283resident with significant stress or psychiatric symptoms is open to a program direc-
tor’s expression of concern or recommendation to obtain an evaluation by a mental
health professional. Other times, a resident may be resistant to this. Having a care-
fully constructed discussion with the resident regarding their performance and ask-
ing the resident if there are any issues that may be impacting performance is typically
the right approach. For example, “I’m very concerned about you. Some of the things
I’m seeing make me worry that you are experiencing stress or other issues that are
making it hard for you to succeed. I’d like to ask you access some resources that may
be helpful to you.” When a resident is forthcoming about a medical or psychiatric
issue, the program director can offer assistance, including helping the resident to
request a medical accommodation. However, if the resident is not forthcoming about
a medical or psychiatric issue, then the program director is somewhat limited in what
can be done, other than being supportive and managing performance.
If a program suspects that a resident is impaired (unable to practice safely, even
under supervision), a fitness for duty evaluation is warranted. By definition, if a resi-
dent is sent for a fitness evaluation, it implies a belief that the resident is not fit to
work and needs to be removed from the clinical workplace. The resident should be
placed on a leave of absence until the fitness evaluation can be completed and the
results returned. It is not something that can be put off until after the resident is done
with call duty that night or until other residents are back from vacation to cover. If
a resident is exhibiting symptoms of impairment, a fitness for duty evaluation that
includes a drug screen should be done immediately, while the resident is exhibiting
the signs and/or symptoms. If, after consultation with the DIO or other individuals
as outlined in your particular institutional protocols, it is determined that a resident
is in need of a fitness for duty evaluation, it is important for the program director and
resident alike to have a full understanding of what can be gleaned from this. In the
case of a mental health fitness evaluation, a psychiatrist or another examiner may be
asked to examine the trainee, prepare a report of detailed diagnostic findings and
treatment options (if appropriate), and offer an opinion regarding fitness for duty.
The report will limit the evaluator’s expert opinion to questions of psychiatric
impairment, not assessments of unsafe medical practice due to lack of skill, knowl-
edge, or training. Specific questions center on the presence of impairment as a result
of psychiatric illness. Illness may refer to psychiatric disorders including substance
abuse disorders, as well as physical disease or disability. Behavioral concerns such
as boundary violations, unethical or illegal behavior, or interpersonal conflicts may
precipitate an evaluation but do not necessarily result from disability or impairment
due to a psychiatric illness. A fitness for duty evaluation must address the specific
functional tasks of the particular trainee’s duties. Therefore, the following informa-
tion should be provided to the examiner: a criterion-based job description, or a list
of resident responsibilities, the specific questions the program would like to address,
and any collateral information that can help the evaluator to more fully understand
the resident’s functional level. Since the purpose of a fitness for duty evaluation is
to provide information to an employer or program director, the resident needs to
know in advance of the limits of confidentiality and sign appropriate releases for the
examiner to provide a report [ 41 ].
17 Optimizing Success for the Underperforming Resident