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ACGME competencies, residents most commonly exhibit deficits in medical knowl-
edge, patient care, professionalism, and interpersonal skills and communication [ 1 ,
2 , 4 – 7 , 14 , 30 ]. Because most of our assessment instruments, milestone informa-
tion, and evaluations are either organized via ACGME competencies or specifically
mapped to them, this is a useful starting point for delineating behaviors of concern
and targeting assessment. An equally useful framework is to conceptualize deficits
as cognitive or non-cognitive, as outlined in Table 17.2. This model is more closely
tied to observable behaviors and lends itself more to designing a behavior-based
remediation program. More importantly, it draws attention to professionalism issues
that may not be remediable.

Contributing Factors

In order to succeed, it is up to the underperforming resident to demonstrate improve-
ment in the behaviors or skills of concern. However, deficits don’t arise in a vacuum,
and often underlying contributing factors can be identified for the performance
problems. If possible, targeting remediation interventions to the underlying cause
will maximize the chances of success. Common contributors and possible interven-
tions are listed in Table 17.3.
Consider this scenario:

Residency training has long been identified as a high-risk time for symptomatic
levels of stress, burnout, and depression. Between 22% and 43% of residents experi-
ence some level of depression during residency [ 31 – 33 ], and 50–75% suffer from
burnout [ 34 – 37 ]. Burnout and depression are not synonymous with performance
impairment, and indeed the prevalence of both in residents is much higher than the

Resident S received above-average faculty ratings throughout most of his

PGY1 year. During PGY2, you are noticing a downward trend of mostly aver-

age ratings with a smattering of below average. Your chief resident recently

came to you with concerns that Resident S seemed withdrawn and not quite as

on top of things. You’ve just received an incident report that Resident S failed

to follow up on a critical lab value for a patient.

Table 17.2 Cognitive vs. non-cognitive deficits

Cognitive

Non-cognitive

Professionalism Organizational

Knowledge base

Clinical reasoning and judgment

Clinical decision-making

Technical skills

Interpersonal conflicts

Dependability

Disruptive behaviors

Dishonesty

Misconduct

Time management

Multitasking

Level of organization

Adapted from Williams et al. [ 6 ], Tabby et al. [ 4 ], Audétat et al. [ 2 ]

17 Optimizing Success for the Underperforming Resident