If residents are not performing to their expectations, remediation is an attempt to get them back on track.
If it gets to that point, probation is meant to act as the final opportunity to improve before getting fired.
If due process is followed per the sponsoring institution’s policies, there is little legal recourse for a resident who has been fired.
Every year, some residents and fellows require remediation during training. Remediation is meant to optimize learning conditions and skill acquisition, while ensuring patient safety and maintaining the professional standards of the specialty.
Despite the efforts of teaching institutions to successfully remediate residents who have lost their way, a small minority are let go.
Overall, 2,128 residents left their 2020-2021 programs prior to successful completion. These trainees left because they transferred (50.3%), withdrew (37.2%), were dismissed (10.9%), unsuccessfully completed the program (0.7%), or died (1.0%).
Getting dismissed is never a first step. Instead, it represents the end of a road which is paved with policy and legal considerations.
First step: Remediation
Authors of a review published in the Journal of Graduate Medical Education (JGME) explain that there are typically two levels of remediation: informal and formal. The goal of informal remediation is to improve performance—this is necessary for a small set of learners. This type of remediation is internally managed and not reported.
Formal remediation, however, results from performance or conduct that registers below the minimum requirements of the program, which likely includes attempts at informal remediation.
The repercussions of failed formal remediation include more remediation, non-promotion, probation, or dismissal.
Even after successful completion, formal remediation may be recorded in future reference letters written on the trainee’s behalf. Designated Official notification should occur with formal remediation and should be considered in some cases of informal remediation.
Probation is the last step
Probation represents a last chance for a trainee to resolve unacceptable conduct or performance. Probation involves a review of institutional policies to make sure that the trainee is ensured due process.
The JGME review authors make an important point: “It is key to note that a program's responsibility to remediate a trainee's performance does not supersede its duty to protect patients from potential harm.” The note that a dismissal, nonrenewal of contract, and/or non-reappointment might be needed if probation “fails” or in the event of “egregious conduct.”
They also write that a resident or fellow’s probationary status will generally be disclosed in future reference letters to licensing boards and employers. As well, programs must withhold credentials in those individuals who can’t meet minimal acceptable criteria.
A note about unprofessionalism
Unprofessionalism exists in a sort of epistemological quagmire. The author of an article on the topic, also published by the JGME, describes the issues.
“There is a general lack of consensus regarding how to define, teach, assess, and remediate residents with behaviors demonstrating a lack of professionalism. Thus, it is not surprising that addressing unprofessionalism is among the most difficult challenges facing medical educators. While more literature exists on approaches to unprofessionalism among medical students than residents, the underlying issues are likely to be similar, and studies often address the 2 groups together.”
The author presents three prerequisites that qualify a resident as being professional—and as unprofessional when they are absent:
Insight into what professionalism means in any given context
Willingness to fulfill these expectations
Ability to adhere to these expectations
Extant models for remediation for unprofessionalism involve mounting levels of unprofessionalism matched with escalating corrective measures. These models do not target contributing or external factors. Addressing the prior three requisites can help faculty plan and minimize or remove ancillary barriers to the resident’s progress.
From the perspective of the program, it’s important to engage in due process to maintain solid legal ground.
The JGME review states that programs and their institutions are typically on solid ground when their actions reflect educational standards and concerns about patient safety.
The ACGME’s Common Program Requirements elaborates further, noting specific interventions should be documented in an individual remediation plan that is developed by both the program director (or a faculty mentor) and the resident. “However, the ACGME recognizes that there are situations which require more significant intervention that may alter the time course of resident progression. To ensure due process, it is essential that the program director follow institutional policies and procedures.”
When a system of due process and grievances is in place an in compliance with the sponsoring institution’s policies and procedures, action can be taken to suspend or dismiss, not to promote, or not to renew the appointment of a resident.
According to the JGME review, unsuccessful remediation leading to dismissal could result in litigation, although institutions are usually not liable. Instead, courts have deemed no difference between postgraduate continuing education programs and degree-granting institutions with regard to the successful achievement of program goals before bestowing a certificate of completion.
“A sponsoring institution, therefore, is not in breach of contract if it withholds a certificate from a trainee who does not complete work satisfactorily,” the authors write. “Courts have also recognized educators' ability to determine eligibility of trainees for credentials, as well as their prerogative to withhold certificates when performance criteria are not met. When dismissal decisions are made with just cause, and in accordance with institutional policy, programs and institutions may reasonably expect them to be upheld.”
What this means for you
Dismissal is typically the result of a negative progression from informal remediation, to formal remediation, to probation. Residents are entitled to due process and the airing of grievances, in line with the standards of the sponsoring institution. Programs that comply with due process are typically not held liable in the case of litigation. In other words, there is little legal recourse for a resident who has been fired after failing to meet minimal standards and receiving due process.