Residents aren't expected to be perfect -- they're on the job to learn. But some inevitably struggle, and whether a resident has one particular area of weakness or 10, program directors and mentors need to identify problems early and move decisively to solve them, according to an expert on residency education.
In a recent talk from the perspective of a residency program director, Dr. Carol Rumack, associated dean for graduate medical education and professor of radiology and pediatrics at the University of Colorado, said that programs must reach out early and often to identify and solve problems, proactively diagnosing issues that arise, proposing goals, and monitoring progress toward solutions.
Dr. Carol Rumack from the University of Colorado.Rumack spoke in a talk at the 2012 RSNA meeting that focused on evaluating struggling residents and building support for resident remediation and mentoring.
Freedom to fail?
When a laissez-faire program allows a resident to fail, it's as much the director's fault as the resident's, according to Rumack. Take the core competency of a resident making a diagnosis, for example.
"There are a lot of tools that we already have -- it's not like you are going to have to go out and invent [them]. You have in-service exams every year, you have national benchmarks ... and you'll see some people ignoring the fact that [a resident] only did the fifth percentile," Rumack said.
But ignoring a poor test result is the wrong way to go, because there's plenty of evidence to show that scores that low will eventually translate into trouble passing the boards.
"And the time to tell them that is in their first year, not in their fourth year when they're about to take their core exam," she said. "You really want to be picking people up and recognizing that they're struggling."
Solving problems
Despite their best efforts, some residents are going to have trouble, Rumack said. First and foremost, residents must succeed in the six competencies included in the Accreditation Council for Graduate Medical Education (ACGME) evaluations. These are the issues that the program must diagnose with the aid of the key people who are in a position to directly observe residents in the performance of their duties:
- Medical knowledge
- Patient care (including observational skills, clinical reasoning, organization, and time management)
- Interpersonal/communication skills (assessed by multisource evaluations including medical student lectures and patient procedures)
- Professionalism (evaluated by technologists, program coordinator, medical students, chief residents, and patients)
- Practice-based learning and improvement
- Systems-based practice (evaluated in projects such as morbidity and mortality or quality improvement initiatives)
Programs need assurance that residents have the technical skills to perform the task at hand. Reasoning skills are a higher order of intellect that merits observation, and time-management skills are another skill worth watching, Rumack said. Mental well-being requires direct observation by faculty, and psychological evaluation if necessary.
"Mental well-being falls under professionalism: If they're not in good shape, it pops up in behavior you wish they hadn't done," she said. "In clinical reasoning, every day we see -- looking at their radiology reports -- that you can tell who's really reasoning and who's sort of vague. We don't spend a lot of time on time management, except in report turnaround time that everybody is after all the time."
Identify problems early
The best indicators of problems are early indicators, which can be gleaned from what's happening in the program, she said. It's valid to pay attention to what people are saying, to hallway conversations, to emails complaining about a resident, to a phone call from a frustrated attending physician.
"I encourage people to keep emails, because if you get an email from an angry faculty member -- somebody didn't show up, or dropped their call or some significant thing -- I throw it in the person's file," Rumack said. "If that's the one and only time it happens, you're eventually going to throw it away, but don't throw it away at the beginning."
There is no written record for complaints made by phone, so the way to document it is to write an email back to the person raising the issue, reviewing what he or she said and asking if you got it right. This creates a record of the call in case one is needed later, she said.
Direct observations from multiple sources produce the best early data, Rumack said. Monthly faculty evaluations are a good source of feedback, but they are far more useful if they incorporate the early signs of trouble from conversations, emails, and phone calls.
"One of the most unprofessional people we mediated was a person who in their first year was doing exceptionally well and who we all thought was outstanding," Rumack said. Then came word that the resident had at one point demanded that the program coordinator drive him home to pick up his keys.
"It was way off the wall," she said. "You can't expect to do things like that and survive in your career."
Use the CCC and other resources
For remediation, the clinical competency committee (CCC), which consists of the program director, associate program director, site directors, and faculty needed to assess competencies, is the most important vehicle for resident evaluation, she said. It should be convened often enough to talk routinely about each resident's progress, and definitely before the semiannual review in order to be able to advise the program directors.
The CCC, not the program director, is the best agent to evaluate the resident, identify the source of weaknesses, and take action because the committee's information comes from several different sources that together can provide a better diagnosis of the problem, Rumack said.
"As program director, it is tempting to review and then talk to faculty about how serious it is, but it's really more valuable to do it the other way around -- convene the committee first and talk about the resident, take the information you have, and put it together," she said.
In cases of suspension for disruptive or unsafe behavior on the part of a resident, 30 days is typically long enough to sort out the issues, and there may be need for a mental health evaluation, she said.
Make use of your institutional resources, such as the physician's health program.
"You obviously want to know if they have an organic problem: Is it a brain tumor, is it a drug problem, is it stress?" she said. "If you see musculoskeletal as a weakness in five residents, you need a better program. Everything that's a weakness isn't necessarily the resident's fault, so be sure you're diagnosing the program versus the resident."
For remediation, choose one or two big issues to deal with, not several, she said. Choose the remediation effort with the greatest potential return for the residents and the coaches or mentors. If mental well-being or professionalism is an issue, then start the process there. Weak skills should be practiced deliberately, with ample opportunity for feedback.
The remediation team
You'll generally approach problems based on your level of concern, she said. At the six-month review, have the resident bring in a self-reflection and compare it with the CCC's evaluation.
Some residents can see what they're doing wrong and others can't, she said. Some are good at listening and others never will be, so spell out the deficiencies in a letter of focused review. The program director should make the expectations clear, and it's the job of coaches and mentors to help residents achieve them. The program director cannot be the coach.
"You can't be a coach and a judge, but the program director has to be a judge at some point, so you need to find somebody else who can [be the coach]," she said. The program director's advice is the action plan.
There are also different kinds of mentors, she added. There are content coaches who impart knowledge in a specific area, and career coaches who focus on professionalism, developing communication skills, and improving test-taking skills. Mentors should report to the program director and the CCC regularly, and there should be regular follow-up meetings, which are everyone's responsibility.
Once the weaknesses are communicated and understood, there are stages of grief -- and you're always hopeful that your residents get past the anger and denial, she said. It's difficult when people remain defensive, and the solution once again is to find problems early.
"If you wait until somebody is a third or fourth year and then tell them they've got a lot of problems, it's really unfair to the person," Rumack said. "They may feel bad if you tell somebody in their first year of residency that they're not doing well, but on the other hand, it's a whole lot healthier to be working on that in the first year."
At that point it's OK to be behind, and "they aren't expected to be experts," she said.
