Residency Corner: How To Address The Underperforming Resident

These residency directors share their insights and discuss the role, impact and effectiveness of remedial programs to get residents back on track.

Q:

How do you address a disappointing performance by your resident?

A:

Matthew G. Garoufalis, DPM, says he first evaluates and quantifies the given issue. He says these issues need to be evaluated and recorded in detail in order to measure progress. While there are many scenarios that one may consider as disappointing resident performance, Robert Eckles, DPM, says for each instance, he opens an incident/remediation file, completes any necessary investigation and then reviews the matter with the resident and at least one member of his facility’s internal Resident Review Committee.

“The gravity and nature of the event(s) will determine the extent of resources directed to the matter,” notes Dr. Eckles.

David Bernstein, DPM, says he and his residency coordinator will meet with the resident immediately and then weekly until the given issues are resolved. If the issues are not resolved in one month, Dr. Bernstein says his facility proceeds to initiate a remedial program.

Concerns over patient safety are the priority, regardless of whether the deficiency is related to skill level, academics or personal communication behavior, maintains Dr. Eckles. He says the response to the issue is proportional and mitigation strategies are developed to establish appropriate standards and milestones for achievement. Dr. Eckles also notes that this conversation with the resident includes “clearly stated boundaries and adverse outcomes for failure to meet these goal points.” At his facility, Dr. Garoufalis says corrective measures are put in place and there is a subsequent timeline for reevaluation of the resident’s performance and outcome measurement.

Drs. Eckles and Garoufalis note that actions are taken with consideration of the tremendous amount of education and training that the resident has had thus far and the potential impact on his or her career. However, patient safety is the prevailing consideration, according to Dr. Eckles.

“The residency director is the last point along the path to full licensure and practice, making effective behavior and skill modification important public safety actions,” emphasizes Dr. Eckles.

Q:

Are monthly or quarterly evaluations done in person to document a resident’s poor performance with another person from the hospital or HR present? In your experience, what are some of the challenges you have run into with performing these periodic evaluations? What benefits have you seen with these evaluations?

A: 

When it comes to first-year residents, Dr. Bernstein and his residency coordinator evaluate them every two months for the first six months. He says they quickly identify any evidence of underperformance and commence with corrective measures. Subsequently, all residents are evaluated every six months, according to Dr. Bernstein. He adds that residents are also evaluated during a quarterly podiatry curriculum committee meeting.

“The benefit of frequent meetings is very important in order to measure if the corrective actions are working,” notes Dr. Bernstein.

Dr. Garoufalis prefers monthly evaluations but usually is checking on a struggling resident more often, either daily or on a weekly period. For residents with inadequate performance, Dr. Eckles says there are monthly “focused evaluations” alongside remediation plans, alteration of schedules and case assignments.

At his facility, Dr. Eckles says residents without significant deficiency have a semi-annual review with the residency director. He also acknowledges the benefit of positive feedback in reinforcing resident performance.

“Positive performance reviews promote confidence and trust between the resident and the program, and offer residents freedom to develop even higher standards of clinical performance and leadership,” says Dr. Eckles.

Dr. Bernstein says he has had no challenges when meeting with residents to discuss their performance and notes that residents are asked to perform self-reviews as well.

At Dr. Eckles’ facility, evaluations are generally handled through a residency review committee and HR only becomes involved during later stages of discipline. In his experience, Dr. Eckles says residents are generally receptive to deficiency notification as there is a shared performance goal. While discipline via probation, suspension or dismissal is certainly not welcomed by the resident, Dr. Eckles says “time-outs” work and that a resident can return to full engagement in the residency program following the given event.

Thorough documentation is critical, according to Dr. Garoufalis.

“Documented evaluations are beneficial because they can demonstrate positive progress toward the desired goal and motivate the resident to continue improving,” maintains Dr. Garoufalis.

One of the challenges, according to Dr. Garoufalis, is when a resident refuses to understand the severity of the situation or its long-term outcome if improvement does not occur. He acknowledges that this resistance can subsequently become detrimental to other attendings, residents, patients and the residency program itself.

On rare occasions, Dr. Eckles has found that a resident is unable to navigate the remedial challenge that has been established. In these circumstances, he says the resident may be dismissed or not be renewed for the following residency year.

“When this happens, it is difficult for all parties and necessarily involves human resources and the legal department, but it sends a message to everyone involved in the program that competence and standards of care cannot be compromised,” explains Dr. Eckles.

He adds that co-residents are generally supportive of these actions as they are generally protective of their own stature and standing within the institution.

Q:

Do you have a remedial program in place that is well documented and supported by your HR department? In your experience, has the remedial program been effective in getting a turnaround in performance by a resident who was struggling initially? From your perspective, what would be the key elements for an optimal remediation program for struggling residents?

A:

Dr. Garoufalis notes that the HR department at his facility has a very well structured program but notes that he has rarely had to involve HR as he often handles resident performance issues within the residency program.

“Early recognition and a friendly, yet firm, approach has yielded excellent results thus far for our program,” notes Dr. Garoufalis. “A clear outline of expectation from the onset of residency selection is crucial to effective teamwork within a residency program.”

At his facility, Dr. Eckles says he implements personal and skill level remediation whenever it is required, and brings HR into the picture if performance issues escalate. He does agree with Dr. Garoufalis about the need for clear communication.

“Care and open communication with the resident allows the resident every opportunity to realize expectations and plan his or her development activities to meet presented goals,” offers Dr. Eckles.

He adds that goals may be developed in concert with the resident that alter his or her progression through the residency program. For example, Dr. Eckles says periods of leave or changing a resident’s program status from reconstructive rearfoot/ankle (RRA) to the standard podiatric medicine and surgery (PMSR) designation may offer ways in which alternate training goals may benefit both the resident and the program. Dr. Eckles says support for the resident is vital, whether it comes through different academic pathways, specific skill set tuition or personal/professional counseling.

“Residents cannot be expected to ‘self-correct’ while managing long hours and stressful conditions,” emphasizes Dr. Eckles.

Dr. Bernstein says the remedial program at his facility is in the hospital’s Podiatry Residency Program manual and has been approved by the hospital’s HR department. He says he has had only one resident in the remedial program in the past several years.

He notes that any performance issues are thoroughly documented with a document signed by himself, the resident, the Residency Program Coordinator and a member of the facility’s Graduate Medial Committee.

Dr. Bernstein adds that the underperforming resident receives performance improvement assignments, meets weekly with a Podiatry Curriculum Committee member mentor to review progress and meets with the HR department as well. He notes that psychological counseling is available as well. Failure to achieve satisfactory completion of the facility’s three-month remedial program can require a second program or possibly be grounds for dismissal, according to Dr. Bernstein.

Dr. Eckles is the Residency Program Director for the New York College of Podiatric Medicine and Metropolitan Hospital Center in New York City. He is the Dean of Graduate Medical Education at the New York College of Podiatric Medicine. Dr. Eckles is also the Dean of Clinical Studies and an Associate Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine. Dr. Eckles is affiliated with the Foot Center of New York in New York City.

Dr. Garoufalis is the Podiatric Medicine and Surgery Residency Director, and Associate Chief of the Podiatry Section of the Surgery Service at the Jesse Brown Veterans Affairs Medical Center in Chicago. He is an Associate Chief of the Podiatry Section of the Surgery Service at the Edward Hines, Jr. Veterans Administration Hospital in Hines, Ill. Dr. Garoufalis is a Past President of the American Podiatric Medical Association and the current President of the International Federation of Podiatrists.

Dr. Bernstein is the Director of the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.