Tuesday, June 23, 2009


Teaching is pretty easy when we have bright, motivated students and residents who share our values and “hang on our every word”. But that is not always the case.

I was facilitating a group of faculty at a conference this spring where the topic was “the problem student/resident.” One member of the group was describing the terrible time she was having with a certain resident and how she “had to come down hard on him” and how she didn’t see much hope of him improving his clinical performance as he had a “rotten attitude” and a “poor work ethic”. She was quick to let our group know that she never had any trouble with “good residents”.

As our group tried to help her explore her main issues, it struck me that I had heard that many times before – “I never have trouble with the good student or good resident”. Well the truth is, NOBODY DOES. Those students and residents would learn no matter what we did. They make us feel like good teachers and so we become better!

Our real challenge as teachers comes when the student or resident 1) is working at top mental capacity and just barely making it, 2) does not share our values or social mores, and/or 3) does not share our expectations for work productivity. At some point, we identify students or residents who need some “special action” on our part. That “special action” is often called remediation. Remediation can be a simple learning plan designed by the resident or student and monitored by a faculty member, or it can be a formal learning plan that is designed by the faculty, approved by a committee and monitored closely with specific consequences attached to not meeting benchmarks.

The issue for discussion for June/July is REMEDIATION ACTIVITIES. What has been your experience? What works? What doesn’t work? Are their specific types of student or resident issues that are more amenable to change through a specific type of remediation? Should we try, as a community, to formalize a series of “remediation steps” that all programs within an institution would follow depending on the severity of the problem? I’ve posed lots of questions,… Now let’s hear what you think.


We had an interesting discussion about "problem residents" and whether one can really know whether a resident is just getting a slow start, or will not realistically be able to become a competent physician. As you might have guessed, no one had a definative "formula" that we could follow. Two readers commented on the interview process and its limitations in exploring values and work ethic. Others commented that "substance use" should always be explored when faced with undesireable behavior. Three readers mentioned two characteristics that had been good predictors of success. The first predictor was a willingness by the resident to acknowledge the problem and the second was an ability to reflect on the feedback given and pose a plan. Finally, one readers posed a rule to follow - "always be working in the best interest of the resident".