1. Benjamin T. Jarman MD, FACS Gundersen Lutheran Medical Foundation La Crosse, WI March 21, 2012

2. Disclosure I have not terminated a resident I have designed successful and unsuccessful remediation plans for senior residents

3. “10% of residents take 90% of the Program Director’s time” John Potts MD

4. “10% of residents definitely take 90% of the Program Director’s time” Benjamin Jarman MD

5. Why? Medical knowledge Patient care Professionalism Communication Mental health Change of interest/lifestyle concerns Drug/alcohol abuse Technically challenged Failure to meet program requirements

6. Step back Tragic event – 24 th /25 th grade How to predict/associated factors? Identify problems / DOCUMENT early Role for personality or learning assessments? Prevention?

7. Actions Remediation - the correction of something bad or defective Repeat year Probation – the condition of being given a chance to redeem failures or misconduct in order to retain an academic classification Suspension – punishment by temporary exclusion from work Contract non-renewal Termination –concluding employment

8. ACGME Requirements IR II.D: Resident Appointment Contract must contain Resident responsibilities Duration of appointment Conditions of reappointment Grievance procedures

9. ACGME Requirements IR II.D.4.d(1): Non-renewal of contract Provision of written notice 4 months prior to end of current contract Resident must be permitted to implement grievance procedure

10. Documentation Essential

11. Gundersen Lutheran Institutional Plan Written letter to resident from CPC List deficiency, resources, plan Resident option to address with CPC Determination of ongoing deficiency Direct meeting with CPC/resident Resident response (<3 days) CPC recommendation CPC = Clinical Practice Committee

12. Gundersen Lutheran Institutional Plan Resident response (3 days) Submit written resignation Agree with recommendations Request formal review by DME/GMEC Review panel Meet with resident, CPC, record review Formal decision (30 days)

13. Remediation

14. Remediation Resources Clinical Performance Committee (CPC) Employee assistance program: Free Provide professional, confidential assistance Address personal and/or work related issues Conduit for additional services Human resources department Professional counselors Teaching faculty Residency coordinator

15. Remediation Performance Improvement Plan (PIP) Focused plan with endpoints Define the issue(s) – competency based Goals for improvement Action plan with defined interval (3-6 months) Ownership – Establish a mentor(s) Monitoring Follow up

16. Remediation (PIP) Ramifications/next steps Completion of PIP Ongoing remediation Probation/suspension Decision to resign Termination Meet with Human Resources and resident Resident and program director sign the document

17. Remediation (PIP) Things to consider while PIP ongoing: Keep faculty engaged Frequent evaluations/feedback Keep the resident engaged Be quick to comment on accomplishments and challenges Respond to rumors, word on the street

18. Resident 1 – Dr. Indecision Problem Filled PGY II vacancy with prelim. resident Technically behind peers Problem: difficulty making definitive intraoperative decisions, trying to appease different attendings’ practice patterns rather than developing independent approach - paralyzing Now 4 months until graduation

19. Dr. Indecision Action plan Required lab practice Encouraged to perform all operations (no teaching cases) Altered training for terminal 3 months and mandated at least 3 months additional training Contacted ACGME and ABS One on one mentorship with dedicated teaching faculty for 4-6 week intervals – focus of establishing operative plan/expectations and completing all aspects of care plan

20. Significant improvement Developed independent style Improved progress of operations Deemed able to graduate after additional training Successful general surgery practice 3 years later Reasons for success; engaged individual and early acceptance that additional training would be needed To do different; earlier plan of action/alter training earlier in experience Dr. Indecision Result

21. Resident 2: Dr. Mean Problem Filled PGY II vacancy with prelim. resident Issues: Professionalism Disrespectful Did not work well with women Protected himself – dumped on other residents Technically/clinically sound All issues became more evident when in leadership roles during the PGY IV year

22. Dr. Mean Plan Complicating factors Transition of program leadership Inadequate documentation of “events” Action plan Series of meetings/sit downs Made it clear that graduation was not a given Established with Employee assistance plan Strongly recommended professional evaluation Provided resources – educated about perceptions

23. Dr. Mean Result Improved behavior with on time graduation Avoidance of some staff Successful in practice – private/solo What to do better? Better compliance with institutional plan Avoid hiring / Anticipate challenges Documentation Less tolerance with better action plan

24. Probation Similar format as PIP More dire ramifications with termination being more likely May restrict clinical duties or those related to areas of deficiency Permanent record

25. Termination Reasons Failure of action plans to remediate clinical or academic performance Moonlighting Substance abuse Theft (skills lab/OR/Hospital) Injuring patients/peers

26. Termination Process Must have written protocol Must keep up with documentation Must consult with legal department/human resources

27. Conclusions Tough situations High stakes with significant implications Identify and manage problems early Rely on CPC Rely on written policies

28. Thank you

31. Remediating the Competencies Medical Knowledge Reading plan Establish mentor Regular testing Assess learning ability

32. Remediating the Competencies Patient care Mock oral exams Establish mentor Written tests Alter supervision Mandate increased communication with regard to decision making

33. Remediating the Competencies Practice based learning/improvement Require evidence based reviews Establish learning goals Witness resident education of patients

34. Remediating the Competencies Professionalism “we own the perceptions we create” talk Variety of books Social media education Gender/race/culure dynamics education

35. Remediating the Competencies Interpersonal skills Mandate documentation review Coding review Directly monitor resident with patient with feedback

36. Remediating the Competencies System based practice Assign to inter-professional teams Assign to systems improvement projects

37. Remediating the Competencies Technical Use skills lab Assure getting into OR Frame future practice Mandate preoperative discussion Provide immediate feedback

39. Remediation PIP Success? Based on testing Based on clinical or technical evaluations Based on peer/staff evaluations Document improvement/progress Failure? Next steps…….