IAMSE 2014
Remediation of Core Medical
Competencies
Regina Kreisle, MD, PhD
Carol Nichols, PhD
Faculty
• Regina Kreisle, MD, PhD
rkreisle@purdue.edu
Professor of Pathobiology
Course Director, Pathology and EBM
Asst. Director for Curriculum Development
Competency Coordinator
Indiana University School of Medicine – Lafayette
Statewide Competency Director – Medical Knowledge
• Carol Nichols, PhD
CANICHOLS@gru.edu
Associate Professor
Phase 1 Modules Co‐Director
Medical Gross Anatomy Director
Department of Cellular Biology and Anatomy
Medical College of Georgia at Georgia Regents University
Competency Remediation
• What is a Competency?
– Competencies encompass knowledge, attributes,
skills, and attitudes necessary for a particular set
of tasks or objectives
• What constitutes a competency deficiency?
• What should be done about it?
MSOP Report
“…The goal of medical education is to produce
physicians who are prepared to serve the
fundamental purposes of medicine. To this end,
physicians must possess the attributes that are
necessary to meet their individual and collective
responsibilities to society.”
MSOP
• Physicians must be altruistic, altruistic and truthful.
• Physicians must be knowledgeable about the scientific
basis of medicine.
• Physicians must be skillful in communicating with and
caring for patients.
• Physicians must be dutiful in working with other to
promote the health of individual patients and the
broader community.
ACGME
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Patient care
Medical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice
Competency-Based Education
• Implies that skills, attitudes, and
behaviors are as important as knowledge
base
• Incorporates curricular components and
formal assessments for each desired
competency
• Competencies are woven throughout
curriculum
The Competency Agenda
• Overt agenda: provide better preparation in
all aspects of knowledge, attitudes, and skills
necessary for the future practice of medicine
• Covert agenda: identify (and potentially
remediate) problems that would otherwise be
missed in assessing knowledge base alone
(usually in only about 5% of students)
Evaluation of Competencies
• Principle One: The competency curriculum in
an integrated part of the entire curriculum.
– Courses incorporate assessment of associated
competencies
– Benchmarks are set for promotion
Evaluation of Competencies
• Principle Two: Competencies must be
formally evaluated in a summative manner.
– Formal achievement results from demonstration
of knowledge, skills, and attitudes.
– Specific courses are asked to evaluate specific
competencies in a formal manner.
– These course evaluations are combined with
other statewide means of assessment (NBME
Exams, OSCE’s, etc.)
Evaluation of Competencies
• Principle Three: Students must receive regular
feedback and multiple opportunities to
demonstrate achievement.
– Achievement should not be based on a single
activity or assessment
– Non-achievement usually triggers remediation
– Failure to demonstrate satisfactory progress toward
achievement of competencies can result in
academic probation or even dismissal
Tracking of Required Competency Based Activities
*Peer and Self-Assessment will be subsumed into the new advising program for Class of 2018 and beyond
2014 Competency
(PC) Patient Care
(ICS) Interpersonal Communication
Skills
(MK) Medical Knowledge
(P) Professionalism
(PBLI) Practice Based Learning and
Improvement
(SBP) Systems Based Practice
Event
Curricular Location
Required Clinical Skills
Promotion Requirement
EOY3 OSCE
Graduation Requirement
BLS
Promotion Requirement
ACLS
Promotion Requirement
Patient Feedback on CS
Neurology Clerkship
Required Clinical Skills
Promotion Requirement
EOY3 OSCE
Graduation Requirement
USMLE Step 1
Promotion Requirement
USMLE Step2 CK, CS
Graduation Requirement
Ethics
Ob/Gyn Clerkship
Peer and Self-Assessment
Promotion for Class of 2017*
LLL activity
Internal Medicine Clerkship
Case Discussions
Surgery Clerkship
Community/ Family Project
Family Medicine Clerkship
Practical Evaluation and Assessment
Requires…
• Well-defined criteria
• Assessment tools that are
– Matched for the competency and instructional
method
– Uniform
– Manageable
• Feedback
Example – Effective Communication
The Level One student will demonstrate:
• effectiveness in written communication of an informal
nature, such as descriptive reports, history and physical
examination write-ups, and tests.
• competence in oral communication in small groups or in
one-on-one settings with an individual faculty member
or with a patient who possesses no characteristics which
would pose challenges to the student.
• the ability to communicate by e-mail, use wordprocessing and use bibliographic databases.
Practical Suggestions
• Assessments are easiest when done in smaller
groups with personal contact
– Labs, Problem-based learning or discussion groups,
physical diagnosis preceptors, etc.
• Use uniform evaluation tools, especially when
multiple faculty are assessing the same
competency
– Use detailed criteria and expected norms for satisfactory
performance
– Make evaluation tool as objective as possible
Practical Suggestions, Cont’d.
• Assess activities already in place whenever
possible (rather than adding to the
curriculum)
– Oral presentations, reports, labs, etc.
• Use mid-term and formative evaluations with
feedback – don’t surprise the students at the
end
• Make sure students are aware of the criteria
and your expectations
Remediating Deficiencies in a
Competency-based Curriculum
Regina Kreisle, MD, PhD
Statewide Competency Director – Medical Knowledge
Indiana University School of Medicine - Lafayette
Competency-Based Education
• For each of the six “core” competencies, criteria
are established.
• Curricular components are developed to
address and assess these criteria even in basic
science courses.
• Different courses identify and develop different
aspects of the core curriculum.
• Other benchmarks are required for promotion or
gradation.
Evaluation of Competencies
• Achievement should not be based on a single
activity or assessment.
• Non-achievement usually triggers remediation.
• Failure to achieve a single competency results in
remediation.
• Failure to achieve multiple competencies may
result in dismissal or repeat of a year.
Assessment of Deficiencies
• Requires clearly communicated expectations
and requirements.
– Competency criteria
• Early feedback to students.
• Documentation!
• Involvement of the student in identifying and
correcting their own deficiencies.
Remediation – Years 1 and 2
• Most common competency failure is failing a
course (medical knowledge competency)
– If one course is failed, student remediates in the
summer
• Next most common is professionalism
• Isolated deficiencies occur with effective
communication and basic clinical skills
Remediation – Years 1 and 2
• Failure of a pre-clinical course automatically
requires remediation in Medical Knowledge.
• Medical Knowledge is usually remediated by
allowing the student a period of study followed
by and examination.
• Failure of a competency component of a course
or benchmark assessment may result in an
isolated deficiency.
Remediation – Years 1 and 2
• Isolated deficiency – remediates specific
issues, usually with help of Statewide
Competency Director
• Complex or multiple deficiencies – student
goes to Student Promotions Committee
– Yes, we have been able to dismiss students for
multiple competency issues, even in the first year
Remediation – Years 1 and 2
• Isolated deficiencies may uncover underlying
specific issues
• Multiple deficiencies almost always involve
health, mental health, learning disabilities, or
motivational issues
• Issues identified in years 1 and 2, but not
resolved, nearly always get worse during the
clerkships
Statewide Competency Director
• Consulted when specific competency issues
arise
• Assist in defining deficiencies and developing
remediation plans
It Works!
• We have remediated issues in students who were
otherwise passing to their benefit.
• We have helped students become aware of issues
and change their behavior through behavioral
contracts.
• We have helped students learn new skills such as
dealing with anxiety, or discovering learning
disabilities.
• Some students cannot be remediated and should not
become physicians.
Remediation – Years 3 and 4
• Many borderline issues become overt issues in
years 3 and 4.
• Unfortunately, many issues are unresolved
issues from the preclinical years.
• Students develop at different paces; not
everyone can master the skills on schedule.
Remediation – Years 3 and 4
• By far the most common isolated deficiency in the third year is
failure of the end-of-clerkship exam.
– Students must take time off to study and then retake the exam.
– Failure of remediation requires repeat of the clerkship.
• Students can receive isolated deficiencies (except Clinical Skills) in
any of the competency and must remediate before going to the
fourth year.
• Failure to demonstrate adequate Clinical Skills results in failure
and repetition of the clerkship.
• Students receiving deficiencies in multiple competencies can be
dismissed.
ID-3: failure of medical knowledge competency (failed clerkship exam)
Multiple academic difficulties (ID-3’s) coupled with Professionalism Concerns
Major concerns with Self-Awareness and Self-Care
Issues in Successful Remediation
Before you get to remediation…
• Multiple assessments and evaluations should be
made directed at specific competency requirements
and objectives.
• Assessments should be made by more than one
individual in more than one setting.
• Students should receive both formative (low risk)
and summative (high risk) evaluations. Students
need continuous feedback, not just a summary
evaluation.
Issues in Successful Remediation
• Passing requirements should be clearly defined
(and be defensable). These should be
communicated early and often.
• Unsatisfactory evaluations should be
accompanied by identification of specific
deficiencies.
• There should be enough time between the
evaluation and academic consequences to allow
for remediation.
Issues in Successful Remediation
Components of Remediation
• Identification of specific deficiencies preferably
linked to competency criteria and objectives.
– Link evaluation tools to specific criteria and
objectives
– Insist on specifics with unsatisfactory evaluations
– Collect as much information as is needed
• Deficiencies (and successes) need to be
communicated in a timely manner along with
supporting evidence.
Issues in Successful Remediation
• Evaluation and consequences must be consistent
with stated policies.
• Students need a chance to respond to the
documentation of deficiencies.
• Students and instructors should develop a plan that
agrees on specific objectives and means for meeting
those objectives.
• Re-evaluation of the competency should take place
that is consistent with the goals of the remediation
process.
Issues in Successful Remediation
Problems crop up when…
• A deficiency is identified, but not defined.
– Insufficient information is provided by the
evaluator
– Competency criteria or objectives are
insufficiently defined
• The deficiency is not properly documented.
• Students are not informed of deficiencies
until late in the process.
Issues in Successful Remediation
• Students are not involved in the
identification of remediation goals or
methods of remediation.
• Remediation is identified as punishment, not
as an opportunity for improvement.
• The student refuses to accept that a
deficiency exists.
Our experience to date...
• Students rise to our expectations
• Early assessment means early remediation
• We find problems exams can’t find and can insist on
remediation of non-academic issues
• Students take competencies seriously
• New approaches to the problem student
• Students take remediation opportunities to better
themselves
• Multiple competency problems = failure
Conclusions
• A successful remediation strategy begins with clear
competency criteria and relies on appropriate, timely
student assessment and feedback
• Documentation of deficiencies, particularly from
multiple evaluators is important
• Early identification of isolated deficiencies is important
– Learning issues – ADHD, dyslexia, test anxiety
– Anxiety, self-confidence issues, time management
– Self-awareness and self-care, relationship issues
Conclusions
• Global issues such as personality disorders and
motivation issues are a bigger problems, but best
identified early
• Early remediation of small problems may avoid bigger
issues in clinical training
• Remediation should be seen as opportunities for
growth, not punishment or corrective action
• Students need to be actively involved in their
remediation planning