Reconceptualizing remediation in practicing physicians

1. Reconceptualizing remediation in practicing physicians Gisele Bourgeois-Law, MD, M.Ed, PhD student (Maastricht) Pim Teunissen MD, PhD Maastricht University Glenn Regehr PhD, UBC

2. Thank you to my co-authors Pim Teunissen MD, PhDMaastricht Glenn Regehr PhDUBC

4. Goal Understand why remediation for clinical competence issues in practicing physicians is such a difficult problem to address

6. Scoping Review Academic literature Grey literature 3 government reports 1 white paper 1 conference presentation withunpublished data 1 policy paper, 1 survey 1 directory 1 stats report to constituents • 11 descriptive papers • 5 research papers • 3 editorials/commentaries • 3 reviews • 1 survey • 1 book • 1 book chapter

7. Findings: gaps in existing literature What falls under the umbrella of remediation? What percentage of physicians require remediation? (1.9 to 30%) What is the success rate of remediation? (~ 75% in the short term; little data long-term, and variable) What works in remediation: We really don’t know. (Realist review protocol published by UK group in fall 2018)

8. WHY?

9. Conceptualizations of Remediation Educational process……. Not unlike remediating residents Addressing a gap Individualistic learning theories

10. Social determinants of performance

11. Remediation as supported practice change…… Grenny J, Patterson K, Maxfield D, McMillan R, Switzler A. Influencer: The new science of leading change. New York, NY: McGraw-Hill Education; 2013 May 17.

12. Remediation as supported practice change……

13. Different questions…. How might we effectively utilize a physician’s community of practice in remediation? What structures ensure long term practice change rather than short-term achievement of learning objectives? How do we determine if remediation goals are feasible for a particular physician in a given context?

14. The individual requiring remediation Focus on individual characteristics Physician factors (often not modifiable) Age Gender Time in practice Isolation History of past complaints or problems Training outside continent of practice

15. Does focusing on the individual lead to ‘othering’? Attribution theory ‘Just World’ phenomenon Tendency to judge actions based on outcomes

16. What can we learn from the deviance literature? “The fallacy of autonomy” (Currie) “Bad” behavior as a reaction to the inability to meet social norms (Merton) The importance of social support

17. Different questions…. What factors in the healthcare system/fee structure incentivize the wrong things/foster less than optimal practice behaviors and/or discourage desired behaviors? Which remediation processes (rather than which individual characteristics) are more likely to be associated with sustained practice change and a lower rate of recidivism?

18. Culture of medicine and remediation Literature focuses on culture of autonomy “Shame and blame” Emphasis on clinical autonomy Reluctance to challenge a colleague’s practice Explains challenges of remediation, or reluctance to be assessed?

19. Might remediation be construed as a de-professionalization? “the single zone of activity in which autonomy must exist in order for professional status to exist is in the work itself” (clinical autonomy) (Friedson)

20. We suggest that… The culture of medicine in which each person is responsible for one’s own competence and only for one’s own competence might require challenging. We each have a responsibility to, (not for) our struggling colleagues

21. Conclusions Gaps in the existing literature on remediation, in part related to lack of clarity Going forward,we wish to now explore in the ‘real world’ conceptualizations of remediation, of those requiring it, as well as coexisting attitudes and culture norms in administrators, remediators, and those in need of remediation

23. Attitudes Towards Physicians Requiring Remediation: One-of-Us or Not-Like-Us? (to be presented atRIME) • Current study interviewing remediation preceptors suggesting incongruities between self-descriptions of role and actions.

24. THANK YOU! gisele.bourgeoislaw@ubc.ca