Background:
This plan is specific for Redacted, MD as it pertains to deficiencies identified early in his training period. Through continuous direct observation in the Emergency Department the Faculty have identified significant deficiencies, that left uncorrected, will result in the failure of his promotion to the EM-2 year. He is operating at a level significantly below that of his peers in terms of his patient care, development of a coherent/cogent treatment plan, utilization management, recognition of acuity, significance of pathology, task execution, and time management. He was placed on this corrective action plan on ZZZ with the following items identified as areas to improve upon.
Previously Documented Directly Observed Competency Based Remediable Issues
Patient Care:
- Inability to interpret common diagnostic tests (No Improvement)
- Inability to process and develop a differential diagnosis and treatment plan in a complicated medical patient (No Improvement)
- Inability to multi-task at a level equal to his peers resulting in a mandated decreased level of responsibility by the Program Director (3 rooms max) (Some Improvement, still below peers)
- Failure to recognize or understand (potential or actual) severe patient acuity (No Improvement)
- Poor time management (Some Improvement, still below peers)
Medical Knowledge:
- Remedial understanding of common clinical situations (No Improvement)
- Failure to recognized and interpret pathology (No Improvement)
Interpersonal and Communication Skills:
- Disorganized, incomplete, and inadequate explanations to Faculty during patient presentation (No Improvement)
Systems Based Practice:
- Inability to identify proper disposition of a patient based on acuity. (Both ICU, floor, and discharge.) (No Improvement)
- Poor resource utilization (Some Improvement, still below peers)
Practice-Based Learning and Improvement:
- Significant difficulty when attempting to synthesize the medical literature and apply it to a specific clinical situation. (No Improvement)
- Student level knowledge concerning the development of a treatment plan (No Improvement)
- Very poor organization and task oriented/directed thinking. (No Improvement)
Professionalism:
- The Faculty recognizes Dr. Redacted’s positive attitude and no significant deficiencies in Professionalism have been identified.
Update:
Since the implementation of the corrective action plan Dr. Redacted still functions at a level significantly below that of his peers requiring constant and direct supervision and correction. His ability to acquire a history, synthesize the clinical data, establish and carry out a treatment plan and accurately diagnose are significantly behind that of his peers and are not improved. (See below OUDEM Faculty comments)
We have observed that Dr. Redacted anchors to a diagnosis with limited or no clinical data then is unable to prioritize his differential as to the most likely diagnosis.
In addition he will be required to remediate his Pediatric Emergency rotation in Oklahoma City as a result of the Faculty consensus evaluation. (see comments below). It should be noted that the PEM Faculty were not aware of Dr. Redacted’s remediation status prior to or during his rotation.
OUDEM Faculty Comments:
These comments are taken directly from monthly evaluations and Forerun Chart Flags, which can be tied directly to patient encounters.
- pelvic pain x 1 year, suprapubic no other complaints. Plan per Dr Redacted is pelvic US. Discussed what his concerns/ differential is and he states ectopic pregnancy prior to receiving UCG results. Continues to have a hard time developing differential and processing information.
- ordered UCG, for testicular CA screening
- I have serious reservations about the resident's care in this case. He was slow to recognize her underlying condition. He did not treat her pneumonia after I discussed antibiotics with him at the beginning of the case. He did not call critical care when I asked. When I asked for BiPaP to be placed he did not rapidly follow up on this to make sure that it was done. He did not recognize, or if he did recognize, did not treat or bring to my attention, her slow onset of hypotension. This was Dr. Redacted's sickest patient in the department by far. He had only 4 active patients.
- Homeless patient, significant dehydration, serum Cr approx. 5. Dr. Redacted wanted to discharge
- Pt given to Redacted on turnover at 1900 hrs. AMS, hypoxia - unclear etiology - work-up in progress. Redacted plan on orders to admit to telemetry on 10 lpm oxygen mask with 100ml NS per hour. When asked as to why the patient was hypoxic on presentation to ED, no answer except he thinks she might have CHF, though no treatment for such is being enacted. My review of CXR shows pulmonary vasc congestion, distinct change from prior and with likely infiltrates for which she is getting IV abx. He is unsure how much fluid the patient has received. On RN check it is 800 ml factoring IV abx amount. We stopped any other fluids, finish abx, change to BiPAP at 10/5 and change admission to ICU status. No BNP ordered, that has been added as well. Distinct change in patient disposition and management.
- Patient with numbness and painful throbbing of index and long fingers. No worrisome findings. No trauma. Ordered plain films of hand, to "rule out fracture". Seemingly unable to understand why those films not indicated. Zebras high on differential. Great difficulty in focusing on correct differential.
Pediatric Emergency Medicine Evaluation:
Dr. Redacted, was a polite, respectful intern to work with. However there are significant gaps in multiple areas of his practice. It was frequently noted that he was unable to get a complete or even a problem specific exam on a lot of his patients. He was quoted multiple times by faculty as saying" I was unable to examine the … ". This unfortunately made if difficult, if not impossible for him to synthesize the information necessary to arrive at the correct diagnosis or any diagnosis at all, for an unusual number of patients at his level of training. In relationship to his peer group, he was noted to have gaps in many areas of practice, including medical history taking, exam finding, formulation of A and P etc…. Although pleasant to work with, It is unclear to the PEM faculty if he has the cognitive ability to care for even the mildly ill child.
The PEM faculty believe that Dr. Redacted, although well meaning, lacks the skills necessary to proceed to an upper level Emergency Medicine physician when it comes to taking care of the majority of pediatric patients. We request that he remediate his entire month on our service for a more intense mentoring and oversight of his performance to specifically address his deficiencies, in order to try and advance his practice skills. Some of these issues were discussed with him during his rotation, unfortunately, he rotated with us over the holidays, so a more formal eval was difficult to due, do minimal man power
Review of Timeline & Consequences of Success/Failure:
- In our initial discussion the initial timeline of 6 months was given (from ZZZ) for the attainment of the measurable goals
- Dr. Redacted understands that this timeline is flexible
- Success: Corrective action is completed and Dr. Redacted will be promoted to the EM-2 year.
- Failure: Continuation of the EM-1 year and a re-examination and determination by the entire Faculty of deficiencies and a re-establishment of a new corrective action plan
Summary of the Meeting and Action Items:
- Dr. Redacted will repeat his PEM month in OKC.
- He will not be promoted to the EM-2 year until all deficiencies have been corrected
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