Dr Calvin Chou (UCSF) returns to talk with us about remediation in health professions education. We outline an easy framework to approach remediation: Identification, Clarification, Intervention, and Assessment. Dr Chou shares specific tips to define the underlying problem when a learner is struggling, how to address bias, and pointers on creating an effective intervention.
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Dr Chou defines remediation as the act of facilitating correction for a trainee who started on the path toward becoming a healthcare professional but has moved off course (Kalet and Chou, 2013). While remediation has negative connotations, it is important to realize we all have struggled at some point in our careers.
Dr Chou describes remediation as “feedback on steroids”. Feedback conversations can have brief corrective recommendations. Remediation is needed for situations where learners have repeated concerns of lower performance, and need a more comprehensive plan rather than a one off feedback conversation.
Identification: Awareness that a learner is struggling.
Clarification: Have a conversation to try to understand why this is happening and in what domain is the area of concern.
Intervention: Develop and implement an individualized learning plan.
Assessment: Assess both the individual learner and also your institution.
A trusted coach or advisor should take the time to sit down with a learner in whom a concern has been identified and begin to understand what might be underlying the area that needs improvement. What is the domain of concern, and is it due to a lack of knowledge or a personal situation outside of medicine? Normalize that we all struggle at some things, and remediation is common. Use the Ask, Respond, Teach approach (check out our prior episode on Feedback with Dr Chou for more on this).
Forty percent of medical students and around sixty percent of residents who are identified for remediation have a medical knowledge issue (Guerrasio 2014, Silverberg 2015). Dr Chou notes that sometimes a learner’s deficit is mis-classified. For example, a medical knowledge deficit might be the issue, but the learner deficit gets labeled as a communication issue.
Be explicit about the outcome of not remediating – “If you do not pass your shelf exams, you cannot pass the rotation.” Align together with the learner to provide the support needed to make sure the explicit outcome does not happen.
It is important to be aware of (implicit and explicit) bias when considering feedback. Try to be aware of other factors that can impact the learner’s experience such as stereotype threat and microaggressions. Intrapersonal, interpersonal, and structural biases can make a learning environment more difficult. Be aware that any learner in remediation has a label and may be treated with bias.
Each learner in remediation should have an individualized learning plan.
It helps to have specialists in each competency (i.e. medical knowledge, clinical reasoning, communication, and professionalism).
Use your learning specialist to help identify learning needs and techniques for improvement.
Find near peers who are successful in the area of concern. Near peers are more likely to know specific details about what will be expected on a coming rotation or test. Remediation groups may be helpful. For example, a group of students who are struggling with medical knowledge can join together with a faculty facilitator to share successful learning techniques (Chou 2019).
Use the science of learning – see upcoming episode with Dr. Cindy Nebel.
All interactions with the learner in remediation should be documented carefully. Dr Chou notes that although there may be concerns about dismissing learners who are not succeeding, there have been no successful lawsuits against programs who dismiss learners AND have consistently documented all the steps of the remediation process. Have the learner summarize in an email back to you key points of your discussion and next steps. This can act as a teach-back method to ensure everyone is on the same page (Kalet 2016).
It is important that the Dean or Program Director is aware of a formal remediation plan.
Feeding forward to attendings on rotation is controversial. This practice may be helpful or encourage biases. There is data from non-medical sources that shows feeding forward remediation concerns can result in the learner being labeled and the faculty generating bias against the learner. However, there may be benefits with feeding forward as informed faculty can focus on specific behaviors and offer targeted feedback to encourage improvement (Chou 2019).
It is important to have a specific timeline and criteria for follow up to assess remediation goals.
The remediation coach should be separate from the person or body (like a clinical competency committee) who is responsible for assessment. Having the remediation coach in a place of power can be a conflict of interest.
If someone graduates medical school or residency, they should be fit to practice. It is important to support learners who struggle, but in the end, if learners are not competent to graduate they should not (check out our episode with Dr. Kinnear on Time Variable Competency Based Medical Education).
Dr Chou recommends that part of the assessment should be of the program, in addition to the learner. In a remediation case, what should the program improve upon to support all learners? Dr Chou shares an example of how a remediation situation with one learner in a small program helped the program realize that they needed better backup and support to allow flexibility for all learners.
Listeners will appreciate the best practices for remediation in health professions education.
After listening to this episode listeners will…
Dr Chou reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Chou, C, Heublein M, Kryzhanovskaya E. “#32 From Struggle to Success: Navigating Remediation. The Curbsiders Teach Podcast. https://thecurbsiders.com/teach. May 23, 2023.
Infographic/Cover Art: Andrew DeLaat DO
Script, CME: Era Kryzhanovskaya MD
Show notes: Molly Heublein MD
Hosts: Era Kryzhanovskaya MD / Molly Heublein MD
Editor: (audio) Podpaste, (written materials) Charlotte Chaiklin MD
Guest: Calvin Chou, MD PhD
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