commentary: kubler-ross 5 stages in the recognition of poor surgical resident performance

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Commentary: Kubler-Ross 5 stages in the recognition of poor surgical resident performance Alden H. Harken, MD, Oakland, CA From the Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA THE AUTHORS are addressing a formidable problem that challenges every residency program director and all residency faculty nationally. The authors derive from an institution that has devoted formi- dable expertise to issues in surgical resident educa- tion and deserves recognition as a very real leader in this area. The authors appropriately note that resident performance ‘‘problems’’ (much like any other disease) obligate precise diagnosis and only then can ‘‘targeted remediation prove likely of suc- cess.’’ Again, however, if the initial diagnosis is im- precise or the remediation is inappropriate, the programmed therapy is likely to fail. Discriminat- ing these 2 alternatives may prove difficult. The purpose of the current study was to identify resi- dents with significant ‘‘recurring academic, clinical and/or professional behavior’’ problems and to describe and classify their nature. Thus, the focus of the current study was diagnostic and not therapeutic. ‘‘Raters’’ performed retrospective analyses of general surgical categorical residents in the single Southern Illinois University (SIU) School of Med- icine surgical program. Because the raters re- viewed the records of general surgical categorical residents over a 30-year period, it is likely that the authors did not personally ‘‘know’’ most of the residents who were evaluated. My bias is that the ‘‘raters’’ at SIU are more sophisticated and more focused on resident education than most programs. Thus, the observations developed in this study are ‘‘as good as it gets.’’ Conversely, I would bet that most surgical residency programs do a fair to poor job of documenting marginal resident behavior until it becomes a very real and unavoidable problem. If Elizabeth Kubler-Ross had been a Surgical Residency Program Director, she would have generated the 5 Stages in the Recog- nition of Poor Resident Performance: d Stage I, Denial: This resident really isn’t so bad. d Stage II, Anger: How did this uncivilized klutz ever get into our program? d Stage III, Bargaining: Although the remediation is not necessary, I am confident that it will work. d Stage IV, Depression: Oh my God, this resident is going to sow unconscionable mayhem upon the unsuspect- ing public and reflect poorly on our program. d Stage V, Acceptance: It’s too late to do anything about this now. I sure hope that the American Board of Sur- gery picks this guy up---I am certain that he’ll never pass his boards. Over a 30-year period, SIU suffered 17 residents with ‘‘significant performance problems.’’ The ‘‘problems’’ were divided into professional behavior and academic and clinical performance. The authors first tested the hypothesis that a single category of problems might provoke overlap into other problem areas. Interestingly, 4 of the 17 residents had only 1 class of problem and 3 of these 4 were purely professional behavior problems. Eight of the 17 residents had both ‘‘academic’’ and ‘‘clin- ical performance’’ problems, and these 2 areas intuitively overlap. Five unfortunate residents ex- hibited all 3 strikes. The conscientious efforts of the authors to examine what must be relatively ‘‘subjec- tive’’ categories must be applauded, and the authors attempted to identify ‘‘performance problem facets,’’ noting a relatively wide range of stumbles from 11 to 2 within the 17 resident suspects. Clearly, the resident with only 2 performance facet problems must have been able to blow these 2 issues into very Accepted for publication March 16, 2009. Reprint requests: Alden H. Harken, MD, Department of Surgery, University of California, San Francisco-East Bay, 1411 East 31st Street, Oakland, CA 64602. E-mail: Alden.harken@ ucsfmedctr.org. Surgery 2009;145:661-2. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2009.03.012 SURGERY 661

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Commentary: Kubler-Ross 5 stages inthe recognition of poor surgicalresident performanceAlden H. Harken, MD, Oakland, CA

From the Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA

THE AUTHORS are addressing a formidable problemthat challenges every residency program directorand all residency faculty nationally. The authorsderive from an institution that has devoted formi-dable expertise to issues in surgical resident educa-tion and deserves recognition as a very real leaderin this area. The authors appropriately note thatresident performance ‘‘problems’’ (much like anyother disease) obligate precise diagnosis and onlythen can ‘‘targeted remediation prove likely of suc-cess.’’ Again, however, if the initial diagnosis is im-precise or the remediation is inappropriate, theprogrammed therapy is likely to fail. Discriminat-ing these 2 alternatives may prove difficult. Thepurpose of the current study was to identify resi-dents with significant ‘‘recurring academic, clinicaland/or professional behavior’’ problems and todescribe and classify their nature. Thus, the focusof the current study was diagnostic and nottherapeutic.

‘‘Raters’’ performed retrospective analyses ofgeneral surgical categorical residents in the singleSouthern Illinois University (SIU) School of Med-icine surgical program. Because the raters re-viewed the records of general surgical categoricalresidents over a 30-year period, it is likely that theauthors did not personally ‘‘know’’ most of theresidents who were evaluated. My bias is that the‘‘raters’’ at SIU are more sophisticated and morefocused on resident education than most

Accepted for publication March 16, 2009.

Reprint requests: Alden H. Harken, MD, Department ofSurgery, University of California, San Francisco-East Bay, 1411East 31st Street, Oakland, CA 64602. E-mail: [email protected].

Surgery 2009;145:661-2.

0039-6060/$ - see front matter

� 2009 Mosby, Inc. All rights reserved.

doi:10.1016/j.surg.2009.03.012

programs. Thus, the observations developed inthis study are ‘‘as good as it gets.’’ Conversely, Iwould bet that most surgical residency programsdo a fair to poor job of documenting marginalresident behavior until it becomes a very real andunavoidable problem. If Elizabeth Kubler-Ross hadbeen a Surgical Residency Program Director, shewould have generated the 5 Stages in the Recog-nition of Poor Resident Performance:

d Stage I, Denial: This resident really isn’t so bad.

d Stage II, Anger: How did this uncivilized klutz ever get

into our program?d Stage III, Bargaining: Although the remediation is not

necessary, I am confident that it will work.d Stage IV, Depression: Oh my God, this resident is going

to sow unconscionable mayhem upon the unsuspect-

ing public and reflect poorly on our program.

d Stage V, Acceptance: It’s too late to do anything about

this now. I sure hope that the American Board of Sur-

gery picks this guy up---I am certain that he’ll never

pass his boards.

Over a 30-year period, SIU suffered 17 residentswith ‘‘significant performance problems.’’ The‘‘problems’’ were divided into professional behaviorand academic and clinical performance. Theauthors first tested the hypothesis that a singlecategory of problems might provoke overlap intoother problem areas. Interestingly, 4 of the 17residents had only 1 class of problem and 3 of these4 were purely professional behavior problems. Eightof the 17 residents had both ‘‘academic’’ and ‘‘clin-ical performance’’ problems, and these 2 areasintuitively overlap. Five unfortunate residents ex-hibited all 3 strikes. The conscientious efforts of theauthors to examine what must be relatively ‘‘subjec-tive’’ categories must be applauded, and the authorsattempted to identify ‘‘performance problemfacets,’’ noting a relatively wide range of stumblesfrom 11 to 2 within the 17 resident suspects. Clearly,the resident with only 2 performance facet problemsmust have been able to blow these 2 issues into very

SURGERY 661

real significance. Perhaps predictably, ‘‘relationswith health care workers’’ was identified most fre-quently, followed closely by insufficient knowledge.The insufficient knowledge category is perhaps theeasiest to quantify in that the ABSITE examinationprovided some measure. Perhaps surprisingly, the‘‘performance problems’’ of 14 residents (82%)were identified in the first year (Stage I, Denial;identified above by our virtual Dr Kubler-Ross). Thisobservation, perhaps, identifies the extraordinarysensitivity and commitment of the SIU residencyprogram in examining surgical residents. Mostprograms do not appreciate or certainly acknowl-edge performance problems until the resident iswell into the senior level resident experience (StageII, Anger). Interestingly and, I would again bet,consistent with most programs, 15 of the 17residents had ‘‘unresolved performance problems’’

662 Harken

at the end of the program (Stage V, Acceptance).This latter observation is consistent with the expe-rience in most residency systems. When we identify aproblem, we try to ignore it for a while. Then, whenit becomes unavoidably obvious, we try some usuallyineffective solutions and eventually the residentsimply ‘‘graduates’’ and the problem leaves theresidency ‘‘unresolved.’’

The group at SIU should be encouraged tocontinue these observations in that their commit-ment to surgical resident education is nationallyrecognized. It is valuable to know that early resi-dent problems ‘‘don’t get better on their own’’ andthe admonitions to ‘‘read more,’’ ‘‘communicatebetter,’’ and ‘‘do your charts’’ do not work. How-ever, the SIU authors need to help the rest of uswith some suggestions. We look forward to thenext article on how to fix these problems.

SurgeryJune 2009