286
For example, a period of increased direct supervision and standardized objective
clinical examination exercises would be useful for a resident with difficulties in
clinical reasoning and judgment, but not a deficit in medical knowledge. A resident
with deficits in interpersonal relations or emotional self-regulation would be better
served by a plan that includes clear behavioral expectations and consequences,
coaching or mentoring, and frequent 360 degree feedback than a series of assigned
readings. For residents struggling with significant stress management, substance
use, or mental health issues, referral for formal treatment or outside resources or
support, schedule decompression, or a medical leave of absence may well be part of
the plan. However, it is important for the resident to understand that any activities in
the remedial plan are being put in place to assist them and it is ultimately their
responsibility to demonstrate the expected performance standards. (See Appendix A
for sample plans).
Once a plan is initiated, the activities should offer the resident opportunities for
focused deliberate practice on the deficiency areas with frequent feedback and
encouragement for self-reflection. There should be at least one identified advisor or
mentor who is meeting regularly throughout the plan’s duration to assist in these.
The resident should be updated frequently regarding progress. This approach maxi-
mizes the chances of success for the remediation plan and minimizes the chances
for a learner to misperceive how he or she is progressing and have a surprise at the
end of the reassessment.
The final step is the reassessment at the end of the prescribed period of remedia-
tion, utilizing the assessment parameters that were outlined in the plan. If the resident
is still not meeting performance standards, and the program feels that the resident has
the capabilities to succeed, the plan may be updated and continued. If the resident is
successful and is performing adequately at the end of the plan, this should be stated
explicitly to the resident and documented in the resident’s file as well.
Impact of Learning Climate
The process of identifying and providing intervention for performance deficits is
smoother in a program with a safe learning climate. Components of a safe learning
climate include shared mission and values, commitment to a common purpose,
clear expectations and performance standards, the ability to speak up without fear
of intimidation or retaliation, and, most importantly, the perceived accuracy of per-
formance feedback and assessment [ 43 ]. Accuracy of evaluations is a concern for
both program directors and residents, although program directors worry more about
grade inflation or leniency and residents worry more about fairness or unwarranted
over-attention to lapses of competence. The motivation of faculty can have pro-
found effects on the accuracy of evaluations. If a program leader sends the strong
message that careful observation, accurate assessment, and frequent feedback are
important, the faculty is more likely to be assiduous in directly observing residents,
rating them honestly, and providing feedback. The level of trust held by faculty rat-
ers that the assessment system is fair may account for up to one third of rating
K. Broquet and J.S. Padmore