Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature;Karen E. Hauer, MD, Andrea Ciccone, MS, Thomas R. Henzel, EdD, Peter Katsufrakis, MD, MBA, Stephen H. Miller, MD, MPH, William A. Norcross, MD, Maxine A. Papadakis, MD, and David M. Irby, PhD. Acad Med. 2009; 84:1822–1832.
Reviewed by Lavjay Butani
What was the study question?
The purpose of the study was to determine if the medical education literature could provide an ideal model of remediation as assessed by two measures: clearly stated outcome measures, and targeting varying levels of learners (undergraduate, graduate and practicing professionals).
How was the study done?
A MEDLINE literature search through October 2008 was performed by one of the investigators using terms related to remediation and other areas such as clinical competence. Bibliographies of retrieved articles were manually searched for additional studies. Opinion articles and reviews were excluded. Based on consensus and small group review, only those studies that addressed the following 3 components of remediation were included: description of how the deficiency was assessed, the educational intervention, and strategy for reassessment of deficiency. A standardized data extraction form based on the Best Evidence Medical Education Collaboration project was used. The robustness and impact of the reassessment strategy used was classified based on Kirkpatrick's 4 levels of assessment.
What were the results?
Of the 170 articles selected for review, only 13 met eligibility criteria for inclusion; 7 addressed remediation of medical student performance, 2 focused on resident performance issues and 4 studies assessed practicing physicians' performance deficiencies. Interestingly, in none of the student and resident focused papers were learner deficits identified during actual clinical performance; rather the articles dealt with remediation of deficiencies on knowledge based tests/in-service examinations or clinical deficits based on standardized patient (SP) encounters. The intervention strategies included tutorials, directed readings, one on one discussions with a mentor, and precepted video reviews of SP encounters. Re-testing strategies for the most part involved use of the same assessment that led to the initial identification of problem performance; all studies showed an improvement in learner knowledge and skills (Kirkpatrick level 2). None of these studies assessed learner behaviors or patient outcomes. The 4 studies addressing practitioner performance (all from Canada) identified deficits using peer assessors and licensing organizations. Remediation included tutorials, clinical training, readings, and coaching. Retesting strategies were of a higher level in 3 studies (Kirkpatrick Level 3), assessing change in physician's behavior, while in the 4th, the only outcome assessed was practitioner satisfaction (Kirkpatrick Level 1). All studies demonstrated improvements after the intervention.
What are the implications of these findings?
This review highlights the gap in the medical education literature pertaining to a critical area - how to design, implement and assess the success of intervention strategies once learners with difficulty have been identified. With greater emphasis on competency-based instruction and assessment, it will become even more critical for educators to engage in scholarship addressing how to be successful in remediating learners. This would then be followed by the designing of a tailored educational intervention strategy and finally to the development of valid and meaningful assessment tools addressing higher levels of outcomes (behavior change). This, obviously, involves lots of resources and time, neither of which are easy to come by. Multi-institutional collaboration is one way to pool resources and expertise to answer these questions. We know that evaluation drives performance, but if we don't know how best to teach learners who are having difficulty, how can we close the loop and expect our learners to succeed? It's time to advance this area, an area that is ripe for scholarly activity!
Editor's note: As the authors conclude, there is little evidence-based guidance on how to best remediate trainees in medical education - perhaps COMSEP will take this on and contribute to this field of study.