The Struggling Fellow: High-Yield Tips for Remediation

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Pulmonary and Critical Care Fellowship leaders are educating in a new era. Our learners are more advanced than ever before, having distinguished themselves in increasingly rigorous residency programs. Many have been chief residents. Most have been able to produce meaningful research despite the demands of training. By their Electronic Residency Application System (ERAS) applications, they tell us that they are paragons of wellbeing, enjoying diverse hobbies and extra-curricular activities. Through their training, they have established a long record of resiliency; they have become accustomed to working nights, weekends, long-hours, and performing at a high level despite the demands of a generational pandemic.

For all of these reasons, fellowship leaders may be surprised by a struggling fellow; due to the low number of new learners each year, many have not been faced with this situation before. The prevalence of struggling learners in fellowship programs is unknown, but is thought to mirror findings in other graduate medical education (GME) settings, with a point-prevalence between 3.5-22%.(1) Given the (often front-loaded) structure of fellowship programs, identifying those fellows who are struggling early is of paramount importance.(2) Below, I would like to highlight several important points distilled by our community in a recent publication in ATS Scholar, “Best Practices for Remediation in Pulmonary and Critical Care Fellowship Training.”(3)

 

High-Yield Points

There are four pillars to a successful strategy of remediation for a struggling fellow, of which the first pillar, early identification, is the most important (Figure 1). For many programs, the quality and volume of written feedback may be inadequate alone to identify a struggling fellow. Proactive use of strategies such as the early solicitation of confidential comments from faculty, use of simulation in orientation, and leveraging the knowledge and early impressions of chief fellows, administrative and clinical support staff, and the program coordinator(s) are helpful.

Figure 1: The Four Pillars of Successful Remediation(3)

 

1. After identification of a struggling fellow, a thorough multi-source assessment of all factors possibly contributing to the situation must be elucidated. In the figure above, note that health (mental, physical, social, substance use, and financial) are listed at the top, as they are the most important factors requiring direct attention. Within this pillar, it is important to remember that bias exists within educational institutions and is reflected in evaluations at every level of training. In no other setting is it more necessary for program leaders to work actively against the effects of systemic bias.(4)

2. Working with the fellow involved to collaboratively create a remediation plan is beneficial whenever possible, as collaboration improves fellow buy-in and agency within a situation which can otherwise feel daunting, and which is often longer than the fellow anticipates.(5)

3. Interventions devised must be frequent (more frequent than fellows believe), fellow-driven, and enriched with opportunities for planned directed feedback aimed at success with pre-specified goals.

4. Although remediation generally is associated with good outcomes(6), leaders must proactively document all communication (meetings, collaboratively developed goals, feedback received both formally and informally, and anticipated consequences in case the fellow is unable to improve within the remediation period.) When appropriate records and clear written communication are proactively used by program leaders, courts have not overruled decisions based on the honest professional judgement of the faculty members.(7) Examples of written communications, milestones-based responses, and multisource reassessment strategies used successfully by programs can be found in the appendix of the aforementioned article.(3)

Struggling learners have been identified at all levels of medical training. Our competitive subspecialty fellowship environment and the low number of new learners added to our programs each year may feel like insulation, but in truth they only increase the challenge of identifying and remediating fellows when they are struggling. Despite our worries that we lack the skills and support to respond to these situations effectively, resources exist both in the literature and within our institutions. Allowing the problem to go on unaddressed can have serious consequences for the long-term wellbeing of our learners. It is our responsibility to be the leaders we wish to see in the world: fearless in identification and quick to action protecting both patients and the doctors who serve them.

 

References

  1. Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000 Sep 6;284(9):1099-104. doi: 10.1001/jama.284.9.1099. PMID: 10974688.
  2. Dudek NL, Marks MB, Regehr G. Failure to fail: the perspectives of clinical supervisors. Acad Med. 2005 Oct;80(10 Suppl):S84-7. doi: 10.1097/00001888-200510001-00023. PMID: 16199466.
  3. Camac E, Stewart N, Santhosh L, Carlos WG, Denson JL, Heath J. Best Practices for Remediation in Pulmonary and Critical Care Medicine Fellowship Training. ATS Sch. 2022 Aug 31;3(3):485-500. doi: 10.34197/ats-scholar.2022-0007RE. PMID: 36312805; PMCID: PMC9590524.
  4. Klein R, Julian KA, Snyder ED, Koch J, Ufere NN, Volerman A, Vandenberg AE, Schaeffer S, Palamara K; From the Gender Equity in Medicine (GEM) workgroup. Gender Bias in Resident Assessment in Graduate Medical Education: Review of the Literature. J Gen Intern Med. 2019 May;34(5):712-719. doi: 10.1007/s11606-019-04884-0. PMID: 30993611; PMCID: PMC6502889.
  5. Li ST, Paterniti DA, Tancredi DJ, Co JP, West DC. Is residents' progress on individualized learning plans related to the type of learning goal set? Acad Med. 2011 Oct;86(10):1293-9. doi: 10.1097/ACM.0b013e31822be22b. PMID: 21869666.
  6. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012. Acad Med. 2014 Feb;89(2):352-8. doi: 10.1097/ACM.0000000000000122. PMID: 24362382.
  7. Irby DM, Milam S. The legal context for evaluating and dismissing medical students and residents. Acad Med. 1989 Nov;64(11):639-43. doi: 10.1097/00001888-198911000-00001. PMID: 2803418.

 

Erin Camac, DO, FCCP is an Associate Professor of Medicine and the PCCM Fellowship Program Director at the University of Kentucky College of Medicine in Lexington, KY. She is interested in mentorship, medical education, interstitial lung disease, role-playing games, loud music, and natural history.

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