A Framework for Successful Remediation within Allied Health Programs: Strategies Based on Existing Literature

Journal of Medical Imaging and Radiation Sciences

Journal of Medical Imaging and Radiation Sciences 43 (2012) 112-120

Journal de l’imagerie médicale et des sciences de la radiation

www.elsevier.com/locate/jmir

A Framework for Successful Remediation within Allied Health Programs: Strategies Based on Existing Literature Leila Makhani, MSca, Renate Bradley, MRT(T)b, Jennifer Wong, BSca, Ewa Krynski, MAc, Anna Jarvis, MS, BS, FRCP(C), FAAP, AB, PEMd and Ewa Szumacher, MD, FRCP(C), MEda* a

Radiation Oncology Department, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Summer Student, University of Warwick Medical School, Coventry, UK b Medical Radiation Sciences Program, The Michener Institute and University of Toronto, Toronto, Ontario, Canada c Higher Education Editorial Department, Nelson Education d Paediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

ABSTRACT The effective assessment methods of various health and allied health educational programs frequently work to identify trainees in difficulty who may require assistance to improve their academic and practical performances. However, although the methods of assessing trainees are often well-established, the essential skills for dealing with a trainee in difficulty are largely underdeveloped across curricula, and research within the field remains limited. This article reviews remediation in medicine and allied health professional programs based on existing literature. The literature suggests that successful remediation involves multiple steps, including prompt problem identification, meeting with the student on an individual basis to develop a learner-centered strategy, and development of an action plan. Remediation requires multiple assessors and several assessment tools, feedback and reassessment, all underpinned by documentation, written policies, and proactive involvement in supporting the identified students. Remediation, when based on a learner-centered approach, can be extremely effective, allowing the majority of remedial students to overcome their difficulties and succeed in their academic endeavors.



RESUM E Les m
ethodes d’
evaluation efficaces des diff
erents programmes de formation en sant
e et dans les domaines connexes visent souvent a rep
erer les stagiaires qui
eprouvent des difficult
es et qui ont besoin d’aide pour am
eliorer leur rendement scolaire et clinique. Cependant, si les m
ethodes d’
evaluation des stagiaires sont souvent bien
etablies, les comp
etences essentielles pour traiter avec un stagiaire en difficult
e sont largement sous-d
evelopp
ees dans l’ensemble des programmes et les recherches dans ce domaine restent limit
ees. Cette
etude examine les efforts d’enseignement correctif en m
edecine et dans les programmes connexes des professions de la sant
e a partir de la documentation existante. Les
etudes existantes tendent a d
emontrer que l’enseignement correctif comprend plusieurs
etapes, incluant une d
etermination rapide du probleme, des rencontres individuelles avec le stagiaire afin d’
etablir une strat
egie centr
ee sur l’apprenant et de d
efinir un plan d’action. L’enseignement correctif exige plusieurs
evaluateurs et diff
erents outils d’
evaluation, de la r
etroaction et des r
e
evaluations, le tout reli
e par la documentation des efforts, des politiques
ecrites et une participation proactive au soutien des
etudiants recens
es. L’enseignement correctif, lorsqu’il repose sur une approche centr
ee sur l’
etudiant, peut ^etre extr^emement efficace et permettre a la majorit
e des
etudiants qui en font l’objet de surmonter leurs difficult
es et de conna^ıtre le succes dans leurs
etudes.

Introduction

remedial efforts to improve their academic performance [1–3]. In this article, we discuss remediation for trainees from various medical and allied health programs and will refer to them as ‘‘trainees in difficulty.’’ We define a trainee in difficulty as a ‘‘learner with academic performance that is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty,’’ as per Vaughn et al’s definition [4]. Additionally, we define remediation as a process of identifying trainees in difficulty,

Medical educators expect that, as students progress through their training in medicine and allied health programs, some of them will develop academic difficulties and will require * Corresponding author: Ewa Szumacher, MD, FRCP(C), MEd, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue 2075, Toronto, Ontario, Canada, M4N 3M5. E-mail address: [email protected] (E. Szumacher). 1939-8654/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi: 10.1016/j.jmir.2011.12.006

and taking appropriate measures to improve their performance. Our focus encompasses both the academic remediation of students in the coursework period of their medical training and the practical remediation of students who have started their clinical practice. Since students are likely to require remediation in either, or both, of these phases, and since the higher level remediation strategies discussed are common to both phases, we will address the remediation of academic and clinical medical students alike. Although data remain sparse, the prevalence of trainees in difficulty fluctuates between 3% and 9.1% and has been known to reach a number as high as 28% depending on the academic program [2, 5–9]. Given the pervasiveness of the problem, it is critical that institutions and program directors identify trainees in difficulty and develop resources for a successful remediation program. However, the literature suggests that the practice of remediating trainees in difficulty across the health professions is often underdeveloped and variable [5, 8–10], despite the recurring consensus that standardized remediation programs are needed. Humphrey discovered that, while the methods of measuring physicians’ performance are sophisticated, ‘‘provision of remediation is more patchy and variable’’ [11]. Dijkstra et al outlined detailed design principles for programs of assessment and identified remediation as a possible consequence of effective program assessment, but did not go on to describe what the principles of a successful remediation program would be for those who fail to meet the established criteria [12]. Similarly, Dhai et al recognized the need to establish effective remediation programs for physicians, but did not define what principles would guide the creation of such programs [13]. Rosenblatt and Schartel [14] indicated that, despite the number of remediation programs offered for anesthesiology residents, remediation programs varied widely across the United States. Similarly, interviews with administrators from five schools of nursing indicated that the remediation methods were not comparable between these schools [15]. Furthermore, although some attention has been given to the remediation of already practicing physicians [16], few reports have been written about remediation for students in allied health programs, such as radiation therapy [8]. Studies have also found that program directors commonly report their lack of confidence in their own ability to manage trainees in difficulty [17, 18] and feel alone in dealing with the challenges of academic remediation [3]. Finally, trainees in difficulty pose a unique challenge for institutions in terms of time and resources, both professional and financial, and thus could become a burden on the institution if remediation efforts are not successfully coordinated [2, 5, 19, 20]. The literature recurrently demonstrates the need for a systematic remediation strategy, whereas it fails to clearly establish principles that would effectively guide the creation of such a consistent remediation program. Despite these challenges, various studies support the beneficial effects of remediation practices in academic and clinical medical training [1, 8, 15, 21–23]. The literature suggests that

the key to successful remediation is a learner-centered approach [24]. Although it is encouraging that there is a growing body of literature to describe the challenges of remediation programs and their effects on students, there has been little attempt to collate existing academic remediation program literature to provide healthcare professionals with a common resource pool of remediation strategies from which to draw appropriate courses of remediation that could be adapted to successfully help individual students. Because of the individual nuances of each situation and each student, we do not claim that we can propose a blanket remediation program that would work for all institutions and students. However, drawing on the literature and our experience, we have identified three key steps in the process that will help structure successful remedial action that can be tailored to meet the needs of each student. These include: 1) identifying and diagnosing the problem using multiple assessment tools, 2) designing a student-centered strategy for remediation, and 3) reassessing, evaluating, and providing feedback for the trainee (Figure 1). We propose these steps as a framework for creating systematic, analogous structures of remediation programs throughout allied health programs. Methods We conducted a literature search on the PubMed database, including MEDLINE and ERIC. Using terms associated with remediation such as ‘‘remedial,’’ ‘‘remediation,’’ ‘‘academic remediation,’’ and ‘‘remediation tools’’; person of interest

Figure 1. Steps to developing a successful remediation program.

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including ‘‘resident,’’ ‘‘student,’’ and ‘‘learner’’; and other related items such as ‘‘academic difficulty’’ and ‘‘problem learner,’’ we searched for articles that would address remediation in any of the allied health professions. We reasoned that the academic and clinical training experience of students in this broad spectrum of professions is similar enough that many remediation strategies used in one would be generalizable to other medical programs. We limited the search to articles from the year 2000 onward and then searched the bibliographies for relevant articles. Though we read many articles, only the most relevant points have been cited to create a concise and coherent framework for the structuring of remediation programs within the health professions. Step I: Identifying the Problem Identification of the Trainee in Difficulty: ‘‘Who Needs Help?’’ The first step in a successful remediation program is the identification of trainees in difficulty, which poses a great challenge for mentors and program directors [2, 10, 25] since trainees’ problems may be attributed to a variety of causes. The literature indicates that difficulties may arise from several problems, such as insufficient academic knowledge, problems with communication, substance abuse, medical or psychiatric illness, family or personal problems, financial difficulty, the stress of a rigorous training curriculum, or others [2, 9]. Common causes of academic difficulty may include deficits in affective, cognitive, structural, interpersonal, psychomotor, or professional skills [3, 4]. Trainees in difficulty are often identified by teachers based on instinct, an isolated incident, a pattern of unsatisfactory events, a patient complaint, written assessment, verbal evaluation, feedback from a colleague, and, rarely, the trainees themselves [9, 26, 27]. A national survey of internal medicine residency program directors reported that the most frequent method by which ‘‘problem residents’’ were identified was through direct observation in the clinical setting (82%), followed by a critical incident (59%) or inadequate performance at conferences (45%). In addition, the troubled resident was often identified by the chief resident, an attending physician, or the program director, but rarely was the difficulty self-reported [18]. Program directors are not always able to observe trainees in a clinical or conference setting; therefore, written evaluation and feedback from mentors, senior residents, and teachers are critical. Formative feedback to the student, written evaluations, and the reporting of immediate concerns must be carried out in a timely fashion [9] to facilitate prompt identification of the trainee in difficulty and to design the appropriate interventions. However, written evaluations have been known to lack honesty [9], or have lacked sufficient documentation to justify identification of the trainee as one in difficulty [25]. Thus, we suggest that written evaluations should not be the sole tool for identification. Trainees in difficulty may present with several problems and consequently, a multiple assessment, or a multimodal tool may 114

serve as the best method to identify their needs [17, 20, 28, 29]. These identification strategies include: written exercises, assessment by supervisors to include direct clinical observation and oral presentations, clinical simulations, peer assessments, selfassessment, and personal portfolios [28]. These methods of assessment, paired with continual monitoring, may improve chances of objectivity. Faculty perceptions of a trainee in difficulty should be discussed with colleagues or other teachers to gather objective data on the trainee and to determine the problem. Following a previously prepared checklist that encompasses the various assessment methods would also allow for an objective identification process [9, 10]. Some methods of identification include: direct observation of the trainee in difficulty in the clinical setting, reports from nurses (and other health professionals) or patients regarding the trainee’s performance, the occurrence of a critical incident involving the trainee, a poor performance by the trainee at morning report or conference, or expressed concern from the trainee’s significant other, family members, or even from the trainee himself or herself. These observational methods, combined with more frequent formal evaluations, can ensure an objective and timely identification of trainees in difficulty. The extensive resources that are required for remediation of trainees in difficulty [2, 19, 20] make it exceedingly important to identify these students as early as possible. Although remediation often focuses on the performance of individual students, it is also important to note that the ‘‘problem’’ may lie not only with the trainee in difficulty, but also with the teachers or the system [3]. Such problems include: instructors whose experiences and assumptions bias their interactions with the trainee, problematic programs that provide unclear standards and responsibilities for the trainee, complex workloads, and/or inconsistent teaching, all of which may seriously affect the trainee. These systematic factors have to be taken into consideration, along with the trainee’s individual performance, before a remediation course can be established. Informing the Trainee in Difficulty In addition to early identification [8, 13, 25], successful remediation requires the prompt notification of the trainee in question [25, 26]. In our experience, the process of informing a student about his or her academic deficits and identifying the expected behaviors is a measure that should be taken prior to official written evaluations. This informal discussion increases the learner’s self-awareness and affords him or her the opportunity to self-remediate. Such a discussion should be supportive, emphasizing to the learner that it is a chance to enhance his or her skills and performance to reach the academic and practical level that is expected of a trainee within the program [5]. It is imperative to successful remediation that the student is in agreement with the plan and concurs with the drafted goals. Without trainee agreement, remediation strategies have been known to fail [3, 10]. Notification of the trainee

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in difficulty, though challenging, can be, in our experience, made most productive by taking the following measures: ensuring the trainee is well-rested (eg, the medical resident is not completing an on-call assignment/duty); arranging a confidential meeting with the trainee and possibly a witness; arranging an appointment with the program’s counselor; and last, ensuring that all faculty members involved with the learner are aware of the plan, and are onboard to provide increased academic and emotional support [5]. The identification of a trainee in difficulty is a sensitive issue. Faculty, peers, or others may negatively label the student; therefore, respect for confidentiality is necessary [3]. In the case of a resident, his or her junior students may also express concern that being under this trainee is compromising their medical education. Faculty members may feel that their practice is under scrutiny while supervising the trainee in difficulty. Other faculty members may limit their interactions with the trainee instead of helping him or her to overcome difficulties; such negative reactions from peers and faculty may exacerbate the situation [5]. Out of respect for confidentiality of the student and the remedial diagnosis, some aspects of the remedial causes of the student’s problems cannot be fully disclosed to all the stakeholders who may be involved in the student’s remediation process. This process may sometimes be perceived as an obstacle to remediation as the remediation team members may not know the true source of student’s difficulty; however, all team members need to be fully engaged in the remediation action plan even if they cannot know the reason for the student’s need for remediation. Because of these possible negative consequences, faculty should respect the confidentiality of the trainees in difficulty while notifying them of their problems and providing them with the support necessary to overcome any obstacles to their learning. Diagnosing the Problem: ‘‘Why Does the Student Need Help?’’ After instructors recognize the trainee in difficulty, the next step is to identify the reason behind his or her poor performance. Uncovering the root of the problem will necessitate gathering information about the trainee to determine the contributing factors, to address the problem at hand, and to confirm the diagnosis [10]. A multiple assessment tool [28], as discussed previously, will aid information gathering by highlighting specific areas of weakness [20, 25, 28]. Some useful methods for evaluating a trainee in difficulty are: monthly evaluations (written and verbal), direct observations in a clinical setting, chart review/medical record audits, videotaped interviews, standardized patients, clinical evaluation exercises, in-training examinations, oral presentations, high technology simulations, Objective Structured Clinical Examinations, peer and self-assessments, and personal portfolios. These methods can be used to reveal the source of the trainee’s problem. Research indicates that cognitive deficiencies [30], insufficient medical knowledge, poor clinical judgment, and unproductive use of time are the most common causes of academic problems [18], but because trainees’ problems are

highly idiosyncratic, it is impossible to lay out a strict process for identifying the cause of their difficulties, thus necessitating the multiple assessment tools. Table 1 is useful for outlining the most common domains of academic difficulty. The first step in a successful remediation strategy then is to identify the trainee in difficulty and to inform him or her of the problem. Once the trainee is aware of the issue and faculty are able to diagnose the root of the difficulty, both parties can work together to establish an achievable remediation plan. Step II: Developing a Successful Remediation Program Learner-Centered Approach The intervention strategy should be tailored to meet the specific needs of the trainee in difficulty. Because trainees and their difficulties greatly vary, we cannot propose a strict remediation formula that would be successful across all cases. In the absence of such a possibility, Table 2 outlines selected strategies for remediation based on specific types of difficulties in an attempt to give examples of possible remediation techniques from which faculty can pick and choose to create a successful remediation program for specific individuals. For trainees demonstrating cognitive difficulty, strategies aimed at closing the knowledge gap may be prescribed, including extra tutorials or lessons [10, 20]. If the difficulty presents as a clinical skills deficiency or one involving inadequate patient interactions, simulated patients scenarios or video-monitored consultations may be enlisted, along with additional skills training [10, 20, 28]. Trainees demonstrating difficulty with behavior, professionalism, or attitude may be remediated with the previously mentioned tools and further reinforced with increased observation and formative feedback sessions, and if actions are serious or have caused harm, suspension or dismissal may be necessary [7, 10, 20]. If the deficits require urgent resolution before the student can Table 1 Classification of the Most Common Academic Difficulties [4, 8] Type

Description

Affective

Problem with adjustment (eg, illness, death, marital problems, poor grades resulting in failure to perform, memory loss, withdrawal, low aspirations, low self-esteem, being overwhelmed, depression) Written: inability to complete assignments, slow or poor reading Spatial: perceptual problem Oral communications: how to ask questions (difficulty interviewing patient) Integration: difficulty with conceptual or abstract thinking Knowledge deficit: gap in knowledge base Unable to structure experience in environment (eg, poor time management, lack of organizational skills, poor study habits) Difficulty interacting with patients or staff (eg, shy, nonassertive, manipulative, overeager) Deficits in technical skills Deficits in behaviors (eg, honesty, integrity, reliability)

Cognitive

Structural

Interpersonal Psychomotor Professional

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Table 2 Examples of Possible Interventional Strategies for Trainees in Difficulty [1, 2, 5, 7, 9, 10, 28, 38] * Type of Difficulty

Examples of Possible Remediation Strategies

Insufficient knowledge

          

Extra tutorial sessions/tutor Core content review Weekly tests, use of test bank Extend training Reading program, self-study Repeat course, semester, or rotation Supplemental examinations Test-taking strategy sessions Chart reviews Learning strategy counseling Modify clinical schedule to ease time demand and allow for extra studying

Clinical skills

       

Skills-based training/clinical simulation Video-monitored standardized patients Structured direct observation and feedback Extend rotation time Increased observation/feedback Objective Structured Clinical Examination (OSCE) scenarios Feedback at end of each rotation Specially designed rotation

Procedural skills

 High-technology simulations  Skills-based training and feedback  Modified operating/procedures schedule with senior staff

Clinical reasoning

   

One-on-one discussions Faculty or peer mentoring Practice scenarios and extra monitoring Role modeling

Communication skills

      

Structured direct observation and feedback Increase time with simulated patients Mentoring Video/audio review sessions Didactic teaching of an interviewing conceptual framework Teacher demonstration and modeling One-on-one teaching

Attitudinal or behavior problems, patient complaints

        

Video review Structured direct observation Faculty feedback Increased time with faculty advisor Psychiatric counseling Modified clinical schedule One-on-one discussions, mentoring Probationary period Leave of absence

Substance abuse

 Formal rehabilitation program  Psychiatric counseling  Limits on elective rotations

Highly stressed trainee

     

Learning disability

 Follow statutes of applicable disability act and decide if trainee can meet essential requirements with the special accommodations B Modification of duties B Extend length of training B Medical treatment/counseling B Special equipment/aids B Extra time and separate space for examination

Change schedule Extend training Counseling Leave of absence Ensure support factors such as trainee camaraderie, planned social retreats Faculty and peer role-modeling

(continued) 116

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Table 2 (continued ) Type of Difficulty

Examples of Possible Remediation Strategies

Psychiatric illness, death in family, family stress

     

Financial difficulty

 Financial assistance  Counseling

Problems with the teacher or system

   

*

Psychiatric counseling Leave of absence Change in rotation/training schedule Ease time demands by extending Course/rotation time Increased time with faculty advisor

Changing rotation/training schedule Change primary supervisor or location of training Change teacher’s schedule to allow increased monitoring and supervision Recruit additional teachers for support

Remediation strategies should be tailored to the individual trainee and his/her situation.

continue, a leave of absence could be called for. If depression, substance abuse, or a psychiatric disorder is suspected, the trainee should be referred to the appropriate medical counseling team for rehabilitation and therapy [2, 7, 10, 20]. Program directors may also choose to pair the trainee with a mentor to provide trainees with a stronger foundation of the necessary skills [2, 6, 10, 31]. It is important that all the learning competencies for the program of interest are addressed and fulfilled in the outlined remediation plan [5, 20, 32]. In all healthcare programs, the trainee’s performance with respect to patient safety is a nonnegotiable outcome or competency; faculty have to implement successful remediation strategies, while ensuring that patient care does not suffer as a result. Remediation programs should be founded on confidential academic mentorship and emotional support [5]. As mentioned, confidential mentorship is important because the assessment and remediation process can induce guilt or shame, which may compound the student’s reluctance to participate and cause them to underperform. In our experience, more than one strategy may often be necessary when designing an action plan to address the student’s difficulty [8]. It is recommended that each of the specific needs or difficulties be identified and regularly evaluated to assess the trainee’s progress. Each of these individual strategies is then combined to form the comprehensive remediation plan and tailored for the individual trainee [5]. Who Should be Involved in the Intervention Strategy? The faculty member who designs the remediation strategy may not be the one to implement it; therefore, the appropriate parties should be integrated into the plan to ensure that the remediation plan is successful [10]. This may mean involving a multidisciplinary team in which a number of individuals such as the chief resident, senior trainee, or mentor are included to provide the trainee with sufficient academic, clinical, and emotional support. Concerns regarding a trainee in difficulty should be discussed with other teachers or colleagues involved in prior training of the student to avoid subjectivity and disagreement [10]. Relevant committees should be notified. These may include the graduate medical committee [5], professional

psychologist [33], or the university’s learning disability program [7], depending on the nature of the difficulty presented. In addition, the involvement of a board of examiners to authorize any formal remediation plans for the program will increase the commitment of the program to ensure that the discussions, documentations, and expected outcomes of the remediation program are explicitly stated. Documentation and Timelines From the early stages, the remediation goals should be clearly defined and timelines should be set [8–10, 15]. Evaluation criteria for the chosen remediation strategy must be predefined. To ensure the appropriate progress of the trainee, regular feedback sessions, and possibly even a formative evaluation, may be scheduled. [10]. It is recommended that consequences for an unsuccessful remediation be discussed with the trainee before commencing the remediation program and be clearly documented [10]. Before discussing the consequences of being unsuccessful, the student should be clear on what exactly is considered to be a successful/unsuccessful outcome. In addition, performance problems should be noted in the trainee’s academic file and should be updated with all proceedings during the course of remediation [5], especially to avoid legal penalties if challenged by a trainee [9]. The documentation also serves as a record or contract of the student’s efforts, reminding the student of his or her commitment to the remediation plan. Formal Policies and Support Mechanisms Written policies should be integrated into the academic constitution to facilitate the identification and diagnosis of trainees in difficulty. Faculty would be able to use these recorded policies to assess all trainees within the same criteria and recognize those who may require remediation. In addition, access to policies, procedures, and expectations should be easily available to students online so that they may be able to self-diagnose their own academic difficulty. The written record of policies ensures that both faculty and trainees are equally aware of the program’s expectations and of the remediation strategies available to trainees in difficulty. Along with formal written policies, a multidisciplinary team consisting of professional counsellors, legal advisors, and

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learning disability specialists should be easily accessible to the student throughout the remediation process [7]. The student’s problems may stem from personal, behavioral, or health issues that would require the attention of various health and other professionals. Both students and faculty would benefit from the clear identification of what support systems are available to students to help them overcome their difficulties. The literature shows that a learner-centered remediation approach should be crafted based on the specific written criteria of the program curriculum and the student’s unique difficulties. A multidisciplinary support team should be involved in the remediation plan so that all parties involved in the trainee’s success are aware of the strategy and its eventual goals. Finally, while the remediation action is in place, trainees in difficulty would benefit from regular feedback that would inform them of their progress.

Step III: Reassessing, Providing Feedback and Deciding How to Proceed Reassessment and Feedback When the predefined remediation program has been completed, trainees should be reassessed to ensure the satisfactory level of performance has been achieved [20]. Alternatively, regular feedback sessions throughout the remediation program can help keep the trainee up-to-date on his or her progress through continual evaluation and reassessment [10]. Some programs require that progress reports from mentors and teachers are shared with the trainee at regular meetings, which should preferably be scheduled before the start of remediation [5, 10]. Trainees in difficulty should be addressed at each step in the remediation strategy to ensure their understanding of the problem as well as the path toward a successful resolution. To reassess trainees who have undergone remediation, faculty can reuse the original assessment tools employed to identify and diagnose the trainee’s difficulty in the first place or they can develop new tools specific to the now-specified difficulty [20]. Regardless of the selected assessment method, remediation is a continuous and evolving process. All trainees undergoing remediation should be supported with continuous feedback on the specific areas of their performance, along with frequent positive reinforcement [5]. If, at the completion of the remediation interval, the trainee demonstrates no change, he or she may require additional remediation at a higher level. Alternatively, the committee may decide to also place the trainee on an extended probation program, which usually ranges from 3 to 6 months [2, 10]. The probation timeframe may be based on the domain of the difficulty. For example, to remediate a safety issue, the probation may last until the end of the learner’s program. Probation may be ideal for trainees demonstrating ethical misconduct, substance abuse, falsifying information, or any other type of intolerable behavior [9]. It is important to note that some trainees will present with problems that cannot be remediated, such as trainees exhibiting 118

inappropriate professional behavior because of a personality trait or lacking insight into their own behavior. Classifying such students as ‘‘non-remediable’’ early in the academic process would save both students and the institution from using expensive resources, only to realize that those students have to be dismissed because they are unsafe in their practice [8, 26]. However, these isolated cases of ‘‘non-remediable’’ students should not affect the creation of systematic remediation programs that would be largely beneficial and succeed in remediating the vast majority of students. Barriers to Remediation Academic and clinical remediation is a challenging area of education where recurring difficulties are often encountered [2, 8–10, 17, 19, 20, 25, 34, 35]. Some of these difficulties are related to:  Level of remedial competency and skills of academic teachers  The time consuming nature of interventions  Level of financial resources available to the students and programs  Deficiencies with remedial documentation  Inadequate commitment from remedial trainees  Confidentiality  Communication gaps between involved remediation parties  Cultural or social diversity of students and faculty members. Barriers to successful remediation may present in different forms; therefore, it may be simpler to classify them according to issues with the student, faculty, system, culture or social diversity, and other [35]. Most often, the trainee is remediable and there is the capacity to change his or her performance, in which case the problems can usually be attributed to a student issue. A faculty issue may refer to a lack of knowledge in dealing with trainees in difficulty or inadequate documentation for early identification. Further, the student may have underappreciated his or her difficulty because of infrequent, inadequate, or misleading feedback. Systemic issues refer to the heavy cost of remediation (time, personnel, testing, or other resources) to all involved parties. Finally, cultural challenges or social diversity may present themselves within the remediation process. Difficulties for international trainees include language, emotional distress, self-esteem issues, cultural identity, financial stress, and perhaps differing relationships with authority figures or standards of care [35–37]. Being aware of the potential barriers to remediation at the outset of the remediation process can guide the creators of the remediation program to include prevention strategies that would anticipate such barriers before they occur. Regular reassessment and feedback can work to keep the trainee in difficulty on track to achieve the remediation goals as well as to indicate to faculty whether any further challenges have impeded the student’s progress.

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Conclusion

References

The literature shows that the remediation of trainees in difficulty continues to be a significant challenge within academic medicine, and that there is substantial need for sound, systematic remediation strategies across the healthcare professions curricula. Although many articles have stressed the necessity of methodical remediation procedures, little attempt has been made to unify these recommendations into a single strategy that would lay the foundation for successful remediation programs across the allied health professions. This article has synthesized the available literature on remediation practices and outlines a framework from which program directors can work to construct useful remediation procedures. The approach to remediation put forth in this article includes objectivity, early identification, multimodal assessment and design, proper documentation of goals and outcomes, regular feedback, and attention to a learner-centered approach. The authors are confident that, using these guidelines, faculty and program coordinators can recognize struggling students and identify the problem at the root of their academic and clinical difficulty. Subsequently, all involved parties can work together to craft an achievable remediation plan and provide regular reassessment and feedback that would result in the successful remediation of trainees in difficulty. Nevertheless, in planning for the remediation of trainees, program directors should keep in mind that prevention is the best strategy to help trainees through any training program and will help alleviate the costly resources required for remediation. Thus, the planning of an effective remediation program can in turn influence the organization of the healthcare professions curricula so that prevention processes are built into the program and problems can be addressed before they reach the level of formal remediation procedures.

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Take-Away Message  Step I: Identifying the Problem B Develop predefined written guidelines and identify a team of professionals to approach when help is required with remediation B Assess, define, and diagnose: using a multiple assessment tool and, involve the trainee in difficulty, as well as the relevant parties  Step II: Developing a Successful Remediation Program B Design jointly: a learner-centered strategy tailored specifically around the needs of the trainee, while outlining the goals and timelines with the trainee’s involvement B Support: provide academic, clinical, and emotional support for the trainee  Step III: Reassessing and Providing Feedback B Evaluate: continually follow the trainee, provide feedback, and reassess the trainee at the end of the remediation program, while documenting the entire remediation process

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