277The presence of one or more of these risk factors may well be balanced by mul-
tiple positive factors, and none are robust enough to predetermine lack of success in
residency. However, a resident with any of these risk factors may well benefit from
added structure or frequency of feedback and assessment during the early part of
training. In particular, verbal expressions of concern from supervisors or complaints
from staff, nurses, or patients, even in the face of average or above rotation ratings,
should be taken very seriously.
Identifying and Assessing Lapse in Performance
Underperforming residents may come to a program director’s attention from a vari-
ety of sources. Program directors and chief residents are most likely to be the first
to identify a problem [ 1 , 10 ]. Underperformance can be identified by a plethora of
methods, but the most common are direct observation of clinical skills by supervis-
ing faculty, by standardized cognitive or clinical performance assessments, or via
critical incidents or external complaints. Sometimes subtle deficits are identified
only after Clinical Competency Committee (CCC) review and discussion [ 10 ]. A
CCC is required by the Accreditation Council for Graduate Medical Education
(ACGME) for all residency programs [ 19 ]. The CCC is an advisory body that is
appointed by the program director and is comprised of at least three faculty mem-
bers. Residents are restricted from being members of the CCC. It is critically impor-
tant to underscore that the CCC is advisory to the program director. The program
director is the ultimate decision-maker and should consider the recommendations of
the CCC regarding resident performance prior to rendering decisions on progress,
promotion, remediation, and dismissal. The ACGME CCC Guidebook for Programs
[ 20 ] provides detailed information for program directors regarding the operation
and function of the CCC. The CCC should utilize multiple assessment sources when
evaluating resident performance. The discussion that takes place between faculty in
the CCC can provide valuable insight to emerging resident performance issues.
Schwind et al. [ 12 ] and Williams et al. [ 21 ] address the topic of group decision-
making in clinical evaluation, noting the committee structure provides for a broader
base of information used for decision-making, allows for calibration of disparate
raters and identification of a presumed “bad day” vs. a pattern of performance
issues, and promotes reasoned decision-making. Holmboe et al. [ 22 ] emphasizes
the “wisdom in the group.” Hemmer [ 24 , 25 ] and Hauer et al. [ 23 ] reinforce this
concept by adding that group conversations regarding performance are much more
likely to uncover deficiencies in knowledge and professionalism and improve feed-
back that subsequently can positively impact learner performance. It is rare for a
resident to self-identify underperformance. Physicians as a rule tend to overestimate
their performance, and those functioning in the lower range overestimate their per-
formance even more [ 1 , 26 , 27 ].
17 Optimizing Success for the Underperforming Resident