remediation of the struggling medical learner · remediation of the struggling medical learner...
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Remediation of the Struggling Medical Learner
Jeannette Guerrasio, MD
Professor of Medicine
Director, Student and Resident Remediation
University of Colorado, School of Medicine
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Remediation
• Limitations: • Rare published evidence to guide best practices in
remediation
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Hauer KE. Acad Med 2009; 84(12):1822-1832.
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Disclosure
Objectives
• Describe a process for identifying the underperforming learner
• Outline a framework for diagnosing learner difficulties
• Employ a methodical approach for remediation based on the identified deficiencies
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What We Know
15%
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Importance
• Time
• Morale
• Reputation
• Patient Safety!
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.
Responsibility
• Low attrition surgery programs • 21.0% versus 6.8%; P<.001
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Schwed AC. JAMA Surgery Aug 16, 2017
Responsibility
• Low attrition surgery programs • 21.0% versus 6.8%; P<.001
were more likely to provide resident remediation
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Schwed AC. JAMA Surgery Aug 16, 2017
10Hauer KE. Acad Med 2009; 84:1822-1832.
Identifiers
• Examinations• Written
• Clinical performance (OSCEs)
• Clinical/Preceptor written evaluations
• Peer assessments
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Identifiers
• Verbal comments
• Reporting system for concerns
• Mid-rotation performance evaluations
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13Hauer KE et al. Acad Med 2009; 84:1822-1832.
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Pro
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Cougar
Attendings
Competencies:
• Medical Knowledge
• Patient Care
• Interpersonal Skills and Communication
• Professionalism
• Practice-Based Learning
• Systems-Based Practice
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The Outcomes Project. Accreditation Council for Graduate Medical Education. 1999.
Competencies “Plus”:
• Medical Knowledge
• Patient Care
• Clinical Skills
• Clinical Reasoning
• Organization & Time Management
• Interpersonal Skills and Communication
• Professionalism
• Practice-Based Learning
• Systems-Based Practice
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Competencies “Plus”:
• Medical Knowledge
• Patient Care
• Clinical Skills
• Clinical Reasoning
• Organization & Time Management
• Interpersonal Skills and Communication
• Professionalism
• Practice-Based Learning
• Systems-Based Practice
• Mental Well Being17
Cases #1
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Identify the deficit…
1. Medical Knowledge
2. Clinical Skills
3. Clinical Reasoning and Judgment
4. Time Management and Organization
5. Interpersonal Skills and Communication
6. Professionalism
7. Practice-Based Learning and Improvement
8. Systems-Based Practice
9. Mental Well-Being
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Additional InformationDirect Observation
• Collect a H&P
• Efficiency
• Prioritize tasks
• Responsiveness/Ownership
Presentations/Rounds• Integration of information
• Formulation of ddx, A/P
• Ability to summarize case
• Formulation of questions
Interview the Learner
• Reading materials
• Stressors
• Substance abuse
• Learner’s perspective
Other Sources
• Chart review
• Arrival/departure time
• 360˚ evaluations
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Medical Knowledge
Presentation◦ A history of poor exam scores◦ Unable to answer fact based questions
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Clinical ReasoningPresentation◦ During Presentations Extraneous information Unable to focus Too many tests Difficulty differential diagnosis analyzing diagnoses individualizing protocols/practice guidelines
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Cases #2
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Identify the deficit…
1. Medical Knowledge
2. Clinical Skills
3. Clinical Reasoning and Judgment
4. Time Management and Organization
5. Interpersonal Skills and Communication
6. Professionalism
7. Practice-Based Learning and Improvement
8. Systems-Based Practice
9. Mental Well-Being
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Time Management & Organization
• Presentation• Unprepared for deadlines• Disorganized in appearance• Presentations and notes missing sections and out of
order• Arrival and departure times
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Professionalism
• Presentation• Inappropriately dressed• Frequently late or absent, unreliable • Dishonest• Try to pass off work • Poor patient - doctor relationships• Specific unethical actions may be brought to your
attention
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Who needs to know?
Make sure the learner receives the feedback as soon as possible
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Z-S
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Sta
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Level of Resident By Expert Assessment
Hodges B Acad Med 2001;76(10 S):S87-9.
Who needs to know?
Make sure the learner receives the feedback as soon as possible
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Z-S
co
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es
sm
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Re
lati
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to
Sta
nd
ard
Level of Resident By Expert Assessment
Hodges B Acad Med 2001;76(10 S):S87-9.
Remediation Team Approach
• Review the learner’s academic record
• Review examples of deficit(s) and confirm deficit(s)
• Look for trends and severity
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30Hauer KE. Acad Med 2009; 84:1822-1832.
Remediation Strategy
The goal of remediation is to target and fix:
the greatest deficit!
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Remediation Strategy
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Feedback
Reflection in Action
Deliberate Practice
Interpersonal Skills• Deliberate Practice
• Check-In with Yourself
• Closed Loop Communication• Emote and Explain
• Nonverbal Language
• Call People by their Name• …say “Thank you”
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Interpersonal Skills• Feedback
• What feedback have you received?
• Have the nurses been interacting with you differently?
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Interpersonal Skills• Reflection
• Who Sounds Like This?
• Apologize• Seek Permission to Learn
...and Try Again.
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• Regan L et al. Remediation methods for milestones related to interpersonal and communication skills and professionalism. JGME 2016;2(1):18-23.
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• Ann Demarais PhD and Valerie White PhD. First Impressions: What you don’t know about how others see you. Bantam Books. New York, NY: 2004.
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Creation of an individualized learning plan
What is different about the way struggling residents learn?
Underperforming Learners
WEAKNESSES
• Lack scaffolding to learning
• Don’t learn from the hidden curriculum
• Trouble identifying feedback
• Can’t actualize feedback
• Large blind spots
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Known To Self Unknown To Self
Kn
ow
n t
o
Oth
ers
Un
kno
wn
to
O
ther
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PUBLIC
HIDDEN UNKNOWN
BLINDJoHari Window
Underperforming Learners
STRENGTHS
• Are teachable
• Have foundational knowledge
• Great memorizers
• Learn from concrete rather than abstract
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Mismatch
Teaching1. Educational Task
2. Assumption of Framework
3. Unconscious/Abstract Learning
4. Feedback Provided
5. Safe Learning Environment
Learning1. Learner’s Competence
2. Absence of Framework
3. Need for Concrete Learning
4. Not Receiving Feedback
5. Fear of Ridicule
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Small Group Exercise
Cases
• John decides that he wants to go to his friend’s wedding over the weekend.
• At 5pm on Friday, John emails the chief resident to let her know that he will not be available to work his previously scheduled shifts on Saturday and Sunday.
• On Saturday morning, the night resident is looking for John so that he can sign out and go home. The medical team doesn’t know where he is.
Cases
• Lindsay was referred for remediation for poor knowledge. However, she scored in the top 85%tile on the Step exams and in the top 90%tile on the in training exam.
• Further assessment reveals that she struggles to build a relevant differential diagnosis and to prioritize tests and treatments.
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The Data
Unprofessional behavior in medical school
Subsequent disciplinary action by the state medical board
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Papadakis MA, et al. N Engl J Med 2005; 353:2673-82.
Kern DE, et al. Curric Devel for Med Educ. 2009; p 67.
The Data
Unprofessional behavior in medical school
Subsequent disciplinary action by the state medical board
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Papadakis MA, et al. N Engl J Med 2005; 353:2673-82.
Kern DE, et al. Curric Devel for Med Educ. 2009; p 67.
Accountability
• Review adherence to requirements (reporting duty hours, procedure log, assignments)
• Discuss professional appearance, punctuality, and wellness techniques; identify barriers to success.
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Professional Values and Conduct
• Pick a mentor role model of professionalism to shadow
• Solicit specific feedback
• Read specific journal articles regarding professionalism; facilitate small group discussion
• Review dangers of social media, discuss infractions
• Participate in wellness education
• Review current policies of department, institution, or state
• Rebuild broken bridges
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Responsiveness to Unique Characteristics and Needs of Patients
• Meet with patients and summarize reflections of the experience with regards to patients' perspectives
• Shadow a social worker or patient representative
• Participate in written/simulated case scenarios
• Perform a self-reflection analysis regarding perceived difficult patients; develop a plan to care for these patients in an unbiased manner.
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Clinical Reasoning
• Deliberate Practice• Framework for creating a ddx
• Create ddx: age, gender, race/ethnicity, & cc
• Feedback• Use Back-up resources
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Clinical Reasoning
•Reflection• Update list of differential diagnoses• What was missing? What was more or less prevalent?
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Clinical Reasoning
• Deliberate Practice Continued• Compare and contrast diagnoses
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Presenting Symptom: Chest Pain
Symptoms and historical info.
Physical Exam Diagnostic Work-up
Treatment
GERD Subacute, epigastric, burning, supine, relief with antacids
Tenderness to palpation of the epigastrium
History alone, Abnormal EGD
Raise head of bed, change diet, avoid tobacco and alcohol, weight loss, H2 blocker, PPI
Stable Angina Male, advanced age, pressure with radiation to arm or jaw, exertional, +/-SOB, nausea, DM, HTN, HLD, tobacco,+ FmHx
May have murmur, lateral PMI, gallop, paradox split S2, or normal
Abnormal EKG, Dynamic EKG, Stress test, Cath
Modify risk factors such as… weight reduction, DM control, HTN control, smoking cessationASA, statin, +/-ACE-I B-blocker, NTG
Etc.
Blankenburg R. et al.. PAS May 2011. 59
Chest Pain
Cardiac
MI
M>F, >50, DM, HTN, HLD,pressures, radiates to
jaw or arm, exertional, SOB, diaphoresis, NV
High or low BP and HR, tachypnea, listen for MR, diaphoresis
EKG, Trops x3, +/-ECHO, Cath for
STEMI new LBBB
Aspirin, oxygen, B-blocker NTG, Statin, morphine, heparin
gtt
Angina
Similar to MI but intermittent and
accelerating
High or low BP and HR
EKG, trops x3, stress test
Aspirin, oxygen, B-blocker NTG, Statin, morphine, heparin
gtt
MSK GI Pulmonary
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• Deliberate Practice• Review Cases
Exertional Burning PMHxDM 2
AbdominalObesity
No TTP of Epigastrium
GERD -
Angina -
Etc.
Blankenburg R. et al.. PAS May 2011.
Clinical Reasoning
• Feedback
• Re-enforce the use of resources and seniors or consultants for feedback
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Clinical Reasoning
• Reflection
• Reflect on the identifying differences between diagnoses
• What questions would be pertinent while taking a history?
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• Guerrasio J. Aagaard EM. Methods and outcomes for the remediation of poor clinical reasoning. JGIM. 2014:29(12):1607-14.
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DeKosky et al. JGME 2018 in press
DeKosky et al. JGME 2018 in press
DeKosky et al. JGME 2018 in press
Resources:
• Regan L et al. Remediation methods for milestones related to interpersonal and communication skills and professionalism. JGME 2016;2(1):18-23.
• Ann Demarais PhD and Valerie White PhD. First Impressions: What you don’t know about how others see you. Bantam Books. New York, NY: 2004.
• Tasha Eurich. Insight. Crown Business, 2017. • Guerrasio J. Aagaard EM. Methods and outcomes for the remediation of
poor clinical reasoning. JGIM. 2014:29(12):1607-14.• Guerrasio J. et al. Study skills and test taking strategies for coaching
medical learners based on identified areas of struggle. MedEdPORTALPublications. 2017;13:10593.
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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.
Reassessment
• Repeat clerkships/rotations
• Standardized patient encounters & simulation
• Directly observed encounters in clinical environment
• Written or web-based assessments
• Chart reviews & Chart-stimulated recall
• Multi-source evaluations
• Arrival and Departure Times
• Attendance
• Attire
• Responses to self-assessment
• Patient and procedure logs
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Fac
ult
y T
ime
in H
ou
rs
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Value of Faculty Time?
the odds of probation by 3.1% per hour
negative outcomes by 2.6% per hour
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0%
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Graduated Resigned Contract NotRenewed
ImmediateTermination
Currently inPractice
BoardCertification
BoardCitation
Prior to Centralized Remediation
Centralized Remediation Program
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…Passed the clerkship or rotation
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“This learner should never be a doctor”
Summary
Challenge of struggling medical learners exist in all programs
Struggling learners need coaching in
DELIBERATE PRACTICEFEEDBACKREFLECTION IN ACTION
Success for teacher, learner and patients!
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Acknowledgements
My Mentors
• Eva Aagaard, MD
Maureen Garrity, PhD
Carol Rumack, MD
Terri Blevins, EdD
Adina Kalet, MD, MPH
Karen Warburton, MD
Contact: [email protected]
www.clinicalremediation.com78
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