluations Based on peer/staff evaluations Document improvement/progress • Failure?

• Next steps…….