#32 From Struggle to Success: Navigating Remediation With Dr Calvin Chou

May 23, 2023 | By Molly Heublein

Audio

Video

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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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Introduction
• Picks of the Week
• Case from Kashlak
• Definition of Remediation
• 4 Phases: Identification, Clarification, Intervention, and Assessment
• Role Play of the Conversation with the Learner: Clarification
• Tips for Interventions
• Documentation
• Feeding it Forward
• Assessment and Follow up
• Addressing Bias in Remediation
• Take Home Points
• Outro

Remediation Pearls

1. Many learners struggle; aim to normalize remediation and reframe it as an opportunity to gain the skills needed to succeed.
2. Approach remediation through 4 Phases: Identification, Clarification, Intervention, and Assessment
3. To gain a better understanding of the learner’s difficulties, explore any underlying situations or circumstances that may be hindering their ability to succeed.  Identifying the specific learning domain of concern in order to target remediation efforts more effectively.
4. Remediation plan follow up should include both an evaluation to determine if the learner has been successful and also a reflection on the overall program, including how it can be improved based on insights gained from the remediation process.

Remediation Notes 

Defining Remediation

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.

Four Phase Approach to Remediation: Identification, Clarification, Intervention, and Assessment

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. 

Clarification

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.  

Intervention

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.

Documentation

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).

Feed forward

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).

Assessment

Of the Individual

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).

Of the program

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.

Take Home Points

• Remediation covers a spectrum from a learner who is struggling a little to someone who needs a formal remediation plan.
• Use the Identification, Clarification, Intervention, and Assessment framework.
• Think of remediation as feedback on steroids.
• The remediation coach should be separate from the arbiter who decides if the learner has been successful with the remediation process.
• Document, document, and document.

Other Stuff

Links

1. K dramas: Extraordinary Attorney Woo and Crash Landing on You
2. Presidio Tunnel Tops 
3. Indian Matchmaking 
4. Remediation in Medical Education: A Midcourse Correction by Drs Kalet and Chou

Goal

Listeners will appreciate the best practices for remediation in health professions education. 

Learning objectives

After listening to this episode listeners will…

1. Recognize the history of remediation broadly in health professions education, and more specifically, for medical education. 
2. Define remediation and its components.
3. Recognize best practices (do’s and don’ts) for remediation in medical education.
4. Employ strategies to ensure anti-oppressive and equity focused approaches for remediation. 

Disclosures

Dr Chou reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Chou, C, Heublein M, Kryzhanovskaya E. “#32 From Struggle to Success: Navigating Remediation.  The Curbsiders Teach Podcast. https://thecurbsiders.com/teach.  May 23, 2023.