Thanks for joining us today. We're going to be discussing methods to identify underperforming fellows and underperforming faculty in your cardiology fellowship program. We'll also provide a framework for some potential solutions to these problems. When we talk about a problem learner, we all know who he or she is when we interact with them. If we look at the ABIM's definition, it's a trainee who demonstrates a significant enough problem that requires intervention by someone of authority. And usually that's the program director or the chief resident. We're going to talk about today, how do we deal with these problem learners and how big of a problem is it really? When we talk about the scope of the problem, we know somewhere between 10 and 30 percent of trainees will require remediation in the form of individualized learning plans. We talk a lot at these program director meetings about how we spend 80 percent of our time with about 20 percent of our trainees. And I think that's really pretty true. When we really talk about numbers, though, in advanced learners and fellows, it's not well defined and there are really no data in the cardiology arena to guide us. So most of what we're going to talk about today is from internal medicine residency programs. When we talk about identifying a problem learner, Glenn, how have you done that in the past and what's your experience? Typically in the fellowship level, it's through word of mouth. Often people don't fill out the evaluations. They just want to complain about somebody. You may get emails, complaints from nursing staff or others. But frequently, or maybe even a chief fellow tells you, frequently you're going to find out through somebody directly verbally telling you. And we're going to talk a little bit about the evaluation issue in a future slide here. But the main thing is identifying there's a problem and defining the problem. So is it a problem with knowledge, attitude, skill? You can think of the competencies, but we really need to specifically define the problem. And when someone tells you that they're a problem, if someone just tells you this person's terrible, that's not helpful. I don't want to go to a trainee and fix that because I don't know what to fix. So really when we're talking about feedback, it has to be very specific, timely, and actionable and behavior-based. It's not personal against the person, the trainee, but it has to be something that's actionable. So I really push the faculty to try to define what is the problem. So this is from a survey of internal medicine residency program directors regarding problem residents. And it turns out that about 82% of the people are identified in clinical settings. And often there's a pattern that emerges. And now we have these clinical competency committees, and other people can validate what your experience was with that trainee. Occasionally it's a critical incident. Something happens that really identifies this person is not where they're supposed to be. It could be a professionalism issue. It could be a complete lack of knowledge or skill that leads to that. You can tell at conferences there may be neglect with patient care responsibility. The in-training exam is an objective measure, but that's not the most common reason that people will come to your attention. So the people, and this again is from internal medicine residency program directors, the chief residents and our chief fellows, they usually know what's going on because they're trusted by their co-trainees, and they come to us as sort of the communication of the whole, of the program, and tell us there's a problem with this person, or this person is either failing or anxious, or maybe it's a problem outside the hospital that they want us to be aware of. Attendings, again, usually it's a verbal comment. This person stinks. I don't want to work with them ever again. And really we try to challenge those faculty to define what the problem is. And again, our faculty, they may be great cardiologists. It doesn't make them great educators. And so part of our job is to give them the faculty development and the skills to help people improve, just like they're diagnosing a patient accurately. You need to diagnose the learner accurately. Those verbal comments, even if they didn't write it down, I will encourage them to complete an evaluation so we have the documentation. But I also want them to be very specific about what the issue was and focus on the behavior. Other program directors or other residents may also tell you these things. So we really need to drill down, confirm there's a problem. We want to see, you know, once you identify you think there's a problem, go through their other evaluations, start talking to other colleagues. Again, your clinical competency committee is a great place to discuss this, and it does allow further documentation outside of the evaluations because you keep minutes at your clinical competency committee meetings. So I don't know what your experience is, Allison, but when I was five years as an associate program director in internal medicine for a residency and six years now as a fellowship director, and when I changed institution, there were almost no evaluations being completed. And part of it was cultural, that people thought, one of them even said, I don't want to get sued if I give a bad evaluation. So we had to change the culture and say, you know what, feedback is a gift. The fellows, other trainees, they want feedback. They want to get better. The majority really want that. They're hungry for it. And so it's okay, and you need to enable it, and it's a positive thing. So we had to change the culture, but I also told them we can't have a teaching program without some documentation of education and feedback. So what's been your experience? Glenn, I think this is a problem that we all struggle with, and actually it was a survey done by the American Association of Medical Colleges that ranked it as attendings unwilling to record negative evaluations 75% of the time. So it is not just our perception. It is the reality. And I think a lot of things contribute to this. There's professional considerations like the extra. A lot of attendings assume that it will be more work if they have to fill out a negative evaluation versus just a mediocre one or even a good evaluation. They also fear retribution, that they'll get a negative evaluation in response. And about half of program directors actually fear legal repercussions from negative evaluations. And we really have to continue to educate people. We need to document when these deviances are occurring, and then that way there really shouldn't be concern on the part of our faculty for fear of litigation. Of course, there's also other concerns. There's personal considerations. We build relationships with these fellows over time, and we really view that as being uncomfortable for us if we have to evaluate someone poorly. But like you said, feedback really is a gift, and this is the key step to getting our fellows better. I think it's also important to remind the faculty that these are formative evaluations. They're just data points. There's no black mark that's permanent on their records. There's no summative evaluation at this point. We're really just trying to put data points together to help them get better. These are three- or more-year training programs. If people came in confident, we wouldn't have a job to have a training program. When you start talking about what the problem is for these learners, about half the time it's medical knowledge, poor clinical judgment, inefficient use of time. And then a lot of the other bucket is professionalism issues, inappropriate interactions with staff and colleagues, unsatisfactory humanistic behavior, lack of doing their clinical skills like they just don't show up at work. And those are actually easier to document than the medical knowledge part and the professionalism sometimes. I like to think about this in terms of the ACGME competencies, though. You know, we all fill out milestones for our fellows, and really we can think of this as competency-based. If we think about, is knowledge the problem? Is it professionalism? What do you think about that, Glenn? How do you document this? I think it's helpful in creating an accurate diagnosis of what the problem is. There's a differential for why they have a problem, but the problem, you can just pull out the milestones, and you can say to someone or think about this is to even help other faculty. What is it? Is it a patient care problem? They're not doing a good presentation? Their HMPs aren't accurate? Their physical exam is wrong? Or is it that they're unprofessional? Because often when people are frustrated, it can be a professionalism issue. Maybe they're lazy. They block all the consults or something like that. So we really need to know exactly what it is, and these milestones and the competencies are ways that you can think of to guide you in generating what you're going to give very specific feedback about to the trainee. So I like to think about it. You can think of any knowledge, attitude, skill, or competency. Think of the 2 plus 2 epitable. So this is actually rare. It's probably more common in cardiology fellows, but in internal medicine residents, my experience was that there were people who were really good and knew it. They weren't necessarily arrogant. They just knew that they were competent. The next box is people who really don't think they're that good or competent, but they are. And this was actually the most common in internal medicine residency. In fact, we would have the fellows or the residents fill out these evaluations every 6 months or a year, and we'd list 3 things you do well and 3 things you could work on. The majority of the people would come in, and they'd write 1 or no things they do well, and they'd have maybe 5 things listed that they could improve upon. So this is a really common thing. And that's okay. They're humble, and it is a training program. They're not confident, and part of it over that time is to build that confidence because they are competent. Then there are people who know they're struggling. They're aware of it. It's okay, but they want to get better. And those people are fixable once you make the right diagnosis. Then there is the arrogant and completely unaware. They have a blind spot. They think they're great, and they're not. And our job is to really hammer on these people too because they're a little bit dangerous, and we don't want to be training assassins. Glenn, I agree with you completely on this concept, and it actually has a name. It's the Dunning-Kruger effect. And this was a large study that showed only about 5% of struggling learners have the ability to self-identify what they're having a problem with. It really looked at people in the bottom quartile, and they consistently overestimated their ability, and the people in the top quartile consistently underestimated their ability. So exactly what you've noticed in your trainees. When we talk about what are the problems that we are dealing with in these learners, this is from one remediation program looking at medical trainees, and what we saw is that in the post-residency learners like our fellows, the professionalism actually was more of an issue than clinical reasoning or medical knowledge. And I think it's interesting that it increases as you go from medical school to residency to post-residency learners, and this does echo what I've seen in our programs and our training environments. I think it's easier to identify the clinical reasoning and medical knowledge before trainees get to advanced learning. When we talk about what happens to these folks, if we look at the trainees who get put on probation as compared to trainees who are not on probation, you can see there's significant differences. Only about half of those trainees will graduate, and when we look at what happens to them after graduation, only about 60% of them will become board certified, and they're much more likely to have board citations than trainees who were not placed on probation. So this really is something that we owe to our trainees as well as to the people they're going to be taken care of to recognize this early. The majority, in my experience in the last 7 years, 11 years, is that almost everybody's fixable. I have seen through the residency, especially with larger numbers, where there are people, it's just not a great fit. But the majority of people, especially when they've gotten to our fellowships, they usually have fixable problems. So when we talk about underperforming faculty, a lot of the things overlap with the fellows, and so the reasons may be different. You know, people, the faculty usually have good knowledge and clinical reasoning. They've gotten this far that they actually made it to the faculty. It may be a professionalism issue. Frequently, the issue is that they're great cardiologists, but that doesn't make them great educators, and our job is to do some faculty development to help them, either give feedback or ways to teach adult learners. And so you also, just like with the fellows, and we'll talk about this in the remediation section, there's a differential, but you have to give everyone the benefit of the doubt. They may say, well, I have a grant due next week, and I didn't have time to round as long as I normally do. You know, if it's a one-off like that, maybe you dismiss it. But you also say, hey, next time you have a grant, why don't you swap rotations so you don't do that again. But again, we need very specific information so that we can create very specific feedback that's actionable so that they can improve. And so there was a study that looked at the bottom 20% of teachers, but they had greater improvement when they completed a faculty education development program. And Glenn, I think it's really important that when we identify people, faculty that may be a part of the program that really have no interest in being a part of the program or disruptive to our mission, that we identify those people and then work with them to either develop a performance improvement plan or move them out of the educational realm. I'd like to thank you for joining us today. The ACC has a variety of faculty development resources on acc.org where you found this webinar. And also don't forget about your local resources. When we talk about underperforming faculty and underperforming fellows, it's very common in internal medicine residencies as well. So reach out to your program directors locally. And also look at your GME committees at your local institution. There's a lot of experience that usually sit on these committees, and we've all had to deal with underperforming trainees as well as underperforming faculty, and you can sometimes get a wealth of knowledge there.

underperforming fellows

faculty

specific feedback

problem learners

Dunning-Kruger effect