Suboptimal performance by practicing physicians possesses all the characteristics of a “wicked problem,”1 in that constantly evolving social and political factors, which vary across time and jurisdiction, render a definitive solution highly unlikely. Perhaps not surprisingly, therefore, the most commonly proposed solution to this problem, individual remediation, is itself a “wicked problem”—one that the medical profession has struggled with for decades. Problems with remediation manifest in several forms: Conceptually, no coherent (much less universally accepted) definition of remediation is available in the medical community; academically, research on best remediation practices is lacking; and administratively, institutional responsibility for enacting and overseeing remediation engenders controversy. Each of these manifestations suggests that the remediation of practicing physicians is not merely a difficult problem to solve but, rather, a problem that the community struggles to grapple with meaningfully. Based on the premise that the first step in addressing a problem is defining its characteristics, we conducted a literature review to determine the state of the art regarding remediation in practicing physicians.
The Scoping Review
We carried out a scoping review2 between July 2016 and January 2017 with the goals of determining the breadth of the literature on remediation, identifying gaps, and exploring current and potential conceptualizations. We focused specifically on the remediation of practicing physicians struggling with clinical competence issues. We did not include articles about physicians whose health concerns (e.g., mental illness, addictions) might affect competence. We therefore excluded articles that referenced remediation only during training; those that focused solely on assessment; and those that focused exclusively on remediation for issues related to professionalism, rehabilitation, or reentry into practice after a prolonged absence for reasons unrelated to clinical competence. We included concept papers and editorials. We included any articles published through December 2016. We searched PubMed, Eric, Web of Science, and Google Scholar, using the following terms: remediation practicing physicians, remedial continuing medical education, dyscompetence practicing physicians, competence practicing physicians, and revalidation. We also scanned the reference lists of the articles we identified, as well as those of two relevant books.3,4 Finally, because much of the available information on remediation at the practice level is located on government and organizational websites, we also searched (using the search terms above) the gray literature using the search engine DuckDuckGo, as well as the Twitter feeds and websites of relevant organizations (e.g., the Coalition for Physician Enhancement, a consortium of organizations with an interest in physician performance improvement). We reviewed the abstracts of identified articles to determine their relevance. Then we extracted information from those selected articles and documents pertaining to remediation in practicing physicians.
Using the above criteria, we identified 33 published articles, plus documents from the gray literature (see Supplemental Digital Table 1, available at http://links.lww.com/ACADMED/A556). The results of the literature search confirmed our belief that remediation is a “wicked” problem. First, we noticed the relative absence of research—educational or otherwise—published on the remediation of practicing physicians. Since 2009 when Hauer and colleagues5 commented explicitly on the lack of research on the remediation of practicing physicians, we could find only two new studies.6,7 In contrast, during that same time, several studies addressed the assessment of competence in practicing physicians,8–17 suggesting that addressing physicians in need of remediation is more difficult than determining physicians’ competence in the first place.
Second, we determined that definitions of remediation are surprisingly scarce. For example, Kalet and Chou’s seminal book Remediation in Medical Education4 begins with a chapter on defining competence, not remediation—and the main delineation of the concept of remediation is found in the book’s subtitle, “A mid-course correction,” not in the text. Similarly, published articles rarely define remediation per se; instead, definitions are implied in the descriptions of underlying causes for its need (e.g., mental health issues), or the descriptions of groups more likely to require it (e.g., elderly physicians). The general lack of clarity (or specificity) about what falls under the umbrella of remediation is not simply a matter of semantics: This ambiguity undermines the community’s ability to determine the incidence of remediation,18,19 thus creating difficulties both for resource planning and for comparing success rates across programs and jurisdictions.
Perhaps the most telling indicator of the wickedness of the problem of physician remediation lies in the apparent hesitation by institutional stakeholders to become engaged in the remediation process. Unlike the assessment and identification of physicians in difficulty, which regulatory and health authorities view as part of their mandate, no single stakeholder group agrees that remediation falls under its mandate. Depending on the jurisdiction, regulatory authorities,20 universities,21 health authorities,22 and specialty boards23 may have a greater or lesser role, or in some cases, no role at all. This lack of clear authority frequently leads (with a few exceptions8,24,25) to ad hoc, rather than programmatic, solutions for the remediation of physicians with clinical deficiencies. Although political issues undoubtedly play a role in this state of affairs, this absence of clear responsibility may be more indicative of underlying issues with how the medical community conceptualizes remediation.
On the basis of these findings, we concluded that to untangle the wicked problem of remediation, addressing the conceptual ambiguity that surrounds it is vital. To this end, we conducted a second, conceptual review of remediation. We explored various literatures that we felt might inform potential conceptualizations of remediation including literatures on learning, on change, on the influence of personality on behavior, and on the sociology of medicine. To identify these literatures, we started with books or articles on specific topics including Kalet and Chou’s book on remediation4 and Bleakley and colleagues’ book, Medical Education for the Future: Identity, Power and Location.26 Next, we followed references of articles discovered through our earlier search, searched our files looking for potentially relevant articles, and spoke with colleagues who suggested other possibilities. The identification and exploration of these new domains of literature was more organic than systematic, emerging from discussions with a broad range of colleagues. The goal was not to be exhaustive but, rather, to develop a meaningful synthesis of these literatures to inform potential conceptualizations of remediation.
For the purposes of this conceptual analysis, we have focused on what we see as the “iconic” physician in need of remediation, the physician for whom there are identified concerns related to knowledge, skills, and performance. When appropriate, we contrast this physician with physicians who require particular assistance because of health problems including physical, mental/emotional, and/or addiction issues. We note that while several issues may be at play (either sequentially or simultaneously), we suggest—and, in fact, argue—that, conceptually, it is the physician who is perceived as struggling in practice but who has no “medical” reason (e.g., underlying addiction or mental health problem) that most challenges the medical community. This is the physician with which the medical profession must come to terms.
Findings and Discussion
The synthesis of this broader set of literatures generated three conceptual domains that may be contributing to the medical community’s difficulties in engaging with the challenges around remediation: (1) the conceptualization of remediation itself, (2) the conceptualization of the person being remediated, and (3) the culture of medicine as an influence on these conceptions. Although these three categories are inextricably intertwined, we discuss each separately in the interests of clarity.
Conceptualizations of remediation
The first domain identified was the ambiguity of the underlying conception of remediation, including the goals of remediation and the processes invoked to achieve those goals. Remediation in practicing physicians is most frequently described as an educational process.7,19,27 The literature suggests that it is usually conceptualized as a means of addressing a gap in an individual’s knowledge or skills (including knowledge and skills in the areas of ethics and professionalism28). We posit, however, that conceptualizing remediation in this fashion can lead the community of physicians down some potentially thorny paths.
First, conceptualizing remediation as simply addressing a gap in knowledge or skill can lead to an overfocus on knowledge acquisition as the solution. Although knowledge is important (indeed, practitioners may need to acquire or relearn knowledge or skills), strong evidence in the continuing medical education (CME) literature suggests that knowledge alone is insufficient to accomplish practice change.29,30 Individual performance is influenced, for better or worse, by the attributes and skills of colleagues,31 by system resources (e.g., the availability of specialized equipment and trained personnel), and by organizational culture—the myriad sociocultural and systemic factors that we term the “social determinants of performance.” Remediation as a purely educational exercise that does not address the contextual factors supporting or hindering competence in individuals is, in and of itself, unlikely to be sufficient to address significant performance gaps.
Second, the model of remediation as (more) education fails to take into account a number of sociopolitical and economic issues associated with being in the learner role. That is, the remediation of practicing physicians seems to be conceptualized similarly to the remediation of residents: Similar attributes are thought to be required of preceptors in both cases (although these are not generally specified),32 and similar methods are promoted (e.g., directed reading, required courses, and possibly further clinical rotations33). Importantly, however, the sociopolitical and economic considerations at play in practice differ from those in residency: Residents are considered learners, and mistakes are viewed as opportunities to learn.34 Additionally, residents are not ultimately responsible for the patients they treat, so they do not suffer the same kind of loss of authority that “supervised” practitioners potentially experience.35 Also, resident remediation is not overlaid with economic considerations, such as funding for the preceptor and physician in remediation. Thus, treating the remediation of physicians as simply an educational problem risks omitting from the equation significant factors that will affect its practices and its outcomes.
If remediation is more complex than simply filling an educational gap, how might the medical community better conceptualize it? In psychology textbooks, learning is often defined as a “relatively permanent change in behavior brought about by experience or practice.”36(p176) In this spirit, perhaps remediation might better be conceptualized as supported practice change. Conceptualizing remediation as practice change allows the profession to recognize that remediation is more of a change management problem than an educational issue. The CME literature notes the difficulties that even highly effective practicing physicians encounter in changing their practice to conform to new developments.37–39 As a result, CME programs are evolving to focus on practice change40–42 with the understanding that such change requires resources, including practice tools and mentorship. In this sense, reconceptualizing remediation as a change management process would be congruent with viewing remediation as situated on the continuum of CME. Physicians requiring remediation would sit on one extreme of the continuum because, compared with colleagues, they simply have more significant change to implement and/or more challenging barriers, including grappling with the emotional toll of being identified as needing remediation and its attendant effect on self-esteem (see below).
Successful remediation, therefore, will likely require, at a minimum, the same magnitude of resources as other practice change initiatives. A benefit of conceptualizing remediation as supported practice change might enable physicians in remediation and their preceptors to better identify underlying factors that could hinder or facilitate that change and, in turn, tailor remediation to the individual to achieve better long-term outcomes. The medical community’s ability and willingness to view and enact remediation as a change management process—as simply an extension of the change management process increasingly promoted in the CME literature—has the potential not only to increase the effectiveness of remediation but also to destigmatize it. One barrier, however, to considering remediation as part of continuing professional development might be how the profession conceptualizes the clinicians requiring remediation.
Conceptualizations of the individual requiring remediation
Perceptions of struggling colleagues are shaped by concepts of competence and the causes of dyscompetence. As Hodges43(p40) has noted, competence is a “sociohistorical construction with links to power.” That is, those with power possess significant influence in defining what constitutes competence or the lack thereof. The same might be said for deciding which individuals and which activities require remediation. How the medical community views competence/dyscompetence may well have important implications for how it frames and approaches those physicians requiring remediation (and, in turn, how it frames and approaches the process of remediation).
Many investigators, seeking to understand risk factors for underperformance and potential predictors of successful remediation, have sought to determine demographic and personal characteristics of physicians requiring remediation.10,44–46 Such studies may inadvertently reinforce a perception that the physicians requiring remediation possess predisposing personal characteristics that have somehow led to their present situation and may further lead to the belief that remediation outcomes depend almost exclusively on the individual being remediated.31 Thus, a focus on the stable personal characteristics of physicians requiring remediation such as age, gender, country of training/origin, or ethnicity may contribute to the reluctance to address dyscompetence: these personal characteristics will make behavioral and practice changes difficult. If the cause is a personal characteristic, then no remediation (of any form) will be sufficient to effect change in the physician requiring it. Perhaps more importantly, a focus on personal characteristics could also lead clinicians to view a colleague in remediation as somehow different from themselves, which only compounds that individual’s struggles. Such a view allows clinician coworkers to distance10 themselves or exclude the struggling physician from the community of practice47—rather than embrace a colleague who is in particular need of support.
This process of “othering” is well described in the psychology literature, which elaborates on several perceptual biases that could influence the conceptualization of individuals in need of remediation. For example, attribution theory describes the human tendency to see other people’s behavior as reflective of their personality or characteristics, and our own behavior as resulting from external circumstances.48 The “just world phenomenon” explains the human need to believe that we all live in a world where people ultimately get what they deserve.49 This bias often results in blaming the victim, or in this case, perhaps a lack of empathy for the situation in which dyscompetent practitioners find themselves. Similarly, humans tend to judge actions on the basis of outcomes whether or not the latter were under the control of the people involved.50 These biases frequently result in a failure to distinguish between the behavior and the person. Trainees and practitioners alike, for example, may be told that they themselves are unprofessional rather than that their behavior at a point in time was unprofessional. Similarly, people are labeled “incompetent” in spite of overwhelming evidence that competence is both content51 and context52,53 specific.
One manifestation of the process of othering is the difference in systemic responses to physicians in need of rehabilitation versus those in need of “reskilling” (i.e., medical treatment versus educational training). All Canadian provinces and almost all U.S. states boast a physician health program to support addicted, stressed, and even, in some cases, disruptive physicians. Yet relatively few formal programs exist for those requiring remediation to address deficits in knowledge, skills, or clinical reasoning. One reason for this discrepancy might be how the community implicitly interprets the source of these problems. Physicians are trained to believe that most illnesses are not any individual’s fault, so they attach less stigma to an individual patient. By contrast, physicians may see dyscompetence as squarely the fault of the practitioner needing remediation. The ill physician invokes others’ support, but a physician who has allowed him- or herself to become dyscompetent may not. This lack of support or empathy, this blame, may be, as we suggested in the introduction, the reason that it is the physician perceived as struggling in practice, but with no medical diagnosis, who constitutes the challenge with which the medical community must come to terms.
We emphasize that focusing on demographics or the personal characteristics of physicians requiring remediation risks not only underestimating the influence of context on competence and remediation but also succumbing to stereotyping (such as ageism54) in ways that isolate rather than embrace and support the physician in trouble—to the detriment of both the individual practitioner and the broader community. Each physician requiring remediation is a unique individual practicing in a context that is never exactly the same as that of his or her peers. We thus return to our concept of remediation as supported practice change and the need to consider sociocultural and systemic factors in addition to those that are unique to the specific individual and relevant to the situation. One characteristic that virtually all physicians share, however, is their embeddedness in the culture of medicine.
The effect of medicine’s culture on conceptions of remediation
The culture of medicine, in which physicians both train and practice, appears surprisingly homogeneous across different countries and health care systems. This culture includes the practice of “shaming and blaming” a physician for errors,55 dictates the types of errors physicians will tolerate in trainees or colleagues,34 and inculcates the reluctance to challenge a colleague’s practice.56,57 Each of these phenomena likely has some bearing both on the willingness to remediate and on the determination of who and what is considered remediable. Perhaps the cultural concept that has the greatest bearing on the willingness to remediate, however, is that of professional autonomy.
Friedson58(p255) has argued that “the single zone of activity in which autonomy must exist in order for professional status to exist is in the content of work itself.” This concept of clinical autonomy acknowledges that the judicious use of knowledge and skills, rather than the blind following of standards, is not only more intellectually satisfying for the professional but usually in everyone’s best interest, including that of patients. While the concept of the autonomous physician is evolving and the need for some form of oversight is increasingly accepted, clinical autonomy remains a core defining characteristic of the profession. Autonomous practice is a right and a privilege that residents work hard to merit, and the acquisition of which marks a rite of passage at the end of training. Removal of that autonomy occurs only in cases of dangerous incompetence or negligence.
A less frequently discussed component of professional autonomy is that of educational autonomy, the freedom of the individual physician to decide what and how to learn. Educational autonomy is also evolving—in that a certain number of CME hours and even types of CME are now mandatory in many jurisdictions. However, the core underlying concept of individual freedom to manage one’s own ongoing professional development remains unchallenged, with one exception. As with clinical autonomy, removal of educational autonomy is invoked when physicians have been shown to be negligent (i.e., not to have managed their learning so as to keep up-to-date in their knowledge and/or skills).
Remediation can thus be conceptualized as involving the removal of an individual physician’s professional right and personal responsibility to self-determine a satisfactory level of competence and to self-regulate when, how, and what to learn. Unlike mandatory continuing professional development, which merely stipulates that physicians must continue to learn (and offer evidence of having participated in the learning activity), remediation prescribes what must be learned and determines when satisfactory learning has occurred. The individual physician has failed to self-regulate, so another authority is assuming that responsibility. In the process, the physician in remediation might be said to have lost a core defining characteristic of the profession: autonomy and the associated right to self-regulate.58 This loss may, in turn, lead to the othering described earlier. Colleagues may feel not only discomfort for and around a physician in remediation but, if disgrace has been public, they may also feel, at least to some extent, resentment for giving the practice, institution, or even the profession a bad name. No wonder, then, that remediation is fraught with personal, cultural, and political baggage.
Interestingly, the removal of autonomy is not always accompanied by a complete removal of responsibility for addressing the deficit. For example, some remediation programs require physicians to identify the resources required for remediation and to pay the entire cost themselves. The unexpressed reason underlying this financial liability may be that because the situation is the individual physician’s “fault,” it is also his/her sole responsibility to find ways to remediate it. Now is perhaps the time for the profession to consider a more social model of remediation. Increasingly, the medical community is recognizing that competence is a team sport.31 Despite this nascent awareness, the culture of medicine in which each person is responsible for one’s own competence and only for one’s own competence might require challenging. Although individual physicians should not be deemed responsible for their colleagues’ competence, we argue that they are responsible to their colleagues and to the profession. Together, physicians are collectively responsible to contribute to the culture and system that motivates the ongoing performance improvement of everyone. We believe the same model should apply to remediation: that everyone is responsible to dyscompetent physicians to support their successful return to competence. Of course, that responsibility will vary depending on individual roles and the circumstances, but at a minimum, responsibility entails accepting or continuing to include a physician in remediation within the practice or community. This shared responsibility is perhaps not so much a culture change as it is a reinterpretation of the requirements inherent in the concepts of professional autonomy and self-regulation.
Our analysis has led us to conclude that currently the medical community views and experiences remediation, ultimately, as a “deprofessionalization” because it removes from the individual two important characteristics of a professional: clinical autonomy and self-regulation. This deprofessionalization makes remediation emotionally and politically fraught not only for individuals but for the profession as a whole. Understanding remediation as a loss of autonomy and therefore a form of deprofessionalization might enable the medical community to understand why grappling with this wicked problem has proven so difficult for so long and in so many quarters.
As a step toward redressing the fraught nature of remediation, we suggest characterizing remediation as supported practice change that focuses on the social and cultural aspects of collective competence rather than on the individual personalities of those requiring remediation. We believe that explicitly taking into account the influence of medical culture regarding remediation might lead to better outcomes. We stress that we view the concept of supported practice change not as a solution to the problem of remediation but, rather, as a different way of framing the problem. That is, reconceptualizing remediation as supported practice change suggests new lines of exploration that the community might profitably pursue.
For example, remediation as supported practice change aligns with social learning theories. Until recently, individualistic learning theories26 such as adult learning theory,59,60 experiential learning,61 and reflective learning/practice62 have had the most traction in medical education, particularly in CME.26 However, individualistic learning theories are not always sufficient either to diagnose why a particular physician is struggling or to develop a successful remediation plan. Such theories do not adequately take into account the considerable sums of money, time, and effort that are often required to enable competent practitioners to alter even one small component of their practice patterns.36,63 Acknowledging—as social learning theories do—that it is impossible to separate individual knowledge, motivation, affect, and ability from the influence of context and culture59 would not diminish individual accountability and/or the responsibility of each physician to remain up-to-date and to provide competent care. Acknowledging the interdependence of individual and contextual factors (the social determinants of performance) would, however, lead to remediation strategies that take into account the learning tools available to a struggling physician, the processes required for practice change (see below), the division of labor, and the community in which the physician practices.64 Starting with social learning theories might stimulate questions such as “How might we effectively use a physician’s community of practice in remediation?” or “How might we determine the influence of context in a particular case of clinical dyscompetence?” Paradoxically, remediation based on social rather than individual learning theories might entail a plan that is tailored to a specific individual in a particular situation; in fact, it would be the polar opposite of a communal one-size-fits-all approach.
Conceptualizing remediation as supported practice change would also lead to the literature on change management. That literature explores issues such as the motivation and ability to change,65 and the facilitators and inhibitors of change (in this case, the facilitators and inhibitors of remediation). Understanding remediation as supported practice change would inspire questions such as “How do conceptualizations of remediation and of struggling physicians interact with medical culture to shape whether/how various institutional stakeholders and leaders envisage addressing remediation?”; “What structures can we create to ensure long-term practice change rather than short-term achievement of learning objectives?”; or even “How do we determine to what extent needed practice change will be possible for a particular physician in a given context?” Models such as the Influencer model (which is based on the work of Albert Bandura) or the theory of planned behavior, which is used to understand the effect of public health interventions, might be explored and adapted to planning and studying remediation.65
Physicians requiring remediation have deviated from professional and cultural norms. The medical community might, therefore, look to the literature on deviance for potential insights into predisposing organizational or societal factors or successful remediation strategies. The deviance literature includes what Currie66 has termed the “fallacy of autonomy”; the fallacy of autonomy suggests that what goes on in a family, or in this case a hospital or practice, cannot be separated from wider social forces. Additionally, this literature has described deviant behavior as conduct arising from reactions to personal inability to meet widely accepted goals67—something that any clinician who has felt frustrated with perceived barriers to providing good care within the confines of a seemingly underresourced, overbureaucratized, or excessively profit-driven system can relate to. Deviant behavior can be moderated by social support68—such as, in remediation, a coach or mentor who provides support and validation. Taking into account the deviance literature might suggest new research questions such as “What factors in the health care system and/or fee structure encourage the wrong behaviors, foster less-than-optimal practices, and/or discourage desired actions?” (rather than “What individual characteristic caused this problem?), or “Which remediation processes (rather than which plans to reeducate) are more likely to be associated with sustained practice change and a lower rate of recidivism?”
In thinking about which literatures might inform the medical community’s thinking around the culture of medicine and how this culture affects the willingness and ability to address remediation, we are struck by how difficult culture change is.69 Henri Nouwen wisely wrote: “You don’t think your way into a new kind of living. You live your way into a new kind of thinking.”70 Similarly, we believe that rather than attempting to change the culture of medicine so that the profession can develop more effective remediation programs for practicing physicians, the profession might be more successful by developing better programs to support struggling physicians in order to facilitate needed culture change.
As we noted initially, remediation in practicing physicians is a “wicked problem”—a problem that has no simple solutions, a problem that must be grappled with, rather than solved. The specifics of remediation programs will vary depending not only on the particulars of each situation and on the jurisdiction and health care system but also on, importantly, the underlying conceptualizations of those responsible for their development. We have suggested, generally, that those conceptualizations might benefit from a closer look and, specifically, that viewing remediation as supported practice change and examining its social and systemic aspects might be a good place to start. The remediation of practicing physicians will, however, necessitate more than simply reconceptualizing remediation as behavior change as opposed to filling gaps in knowledge or skills. It will also require a culture change in how the profession views its struggling members; a readiness on the part of institutional stakeholders, especially leaders, to assume responsibility for those aspects of remediation they are best suited to address; and a collective willingness of physicians to support struggling colleagues. The first step going forward will be to explore exactly how these attitudes and culture norms manifest in administrators, those who lead remediation efforts, and those in need of remediation.
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