This week, the group discusses remediation of unprofessional behaviour. The article selected looks at the methods of intervention used and synthesizes the evidence on the topic to determine their effectiveness, as well as to facilitate the ability of organizations to design these interventions.
KeyLIME Session 290
Brennan et. al., Remediating professionalism lapses in medical students and doctors: A systematic review. Med Educ. 2020 Mar;54(3):196-204.
Jon Sherbino (@sherbino)
Previously we have talked about failure-to-fail on the KeyLIME podcast. See episode 282 In that episode, we discovered a new perspective on failure-to-fail. Faculty assessors are surprised by under performing residents and have strong antibodies to the term incompetence. In fact, many faculty suggested that the underperforming resident has simply not had the opportunity or support to appropriately acquire an ability or remediate performance.
Enter Brennan et al. on remediation…. but now with a twist – remediation of unprofessional behaviour. If ever I have experienced the Pareto principle (80:20) at work in #meded it is in remediating lapses in professionalism. (This principle suggests that “80%” of your effort is focused on “20%” of individuals. In my practice it feels more like 90:10.)
“What interventions are used to remediate lapses in professionalism in medical students and doctors and what is the evidence for their effectiveness? By synthesising the evidence on this topic, this review will facilitate the ability of organisations to design remedial interventions…”
Key Points on the Methods
Remediation = “an intervention or a range of interventions ‘required in response to assessment against a threshold standard of performance.’ Remediation interventions vary from informal agreements to undertake some reskilling to more formal programmes of remediation and rehabilitation, with most based around a three-step model that involves the identification of a performance deficit, the implementation of a remediation intervention and retesting after the intervention.”
Professionalism = “Wilkinson et al clustered the various attributes of professionalism into five categories: ‘adherence to ethical practice principles, effective interactions with patients and with people who are important to those patients, effective interactions with people working within the health system, reliability, and commitment to autonomous or improvement of competence in oneself, others and systems.”
Essentially this is a PRIMSA positive methodology.
- A systematic search was conducted. MEDLINE, Embase, ERIC and (for those playing database bingo) British Education Index were searched from 1990-2018 for interventions involving medical students or doctors that had been implemented.
- Articles were selected by consensus; data was abstracted independently; manuscript quality appraisal was conducted.
- A narrative synthesis of the evidence was completed.
From 2319 articles, 23 were included in the synthesis. When more than 1 article described a common intervention the data was pooled for each of reporting (n=4). Nearly all studies were from the USA. There were 13 case, 5 cohort and one qualitative study, involving doctors (37%), medical students (26%), residents (16%), mix (16%) or other health professionals (5%).
The majority of interventions (37%) incorporated professional interventions into general skills interventions such as knowledge deficits or time management. One fifth addressed general professionalism issues; one fifth addressed boundary (e.g. sexual or financial) or ethics violations. 10% addressed communication; 10% addressed disruptive behaviour. Of note, only 12 studies addressed professional prlbmes specifically, in isolation from other remediation issues.
Interventions often included a diagnostic phase using MSF or psychometric testing, among others. This was followed by the intervention that included: didacting teaching, small group learning, simulation and role-play, tailored learning plans, coaching models and reflection.
There was variation in the amount and degree of behaviour change tactics, including: goal setting and feedback.
The quality of the cohort and qualitative study was moderate.
The authors conclude…
“The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can work to …pass medical licensing examinations, but it is not apparent from this literature whether these interventions are successful in remediating lapses in professionalism specifically. The findings of the study reveal a paucity of evidence to guide best practices of remediation of professionalism lapses in medical education at all levels.”
Spare Keys – other take home points for clinician educators
A spare key to Decision Editors. Figure 1 is the PRIMA flow diagram, taking up a whole page of text. Appendix 1 (included with the manuscript) is also a page in length with the search strategy. This is at the expense of not including the two supplementary files that contain all of the study-level data around intervention, population and quality.
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