The Crucial Need for Remediation
Dr. Miller spent four hours tossing and turning in bed. He finally sat up and walked to the foyer closet. Distracted, he pulled on his winter coat, wrapped a scarf around his neck and stepped out into the crisp night air. Walking alone in the darkness of night seemed to help clear his mind. Tomorrow, he would find out if he would lose his medical license.
The state medical board had reviewed him five times since he graduated from residency just three years ago. Most recently, he gave a woman in septic shock the diuretic furosemide. She was infected with pneumonia and hypotensive, but her history of congestive heart failure, from left ventricular dysfunction, threw him off course. He anchored on the patient’s history and his vague memories of the Starling Curve, despite a physical exam that supported her dehydration. She died and he could only anticipate another lawsuit. He was already facing two malpractice suits.
Dr. Miller was consumed with guilt, regret and frustration. During his non-clinical years in medical school, he did very well, acing every exam. But by the end of his third year of medical school, he silently knew that he was struggling. He wanted to ask for help, but didn’t know where to turn. His fourth-year grades and evaluations were marginal, but he had already been accepted into a competitive residency, and graduation was guaranteed.
All through residency, he received borderline evaluations. His quiet persona helped him slide under the radar the first two years, and he was so likeable that his colleagues often helped to the point of making his decisions for him. He lacked clinical reasoning skills. It wasn’t until he was paired with a weak intern in December of his third year that his deficits could no longer be ignored — or could they?
He received an honest and scathing evaluation from his supervising attending, claiming that he was a danger to patients and not ready to graduate. The residency program director did not think that he should graduate but feared the costs and hassles of litigation. The lawyers at the university warned that there was not a solid trail of documentation highlighting his deficits, and in fact, only one faculty member recorded his concerns. The residency program director felt obligated to graduate him with only one weak evaluation in his file.
Instead of pacing the neighborhood, in the shadow of darkness, Dr. Miller’s life could have been different. What if an individualized learning plan had been created for him in his third year of medical school when he first struggled? What if his residency program had a remediation program in place to work with him? Would it have saved his career? His patients? His pride? Would he have chosen a different specialty or career better suited to his skills?
From the beginning
All medical learners struggle at some point along their educational journey. While the type and degree of struggle varies, it is our role as teachers to help all of our learners reach their maximum potential. Yet, teachers have very little guidance on how to remediate struggling medical learners. The published literature on remediation in medical education is minimal, and there are no concise texts to guide program and course directors, institutions, teachers, or struggling learners themselves.
After extensive discussions with teachers across the fields of medicine, I grew to appreciate the overlap and commonalities across all disciplines of medical education. So I have chosen to use the words “medical learners,” because it encompasses all levels of medical training
Teaching those who need us most
Working with medical learners is a tremendous honor, opportunity, and responsibility. But do you get a pit in your stomach when you hear that one of your learners is struggling? Do you feel overwhelmed or discouraged? With a standardized, successful approach to the learner in difficulty, the task of remediation still requires time and energy but can be approached with focus, confidence, and hope. While it is easy to teach and mentor the learners who, in truth, would succeed in any environment, the struggling learners differentiate the quality teachers from their peers.
While remediation often has a negative connotation, reserved for the failing student, I challenge you to broaden your perspective. All students and practitioners have areas of weakness, as they have areas of strength. Remediation is teaching that is individualized and targeted towards these areas of weakness to maximize the learner’s potential. We would all benefit from this customized form of remediation.
Why invest the time, money, and people power?
Here are six reasons why helping our struggling medical learners is crucially important.
- Struggling learners take up time.
- They affect morale.
- They impact the reputation of the program and institution.
- Deficiencies don’t magically resolve themselves.
- They impact patient safety and the quality of care.
- It’s our obligation to educate all learners — not just the brightest.
Just how many learners need remediation?
My inbox seemed to be overflowing as I received four e-mails today voicing concerns about four different learners. Only one had been referred before. Jack is a resident, failing to pay attention to details in clinic and has been resistant to getting treatment for his depression. Then there is a student, Maria, who passed her clerkship but can’t write an H&P, and the fellow, Dimitry, who failed his boards. Not to mention Isaac, the resident who fought with his attending in front of a family. The feelings are always mixed with sadness for the struggling learner, disappointment for the multiple uphill battles that lie ahead, and excitement that perhaps the program can truly improve the trajectory of someone’s career.
- A national survey of Internal Medicine Residency program directors demonstrated a point prevalence of residents in need of remediation of 7%.
- The American Board of Internal Medicine estimates that 8% to 15% of residents have significant areas of learner difficulty.
- Statistics vary little from one specialty to the next, with the exception of General Surgery, which has reported that up to one-third of its residents need remediation.
Some physicians hope that the problem will just go away, but it would be naïve to wait for the impact and challenge of the underperforming learners to disappear. In fact, the percentage of residents in difficulty has grown at the same frequency for the past several decades.
When asked, 17% of practicing physicians reported that they were aware of and had encountered an impaired or incompetent colleague within the past three years.
Deficiencies in medicine are observed across multiple levels of training. Does this imply that physician trainees are not the only medical learners who struggle? Are there strugglers among all levels and types of medical learners? Fortunately, the principles of remediation are universal and even apply to physicians who are competent but want to be better.
Despite the magnitude of the problem, we as teachers and educators struggle to rapidly identify, accurately diagnose, and adequately remediate medical learners. Methods for identifying learners with deficiencies are not standardized and, until this text, practical assessment tools and readily available strategies for remediation did not exist.
It is our responsibility to self-monitor our professions. No other group of individuals is better qualified to assess and monitor the performance of our peers. We must preserve the integrity of our profession by diligently teaching, accurately evaluating, and providing remediation for our future and current colleagues. At the end of the day, I want to know that I could willingly and confidently sign my patients out to my learners or have them take care of my own family members.
Other PandoTM workshops
Dr. Guerrasio, author of Remediation of the Struggling Medical Learner, will be facilitating the new PandoTM Remediation workshop in March. If you haven‘t done so already, check out this workshop as well as the other valuable faculty development opportunities being presented in Washington, D.C., this spring.