Jeannette Guerrasio

Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012.

Purpose To identify deficit types and predictors of poor academic outcomes among students, residents, fellows, and physicians referred to the University of Colorado School of Medicine’s remediation program. Method During 2006–2012, 151 learners were referred. After a standardized assessment process, program faculty developed individualized learning plans that incorporated deliberate practice, feedback, and reflection, followed by independent reassessment. The authors collected data on training levels, identified deficits, remediation plan details, outcomes, and faculty time invested. They examined relationships between gender, training level, and specific deficits. They analyzed faculty time by deficit and explored predictors of negative outcomes. Results Most learners had more than one deficit; medical knowledge, clinical reasoning, and professionalism were most common. Medical students were more likely than others to have mental well-being issues (P = .03), whereas the prevalence of professionalism deficits increased steadily as training level increased. Men struggled more than women with communication (P = .01) and mental well-being. Poor professionalism was the only predictor of probationary status (P < .001), and probation was a predictor of other negative outcomes (P < .0001). Remediation of clinical reasoning and mental well-being deficits required significantly more faculty time (P < .001 and P = .03, respectively). Per hour, faculty face time reduced the odds of probation by 3.1% (95% CI, 0.09–0.63) and all negative outcomes by 2.6% (95% CI, 0.96–0.99). Conclusions Remediation required substantial resources but was successful for 90% of learners. Future studies should compare remediation strategies and assess how to optimize faculty time.

Determining Need for Remediation Through Postrotation Evaluations

INTRODUCTION Postrotation evaluations are frequently used by residency program directors for early detection of residents with academic difficulties; however, the accuracy of these evaluations in assessing resident performance has been questioned. METHODS This retrospective case-control study examines the ability of postrotation evaluation characteristics to predict the need for remediation. We compared the evaluations of 17 residents who were placed on academic warning or probation, from 2000 to 2007, with those for a group of peers matched on sex, postgraduate year (PGY), and entering class. RESULTS The presence of an outlier evaluation, the number of words written in the comments section, and the percentage of evaluations with negative or ambiguous comments were all associated with the need for remediation (P  =  .01, P  =  .001, P  =  .002, P  =  < .001, respectively). In contrast, United States Medical Licensing Examination step 1 and step 2 scores, total number of evaluations received, and percentage of positive comments on the evaluations were not associated with the need for remediation (P  =  .06, P  =  .87, P  =  .55, respectively). DISCUSSION Despite ambiguous evaluation comments, the length and percentage of ambiguous or negative comments did indicate future need for remediation. CONCLUSIONS Our study demonstrates that postrotation evaluation characteristics can be used to identify residents as risk. However, larger prospective studies, encompassing multiple institutions, are needed to validate various evaluation methods in measuring resident performance and to accurately predict the need for remediation.

Acute care nurse practitioner as hospitalist: role description.

There has been an explosive growth in the practice roles of acute care nurse practitioners (ACNPs) since the administration of the first certification examination in December 1995. The expansion of these roles is largely due to changes in medical residency requirements, pressures frommanaged health care organizations to reduce inpatient length of stay, increases in patient acuity, and the overall need for cost containment. Because of these changes, nurse practitioners (NPs) are now employed in emergency departments, tertiary care settings, intensive care units (ICUs), trauma centers, and specialty medicine areas, including oncology, interventional radiology, and neurology. NPs are performing more clinical skills such as central line catheter placement, ventilator management, and interpretation of radiographs. In addition, increasing numbers of NPs are taking responsibility for teaching roles, quality improvement, formulation of standards of care, and participation in research within the aforementioned settings. A literature review of articles from 1995 to the present places ACNPs in teaching, community, rural, and military hospitals. Kleinpell surveyed ACNPs over a period of 5 years, revealing over 50 practice settings. A small sampling of practice settings within the hospital include adult and pediatric cardiac surgery, neonatal ICUs, oncology, general surgery, and neurosurgery. In 2006, Becker et al published results from a single survey of 77 ACNPs in which 34 primary practice units were identified. In these 2 articles, the largest reported practice areas were cardiovascular ICUs, surgical ICUs, and step-down

Twelve tips for developing and maintaining a remediation program in medical education

Abstract Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors’ three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

Failure to fail: The institutional perspective

Abstract Purpose: To determine institutional barriers to placing failing students on probation, dismissing students. Methods: An online survey study was distributed to Student Affairs Deans or the equivalent at allopathic (MD) and osteopathic (DO) medical schools, and physician assistant (PA) and nurse practitioner (NP) schools across the United States. Nineteen (40%) of the 48 schools responded: six MD, four DO, five PA and four NP. The survey contained demographic questions and questions regarding probation and dismissal. Themes were independently coded and combined via consensus based on grounded theory. The survey was distributed until saturation of qualitative responses were achieved. Results: Respondents identified variations in the use of probation and dismissal and a wide range of barriers, with the greatest emphasis on legal concerns. Respondents felt that students were graduating who should not be allowed to graduate, and that the likelihood of a student being placed on probation or being terminated was highly variable. Discussion: Our results suggest that institution culture at heath professions schools across the United States may represent an obstacle in placing failing learners on probation and dismissing learners who should not graduate. Additional studies are needed to prove if these concerns are founded or merely fears.

Association of Characteristics, Deficits, and Outcomes of Residents Placed on Probation at One Institution, 2002-2012

Purpose To describe the population of residents placed on probation, identify learner characteristics associated with being placed on probation, and describe immediate and long-term career outcomes for those placed on probation as compared with matched controls. Method The authors collected data for residents at the University of Colorado School of Medicine placed on probation from July 2002 to June 2012, including postgraduate year placed on probation, deficits identified, mandated evaluation for physical and mental health, duration of probation, disability accommodations requested, and number of additional training months required. They were retrospectively compared with 102 controls matched for specialty, matriculation, and postgraduate year. Variables assessed included demographics, academic performance, license status, specialty, state board certification, and board citations. Results Of 3,091 residents, 3.3% were placed on probation (88 residents; 14 fellows). Compared with controls, those on probation were more likely to be international medical graduates, married, not Caucasian, older (all P < .001), male (P = .01), to have transferred from another graduate medical education training program, and to have taken time off between medical school and residency (all P < .001). Among those currently in practice, 53 (63.9%) were board certified compared with 93 (100%) of the controls. Placement on probation was associated with failure to graduate and lack of board certification. All 7 graduates cited by state medical boards were in the probation group. Conclusions Further research is needed to understand these associations and to determine whether changes in curricula or remediation programs may alter these outcomes.

Heuristic errors in clinical reasoning

Errors in clinical reasoning contribute to patient morbidity and mortality. The purpose of this study was to determine the types of heuristic errors made by third‐year medical students and first‐year residents.

Creutzfeldt-Jacob disease presenting as severe depression: a case report

BackgroundAn 81 year old female presented with altered mental status after new onset of severe depression and suicidal ideation with recent psychiatric hospitalization.Case presentationKey clinical features included muscle rigidity, prominent startle reflex, and rapidly progressing cognitive decline. Initial working hypothesis was serotonin syndrome or neuroleptic malignant syndrome but continued deterioration after medication removal prompted evaluation for alternative etiology. Work-up revealed elevated 14-3-3 CSF protein which suggested the prion disorder which was confirmed on post-mortem examination of brain tissue.ConclusionWhile the degree of depression was unusually severe, the case highlights the behavioral and psychiatric manifestations which frequently accompany Creutzfeldt-Jacob disease.

A qualitative study of medical educators’ perspectives on remediation: Adopting a holistic approach to struggling residents

Abstract Introduction: During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation. Methods: We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis. Results: Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation. Conclusions: The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

Academic Remediation: Why Early Identification and Intervention Matters

At our institution, we have developed a remediation team of strong, focused experts who help us with struggling learners in making the diagnosis and then coaching on their milestone deficits. It is key for all program directors to recognize struggling residents because early recognition and intervention gives the resident the best chance of success.