Junior doctor remediation: an international reflection

Lessons from both sides of the Pacific on how to approach struggling junior doctors

Remediation in medical education is “the act of facilitating a correction for trainees who started out on the journey toward becoming a [doctor] but have moved off course”.1 As American medical educators with expertise in remediation, two of the authors were invited to Victoria to visit clinical sites (Monash Health and Deakin University) and to speak at the 23rd Australia and New Zealand Prevocational Medical Education Forum (ANZPMEF) in Melbourne in November 2018. Based on observations at the sites and on discussions at ANZPMEF with medical educators from universities, hospitals and medical centres throughout Australia and New Zealand, the American and Australian authors reflected on pre‐vocational junior doctor remediation trends in our two regions. Medical education remediation is a global challenge, yet to the best of our knowledge, international comparisons have not been previously described. We aim not to judge or laud but rather to pave a path for future enquiry and collaboration. Wherever we agree elements of one system to be clearly more effective, we say so.

First we note differences in our medical education systems, as this forms the remediation context in each system. In the United States, after 4 years of undergraduate education in any area of study but including pre‐medical requirements, students enter medical school, studying medical sciences for 2 years, followed by 2 years of clinical rotations. They then enter a 3–7 year intern or residency program in their chosen specialty (eg, surgery, internal medicine etc), thereafter serving as consultants (called “attendings” in the US).2 In comparison, in Australia and New Zealand, after medical school there is a general intern year requiring satisfactory completion of five terms including medicine, surgery, and emergency medicine to advance from provisional to general registration. Only afterwards can a doctor enter a specialist vocational program. Frequently, junior doctors undertake one or more additional pre‐vocational training years. For both regions, full registration is achieved in one year (although some states in the US require 2 years), but in neither does this time frame have bearing on the remediation process, as each year requires competency to move on to the next.

Terminology and consequences

Most noticeable in all our conversations in Australia was sensitivity to remediation terminology commonly used throughout US medical training. Australian Medical Council forms are titled Improving Performance Action Plan, but the term for the person requiring the plan is less clear.3 US phrases such as “struggling learner”, “doctor in difficulty” or “deficits” raised discomfort in Australian and New Zealand educators and trainees. Junior doctors preferred terms such as “gaps”, “resources”, “learning support” and “doctor receiving individual supports”.4 Although we prefer the use of more direct terms, if one aim is to encourage learners to self‐seek remediation support, using geographically preferred nomenclature may be essential to success.

There was concern about confidentiality of junior doctor term assessments used to document the Improving Performance Action Plan. Anecdotal reports noted prospective employers requesting copies of these forms as part of recruitment, using them in ways never intended. This has resulted in fears that documentation, critical for successful intervention plans, could cause difficulties getting jobs or placement in vocational training, negating the value of remediation. Maximising confidentiality is essential to successful remediation and, except for serious wrongdoing or patient safety risks, maintaining confidentiality must be addressed head‐on.

US medical training programs have worked to change a negative or punitive perception of remediation by emphasising the value of supplemental learning and support.1,5 This has been most successful by separating those involved in remediation endeavours from any formal process of probation or dismissal.5 Australian health services supervisors are involved across both these areas. In our opinion, it would be advantageous if remediation and summative assessment roles were clearly separated in Australia too.

Learner assessments

From what we found out, compared with the US, learner assessments in Australia and New Zealand occur less frequently and are less formal. In the US, interns take yearly standardised medical knowledge multiple choice examinations and receive several monthly written evaluations from their supervisors, peers, and medical students. In Australia and New Zealand, interns are assessed on their performance twice during a 10‐week term across different practice domains, such as knowledge, patient assessment, investigations, and time management; the mid‐term assessment is formative and the end‐of‐term one is summative. Each assessment is usually completed by the consultant supervisor, typically informed by others, such as the registrar or nurse manager. At present, there are no competency assessments of specific clinical tasks in Australian and New Zealand pre‐vocational training, which has been identified as a gap. Plans are underway to introduce workplace‐based assessments or entrustable professional activities.6 More extensive and frequent evaluation permits earlier identification of junior doctors who could benefit from remediation.

The picture is not completely rosy in the US. Even with higher frequency of evaluations involving more individuals with direct contact with junior doctors, educators have found these tools are still insufficient for early identification of struggling learners, as evaluations are often delayed or vague.7,8 As a result, US educators may use informal conversations or email communications as triggers to initiate a remediation plan.5

Learner supervision

Developing the skills of senior medical staff to assist in remediation of learners is a major challenge in the US, Australia and New Zealand, although greater in Australia and New Zealand. In these two countries, pre‐vocational junior doctor rotations last 3 months compared with the typical US model of one month. Despite longer periods, many people with whom we spoke reflected that Australian and New Zealand consultants generally have less time and less direct observation.

Across Australia, the increase in consultant workloads plus a reduction in full‐time roles have resulted in reduced time available for supervision and teaching. We were told that many consultants work on wards, the primary learning space of pre‐vocational staff, for periods of 2–3 weeks at a time, 2–4 months per year. It is uncommon for time to be allotted specifically for supervision. In addition, part‐time staff may work at other hospitals (public or private), which reduces their availability at each place across the week. In the US, teaching consultants tend to be full‐time employees in that role, serve in a supervisory role for a greater percentage of the year, and (at least while on services with learners) often have lower patient numbers.2 Some specialists colleges, such as the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons, have developed required training programs for trainee supervisors. However, numerous Australian and New Zealand educators commented on the difficulty senior medical staff had in identifying struggling learners, referring them for assistance, and effectively participating in the remediation process. At ANZPMEF comments abounded, including “How can I get a consultant here for a week to let me know who is struggling and to help that struggling person fill gaps?” There is an expressed need for a remediation structure to support educators.

Failure to fail

The US, Australia and New Zealand share the same challenges around “failing to fail”.9,10 From nearly every conversation, it seemed that a trainee, acknowledged to be struggling, may still be advanced onto the next rotation or even complete pre‐vocational training without formal recognition of any problems. The discomfort caused by formally acknowledging that someone is struggling, along with fear that once acknowledged “the problem becomes our responsibility to fix,” appears to be a universally strong driver for inaction.9,10 Further, in Australian pre‐vocational training, if an intern fails a term, particularly a core term, they may need to repeat that whole term at the start of the following year if the hospital determines their performance does not meet the required level for the year. This can have significant consequences for finding a hospital for an accredited term, having appropriate funding, and delaying the advancement to hospital medical officer level.

Greater non‐medical role and support

At the visited sites, Australia and New Zealand notably used non‐medical educators in more prominent medical education roles compared with the US. The role played by medical education officers, who are predominantly nurse educators, is without counterpart in the US. Medical education officers meet frequently with junior doctors, both in observation of clinical work and for catch‐ups (welfare “coffee chat”). It was suggested by junior doctors that this frequent contact and discussion with a nurse felt less intimidating than approaching a consultant. Therefore, the observation and check‐in with a medical education officer was more readily acceptable. Indeed, several junior doctors shared they were more comfortable approaching a medical education officer to self‐identify a remediation need. This clearly is an opportunity for US medical educators.

Future directions for research

Most perspectives outlined here are derived from conversations and observations. We attempted to obtain as accurate a picture as possible by speaking to diverse educators who work throughout Australia and New Zealand, and had the benefit of a remediation authoritative expert (JG) who has done extensive site visits. However, memory is prone to bias and conversation does not replace research. Our aim was to be the start of a conversation. Rigorous and quantifiable study is merited, both to assess and validate the information included here and to study how to improve it. It is necessary to understand Australian and New Zealand remediation needs, use and failure rates; consultant time with learners; the purported misuse of Improving Performance Action Plan forms; regional practice variations; and best remediation practices.

Conclusion

We hope that by sharing our respective approaches — in preferred terminology, evaluation and supervision, in “failing to fail”, and in the possibilities for the role of medical education officers — we take the next steps together in advancing remediation efforts and successes in both regions of the world.