Board 281 - Program Innovations Abstract How Do You Change a Resident in a Month? Using Simulation as Goal Directed Remediation of Resident Performance (Submission #164)

Abstract

Introduction/Background Residency represents a complex amalgamation of acquiring medical knowledge, applying this knowledge to various clinical scenarios and ultimately learning how to deliver efficient and proficient care to patients. If any of these aspects are deficient in a resident, it jeopardizes the ultimate goal of residency, which is to develop competent physicians. And while assessing and remedying gaps in medical knowledge may seem relatively straight forward, the other aspects of resident competency (application of knowledge, delivery of care, etc.) are often much more subjective and remedies for deficiencies seem much more aloof. However, through individual learner assessment and the use of high fidelity simulation, it was our hope that we could objectively assess and remediate specific deficiencies and ultimately change the trajectory of a struggling resident. Methods Growing concerns were raised for a PGY-1 internal medicine resident regarding substantial gaps in application of medical knowledge, ability to triage patients based on severity of disease, and adaptation to a busy and high acuity service. These concerns were significant enough to warrant an individualized remediation plan in hopes of readying the resident for the rigors of their second year of residency. Due to limitations in scheduling, this formalized remediation was scheduled for an individual four week block. Prior to the initiation of the block, the resident was formally assessed by an expert in adult learning who utilized Kolb’s Learning Style Inventory so that we could better understand potential barricades to our learning plan. In this case, she was found to be a reflective learner (diverger) which was contrary to many of the teaching styles of the faculty. This allowed for greater insight into the potential discrepancies between learner and faculty and provided a latticework from which we could construct a more effective learning experience for the resident. Based on this assessment, a formalized program was created consisting of both bedside patient care (permitting for close one-on-one observation and immediate personalized feedback) and high fidelity, high stakes simulation. This culminated in a multifaceted scenario of several overlapping simulated patients designed to exploit many of the resident’s perceived limitations. The ability to triage patients and problems simultaneously and all aspects were recorded for the review of the program director. The resident performance substantially improved not only as measured by direct observation of attending physicians and subjective assessment by the resident but has also continued in ongoing faculty evaluations. Results: Conclusion The progression and maturation of learners throughout their residency has been historically subjective and variable. However, with the ongoing evolution of competency-based assessment, much greater scrutiny is going to be placed on resident milestones of performance. Simulation clearly offers a unique opportunity not only providing a controlled, safe environment for assessment but also allowing for enrichment of skills and remediation as necessary. Although labor intensive and time consuming, the investment of resources to better understand struggling residents’ learning styles and mental models is one that can have significant returns. In this case, the investment in time and resources completely changed a resident’s course of training, competency as judged by attending faculty and ultimately her overall efficacy as a physician. While not feasible on a global scale, the appropriate utilization of simulation in concert with the formalized assessment of mental models and learning styles has the potential to close significant gaps in learners’ education. This clearly not only benefits the learner and educators but also has the clear potential to improve patient safety in the process. Therefore, while resource utilization in a program like this is undoubtedly significan,t so is the return on investment.