This section describes the process of remediation, and I worked together with Dr. Allison Bailey from the University of Tennessee College of Medicine in Chattanooga to create this section. The objectives are to review the stepwise process of remediation and also describe the key components in this remediation process. We'll go through a case in this section, but also there is another case supplied as ancillary reading. So the key first step is to identify the problem learner, and often a fellow could be underperforming in a variety of ways, but at the end of the day, there is some deficit in regarding expectations, and they're related to either knowledge, attitudes, or skills. But that identification can be the most challenging step. A lot of times, people can fly under the radar for even months or the year until a clinical competency committee may get together. So step one is to really look at the competence issues related to this fellow and assess across all the modalities. One of the easiest ways to do that is to think in terms of the core competencies because we want to make an accurate diagnosis of what is the actual problem. Is it just a knowledge problem? Is it a professionalism problem? Is it a communication issue, et cetera? So we need to identify those deficiencies, and they can be done in a lot of different ways. They can be done with the observed encounters, whether it's in clinic or from other peers who may have observed certain behaviors, record reviews, et cetera. The clinical competency committee also can provide significant information in this regard. But it's important to both identify the deficiencies and to document them. So that is step two, is diagnosing the deficiency and then developing an individualized learning plan for the fellow. And what does that include? Clear expectations of what's acceptable performance, guiding them to get to acceptable performance, coaching, clarity about whether this is required or voluntary, and what the consequences are if this is not done successfully. Step three is giving the instruction about remediation, what activities are going to be prescribed. These could be guided clinical experiences, it could be using a simulator if it's related to procedures, could be one-on-one mentoring with another coach that may be a different faculty member or a chief fellow. Depending on the issue will determine how you best approach this remediation issue. So when it comes to knowledge, for example, reviewing specific content such as AXAP may be useful. So these could be, they need to be specific and they need to have feedback after each of the experiences. So if what we typically would do is find those people who are willing to be coaches for fellows who are struggling and we talk with them about what the deficiencies are so that they can be sensitive to observe for those and also give constructive feedback. In general, feedback needs to be timely, specific, and actionable, and behaviorally based so that they can get better. So we have to treat the problem which is really a knowledge, skill, or attitude problem and making expectations clear, communicating this is a critical step to solving the problem. So design the program with defined goals, objectives, strategies, evaluation method, arrange for that type of support, and you can think outside the box of how you want to do it. It depends on what year they are, what their goals are to be able to do this. Sometimes you always have to give people the benefit of the doubt. When you meet with someone, hear their side of the story, you may uncover a substance abuse problem, you may uncover significant stress outside the home that's affecting their work-life balance and they're unable to concentrate at work. So it's always good to come in with an open mind because that will help you get to the problem resolution much better. Again, documentation is critical. So ensure a fair process, give everyone the benefit of the doubt, keep things confidential, and also if they are working with other people, ask for their permission. You can recommend it, but talk about who you were going to recommend to work with and get their feedback on that. They may have had an issue with a specific faculty or other fellow. Again, document all the different assessments, evaluations, what interventions were performed, and when you meet with the fellow, both initially and in follow-up. So which interventions help? Now this comes from a paper in JAMA which found that more frequent feedback sessions was the most popular and most useful. Part of this data here is that substance abuse is more rare, so that's not frequently going to be helpful if people don't have a substance abuse problem, obviously. But these are some ideas to think about which may be useful. Most of the people don't need probation. They need someone to identify the problem and start working with them to solve it. And finally, step four is really to reassess where they are and reassess competence and when the remediation can stop. And if it doesn't achieve the desired result, what is the way that is going to be handled? And frequently, you can work with both your graduate medical education council locally, but the first stop would be with your internal medicine program director because the fellowships all are tied into the internal medicine accreditation. So they frequently, because they have so many residents, they run into these problems more often than we do as cardiology program directors. So let's walk through a case, and this is a problem with someone who has a knowledge deficit. As the program director, you note fellow one appears to have a weaker than expected knowledge base as compared to others. Their scores are about the same on evaluations, but then you get their in-training exam score back and it's below the 20th percentile. At the first clinical competency committee, faculty speak openly about these deficiencies, and this is a really common problem. People don't like documenting negative evaluations. So during the next six months, the knowledge doesn't go up for this fellow, and they're not on the same trajectory as their colleagues. So they now have low, mediocre scores from the faculty in both medical knowledge and subsequently patient care. So document this deficiency with the in-training exam, the clinical competency committee remarks, especially in the minutes, and the fellows' evaluations. You can document an individualized learning plan to improve knowledge gaps with clear expectations. So that could be doing the ACC in-training exam review with the knowledge gaps that are outlined there and telling them to target those initially. It may be assigning other things like AXAP, structured reading, to fill in those gaps. There are other board review courses. There are videos. There's a lot of content in the ACC.org, but obviously there are other materials as well. Stimulated recall of the chart with the program director is an option I have not personally done. I find personally that knowledge deficits are one of the easiest things to fix because that's usually just spending more time learning the content. Patient care and the synthesis aspect of it can be more challenging, and there's going through specific cases and going through chart recall then can be useful to see the branching logic you're using in your decision making to help guide them along the way. Finally, after they've completed your plan, there's a reassessment. Now there should be reassessment ongoing, but there has to be more of a formal reassessment to say have they met the expectations that were laid out for them so that they are getting to a level of competence so that you feel comfortable graduating them either to the next year or even out of the fellowship. So we return to case one, and the PD says, thanks for meeting with me. I noticed that your knowledge base is less. First year fellow is surprised. Really? I noticed your initial evaluations didn't reveal any deficiencies, but your entry exams were low. The scores were low, and those predict future ABI on board exam failure. If you haven't seen the paper by Julia Indyk, I-N-D-I-K, in JAK, there is a cutoff. I believe it's 600 is the score that predicts below that as it starts to have a higher rate of board failure. I would encourage you to look at that. I had that figure printed and on my desk whenever I met with fellows when I went over their entering exam scores. Unfortunately, the clinical competency committee also noted you have a lack of knowledge and commented on it during the meeting, and the evaluations are congruent with that. The fellow says I'm not surprised. I've been overwhelmed this year, frequently feel lost when I'm trying to read about a topic. I'm so far in the hole I can't catch up. What can I do? This is an encouraging sign when someone wants to get better. When you're dealing with professionalism issues, those can be more challenging because someone may have an attitude issue about the way they see the world, and it's a little more difficult to help shape that. So this one's motivated to get better, and the PD says I think it's great you recognize you have the knowledge gaps. We'll sit down and arrange structured learning to help you tailor your reading. Let's start where you scored the lowest on your entering exam using that feedback. You can use those to find material in AXAP or the ACC board review materials. Again, there are other resources you could use, and we'll go over your faculty evaluations and the comments from the Clinical Competency Committee to try to help you improve. Okay, how will I know if I'm improving? What pace should I be on? We'll plan the knowledge reassessment, and we'll come back to your faculty evaluations in the future and also your future entering exam score and feedback from the Competency Committee as well. That sounds great. What's next? We need to be clear on the expectations. This is an important thing to lay out these expectations. This is not an elective, but it's required, and we're going to need to do something so that we don't have to put you on probation. And then be supportive. I have every confidence that you'll be successful. I'm invested in your success. You need to be committed. Okay, this sounds serious. Am I in trouble? This is serious. We're committed to help you. We'll meet regularly to see how things are going, and I would tell them that you're optimistic, and knowledge is, again, I think one of the easier things to remedy. And so I include, as a separate resource from Dr. Bailey and I, an additional case and this resource, this reference, which gives an example of a remediation program. So, thank you for your attention. This is a common problem. It's not unique. You didn't do a poor job recruiting fellows. It happens everywhere. And this is an important skill. And again, I remind you, don't hesitate to reach out to the Internal Medicine Program Director or Associate Program Directors for advice or even through the Graduate Medical Education Council since they're across the specialties. This happens in every specialty.

remediation

underperforming fellows

competency issues

individualized learning plan

feedback