Resident Remediation: Start From Scratch

To the Editor Domen1 described a very clear “new approach for pathology training programs to consider when a resident requires remediation, probation, or dismissal.” His development of a remediation or probation plan is very useful indeed, also for residency training programs outside pathology. Domen1 writes that “unprofessional behavior is the single most common cause for disciplinary actions.” Furthermore, he suggests that “every effort needs to be made to ensure that the correct underlying problem, deficiency, or performance issue is identified, before a remediation plan can be developed.” However, in many cases of unprofessional behavior, the correct underlying problem is not immediately evident. In these cases, it is very tempting to interpret the unprofessional behavior to quickly and subsequently remediate this assumed problem. If we want to be sure we are remediating the right problem, we need to start with describing the unprofessional behavior in as much detail as is workable. The next step would be categorizing the unprofessional behavior. The recommendations from the Ottawa 2010 conference could be used as a starting point. The authors suggest a classification as an individual, an interpersonal, or a societal perspective.2 When we are confronted with unprofessional behavior of a resident, we as doctors must do what we are good at: going step by step through the diagnostic process. The first step is describing and categorizing. At the end of this diagnostic process, we may interpret, and after this we start remediation. Only when we have a clear picture of the nature of the problems, the context, and the risk factors can we offer tailor-made remediation. And only when we know to whom which type of remediation is offered can we evaluate our remediation practices. Domen1 advocates a basic new approach for training programs, but this admirable initiative will gain momentum when we start at an even more basic level. 2015 I appreciate the comments by Barnhoorn on my article concerning resident remediation, probation, and dismissal.1 Lapses in professional behavior are at the top of the list for disciplinary actions taken against residents but, as noted, are also among the most difficult to assess and remediate. I believe that Barnhoorn and I are in agreement that before a proper remediation plan can be developed, it is imperative that the underlying problem or issue be correctly identified so that an appropriate remediation plan can be devised.1 With professionalism issues, however, correct identification can be a difficult process under the best of circumstances due to ambiguities surrounding professionalism values and contexts, as well as simply trying to define the specific unprofessional behavior.2,3 Rapidly changing perspectives on professionalism and the use of social media—to choose just one current topic area—highlight some of these uncertainties and difficulties.4 However, I think the eight-point approach detailed in my article provides a good starting point to clarify and address clearly delineated as well as more ambiguous professionalism issues.1 In residency training, the context within which professionalism is assessed can be an important factor for consideration. In general, expectations are established by the faculty and the program director(s) of the training program, and whether they are codified in some formal format or “mirrored back”5 to the residents through role modeling (or a hidden curriculum), professional values and acceptable behaviors are communicated. Of course, the faculty’s ability to identify and properly evaluate unprofessional behavior is also an important element that needs to be considered and developed. Obviously, the faculty and teachers must also be held accountable to the same professional standards and expectations (ie, the macrosocietal/institutional/departmental context) if formative and transformative growth is to be expected in residents, but identification and remediation of unprofessional behavior in faculty members entails its own array of unique ambiguities and confusion.6 As noted by Barnhoorn, the Ottawa 2010 conference offers a starting point to help define and assess what we mean by professionalism and how we might begin to identify, evaluate, address, and think about associated lapses in professional behavior in our teacher-student, student-teacher, and physician-patient relationships.3 While there is a robust literature on professionalism that spans several decades, further research is clearly needed in a number of areas.2,3