Situation: I have a PGY3 resident who has been on formal improvement plans and reportable remediation since the end of his PGY1 year. Since November he has been on probation. His issues mainly concern the Professionalism competency. They started as not logging procedures, poor conference attendance, and occasional tardiness for shifts. At the beginning of his PGY3 year he lied to a colleague about needing to leave an ED shift 2 hours early. He has essentially alienated himself from his entire class and program. Under increased scrutiny during his probation more issues have to light such as signing in for conference attendance for more time than he attends, less than ideal effort on shift, and some instances of poor patient care.
As part of his probation I have met with him weekly, he has been assigned a coach to help work through these professional duties, he's written reflective essays and done some reading on the issue, completed extra simulation and Q&A testing, completed a series of appointments with a test taking specialist (ITE was <1%ile in 2nd year, ~40%ile 3rd year after the apps), and completed 2 months of extra shift assignments. He was also recently late to two shifts.
My question is how to respond to this. My inclination is that he has not met the professionalism competency standard but has shown improvement and perhaps a 6 month extension of training would be useful. I'm not sure I have a whole lot more to offer him during those 6 months but additional time to demonstrate competency may be useful.
Response:
It appears that you have implemented a robust plan to address the resident's deficiencies. This appears to include:
Nice work on attempting to remediate one of the most difficult areas to remedy. Despite these efforts, the resident continues to demonstrate unacceptable performance in key areas. In planning next steps, it is important to note if the resident violated the terms of his probation and if the consequences of this included non-promotion, non-renewal or dismissal. If so, any of these actions should likely be upheld by an appeals committee. As you know, any of these actions requires written letter of intent from the program to the resident, an opportunity for the resident to review this determination and the implementation of due process (usually including an appeal). Also, you will want to confirm your resident contract about timing. Some contracts require a notice of 30, 60, 90 or more days in cases of non-renewal or non-promotion. If you are inside that time window, your options may be limited. If this is the case, legal counsel can help navigate.
If you believe the resident has met residency training standards and appears ready to safely practice Emergency medicine independently, promotion/graduation should not be withheld. If this is the case, the resident should be apprised of future reporting of his probation status to state licensing boards and future employers. It is helpful to work with your legal counsel to determine standardized wording of this future notification to outside parties and share this with your resident to avoid any confusion (or surprise) later.
If you do not believe the resident has met all requirements of residency training satisfactorily, promotion can be withheld. Asking your CCC to provide formal recommendations in this case could prove useful in deciding to withhold promotion and will lend weight to your final determination. Extension of training could be a reasonable course of action however the question should be asked: how will additional time in training improve his performance in the realm of professionalism? You may find yourself in the same situation again in 6 months.
Bottom line: if it is the professional opinion of your residency leadership and your CCC that this resident has not met the requirements of residency training, non-promotion could be a reasonable action (assuming your resident contract supports the timing of this) and the concern about losing an appeal should not deter you from this action.