HELPING THE STRUGGLING RESIDENT PHYSICIAN

BEHAVIORALLY BASED REMEDIATION FOR RESIDENT PHYSICIANS WITH INTERPERSONAL & COMMUNICATION SKILLS AND PROFESSIONALISM DEFICIENCIES LEVERAGING THIRD PARTY COACHES & VIDEO SIMULATIONS

HCA West Florida (Brandon Regional Hospital) and HCA East Florida (d/b/a Aventura hospital) partnered with Javelin Learning Solutions to implement an innovate, online based remediation program designed to 1) create self-awareness in the resident to recognize their behavioral shortcomings, 2) make definitive and positive behavioral changes in conjunction with the third party coach and the resident’s faculty mentor, and 3) ensure that behavioral changes are manifested on the job on a sustained basis.

Struggling residents are ubiquitous in graduate medical education (GME) programs and requires intensive, organized, and directed efforts to remediate. Left unaddressed, resident interpersonal problems can create a toxicity in the work environment that can not only adversely affect patient care but negatively impact your culture of learning, cooperation and engagement. Although GME programs are responsible for ensuring competency in all six ACGME competencies and that residents identified as having deficiencies should be remediated, residency programs often struggle with providing effective remediation for those who fail to meet expectations in professionalism and interpersonal & communication skills. Remediation is resource-intensive, requiring individual mentoring by faculty, increased supervision, development of an individualized development plan, support through additional learning materials, and associated, formal evaluations. It’s not unreasonable for a small number of struggling residents to consume an inordinate amount of faculty time. 

From April until November of 2017, residents struggling in their interpersonal & communication and professionalism competencies were enrolled in an eight-week remediation program. The program includes a diagnostic stage to identify and describe problem behavior, developing a behaviorally based development plan that both residency staff and resident agree to, implementing the plan utilizing video simulations and video coaching, and documentation and final evaluations of the resident. 

The following steps were conducted for each struggling resident:

Diagnosis

Gather and use data from multiple unique sources to identify and describe problem behavior. 

Individualized Development Plan

The residency staff and the resident agree to time lines and specific, behavioral measures to be met as documented in an individualized development plan.

Video Simulations

The resident completes simulations, by creating video responses, both as an observer and then as a fully immersed participant in the simulation.  The participant is allowed to reflect on his/her responses and then receives specific behavioral feedback on what was done well and what could have been done better. 

Feedback & Coaching

Third party coaches meet weekly with the resident to debrief simulation performance and discuss on the job activities

The range of problems included defensiveness, mistreatment of nurses, poor interprofessional teamwork, arrogance, ineffective communication, allegations of harassment, workplace outbursts, lack of empathy, failure to take accountability, and integrity concerns. Of the 11 enrolled in the remediation program, 2 have failed to complete. Both resident and program leadership reactions to this ongoing process have been uniformly favorable. Program leadership is recognizing significant behavioral improvement on the job. This suggests that the skills learned through the simulations and coaching are transferring to successful change on the job.

The United States needs more physicians, especially well-rounded physicians with both technical and interpersonal competence. Residency is a critical time in a physician’s career. Bad habits can be corrected early or, if not adequately addressed, can persist for decades. Interpersonal skills and professionalism play a critical role patient experience, safety, and interprofessional collaboration. According to research, they are also the most difficult competencies to change. The aforementioned remediation process provides a framework, structure, and process to successfully change physician behavior. By the time a person enters a residency program, there has been a major investment in his or her professional preparation. The time, money and effort invested is substantial and continues throughout the residency program. A formal remediation process for struggling residents is necessary to ensure we’ve done everything we can to make every resident successful, while still recognizing that not every resident should move on to unsupervised practice