297clinical assessments, and critical incidents or complaints. Faculty may be reluctant to
document concerns about underperformance on written evaluations. Verbal
expressions of concern or complaints, even in the face of average rotation evalua-
tions, should be taken seriously. Residents often have deficiencies in multiple
domains, although the competencies of medical knowledge, patient care, profession-
alism and interpersonal skills, and communication are the most common. Remediation
efforts are felt to be more successful in medical knowledge and less so with deficits
in clinical reasoning or professionalism. When underperformance is identified, the
nature and extent of the deficiencies should be elucidated as clearly as possible. This
educational formulation should include assessment for any underlying or contribut-
ing factors such as resident stress or burnout, time management or organizational
problems, unreasonable service expectations, or inadequate medical school prepara-
tion. A remediation plan should be targeted to the deficits and formulated with active
input by the learner and CCC. It should clearly outline the expected performance
outcomes, as well as the prescribed learning activities and any adjustments to the
resident’s regular schedule, the process for monitoring and feedback, timetable and
criteria for reassessment, and consequences for not achieving the expected standards.
We also reviewed the parameters of a good learning climate which include clear
expectations and performance standards, consistent feedback, and the perceived
accuracy and fairness of performance feedback and assessment. We discussed some
of the challenges of the nonreflective learner and reinforced the vital importance of
consistent, focused, direct, and accurate feedback.
We reviewed the legal context of underperformance, in that residents are both
employees and students. In instances of academic or remediable professionalism
deficiencies, a resident must be afforded notice of the deficiency and an opportunity
to correct it. In instances of misconduct, a resident must be afforded a notice of the
deficiency and an opportunity to be heard. In both cases, any decisions made regard-
ing progress in the program must be made thoughtfully and deliberately, with active
CCC involvement. In the case of serious deficiencies, or if the resident is unable to
progress in the program, scrupulous adherence to program and institutional policies
is paramount, as is involvement of other appropriate administrators, which gener-
ally include at a minimum the DIO, and representatives from legal and human
resources.
Appendix A
Remediation Plan: Sample 1
This is an initial remediation for a PGY1 resident with a discrete deficit in medical
knowledge and good insight. This is a program-level remediation. The resident is
not being placed on official academic deficiency or probation status.
Dear Merle,
As we discussed last week in your semiannual review meeting, it is the consen-
sus of the faculty that you have a deficiency in the ACGME competency domain of
medical knowledge. As you know from our discussion, we are concerned that you
are not learning to your ability. You identified time management and lack of reading
as your primary challenge. You and I discussed the options and activities that you
17 Optimizing Success for the Underperforming Resident