joint conference of ipac cpe 4th 6 september 2014 th...

Joint Conference of

IPAC

&

CPE

4th – 6th September 2014

Druids Glen Resort, Co. Wicklow,

Ireland

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Remediation of practicing physicians

Why?

When?

How?

For whom?

What are the success factors?

What are the impacts of remediation activities?

François Goulet, M.D. Assistant Director Practice Enhancement Division

Disclosure

I am an employee of the Collège des médecins du Québec, the medical regulatory authority in Québec. I do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to the content of my presentation.

François Goulet, M.D.

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Objectives

At the end of the presentation, participants will be able to: • Understand why it is important to prescribe education

interventions (remediation) for practicing physicians

• Prescribe the best educational remediation tool for different types of competence/performance problems and for different physicians

• Analyse the success factors in the remediation process of practicing physicians

• Acknowledge the impact of the remediation process for the medical community

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1. Health is an essential value in our modern societies o Canada Health Act: "To protect, promote and restore the

physical and mental well-being of Canada and to facilitate reasonable access to health services"

2. Society expects to receive quality medical services

3. Countries and provinces invest a lot in physicians’ initial training

4. Some countries or regions have a shortage of physicians, particularly in primary care

Why not remediate physicians who have competence/performance shortcomings?



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All practicing physicians are different from one another in terms of: • Specialty • Scope of practice • Practice setting – hospital, home care • Clinical environment

Solo vs group practice Low vs high socioeconomic areas

Age Sex


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Practicing physicians have different competence/performance problems

Wide-ranging vs specific areas of shortcomings • Knowledge:

o Data collection o History taking o Physical exams

• Clinical reasoning o Diagnostic approaches o Treatment plans

• Surgical skills • Communication skills • Professionalism • Record keeping


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Practicing physicians have

different performance problems.

This is why, in the remediation process of practicing physicians,

a one-size-fits-all approach DOESN'T WORK

In your context:

What educational tools

are you using?


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The various educational tools

used by the

Collège des médecins du Québec

Workshops, conferences, meetings

and CPD courses

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• Description The physician participates in one or more suggested CPD courses, conferences,

meetings or workshops Examples: record-keeping workshops, pharmacotherapy conferences, periodic

health examination workshops, doctor-patient relationship courses, radiology "bootcamps" , ATLS, ACLS, APLS, etc.

• Indications Problems in specific areas of clinical practice

• Duration 90 minutes to 3 days

• Advantages Time-limited educational tool

• Generally Focus on a specific topic Up-to-date knowledge

• Limits No guarantee that the knowledge acquired will be translated into clinical

application

Focused reading

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• Description The physician reads articles (scientific papers or

clinical practice guidelines) chosen by an instructor based on the physician's specific needs

The instructor validates the knowledge acquired and provides practical tips and clinical examples adapted to the local or regional clinical context

• Examples Review of CPG for diabetes, STD, HBP, COPD

• Indication Specific or broad gaps in knowledge, especially in the

diagnostic and investigation process or in treatment planning

Focused reading

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• Frequency and duration Meetings every 2-4 weeks

Duration from one month to one year

• Advantages Personal reading to be done

Reading guided by an instructor

Monitoring and individual feedback with the instructor on the reading (reinforced learning)

• Limits No guarantee that the reading will be translated

into clinical application

Mentorship

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• Indication Problems related to professional isolation or organizational problems

(workload, office management, appointments, follow-up of laboratory results)

• Frequency and duration Meetings every 1-4 weeks (1-2 hours) Duration from one month to 2 years

• Advantages Coaching and guidance to help physician Possibility of asking questions and having clinical discussions Monitoring and individual feedback with a "mentor" Targets the physician's practice

• Limits No direct observation of the clinical process No discussion about knowledge

Chart-stimulated recall tutorial

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• Description The physician reviews some of his/her actual patient

charts with a physician tutor

The tutor discusses the charts with the physician and makes recommendations on chart keeping and quality of practice, based on the physician’s actual cases

The tutor may suggest and provide scientific papers and clinical practice guidelines to support learning

At the end of the tutorship, the tutor may assess the physician’s level of learning by asking him/her to bring charts previously discussed

Chart-stimulated recall tutorial (cont.)

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• Indications For physicians with adequate history taking and physical examination skills,

but who require considerable updating on topics such as record keeping, investigation or treatment plans

• Examples Meeting 1: HBP with 3 patient charts Meeting 2: Diabetes and lipids with 4 patient charts

• Advantages Can target the candidate’s specific needs Enhances the candidate's diagnostic skills, clinical reasoning, investigation

and treatment planning Enhances chart keeping skills

• Limits No clinical work with a patient No possibility of direct observation of the clinical process Charts usually selected by the candidates

Clinical training (mini-residency training)

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•Description Physicians perform clinical tasks in specific problem

areas under the supervision of a clinician instructor

The training usually takes place in a university teaching setting

The clinician instructor can be assisted by peer colleagues in training the physician

The instructor may also recommend scientific papers, workshops, conferences, meetings or other academic activities to complement the training

Clinical training (cont.)

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• Indications Lack of knowledge, skills, clinical reasoning or

communication skills

• Frequency and duration

Part- or full-time (2-5 days/week)

Duration from one week to one year


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•Advantages Enhances the candidate’s clinical reasoning

Enhances communication skills and patient-centered approach

Enhances history taking and physical examination skills

Enhances clinical knowledge and record keeping skills

Focuses on the physician's needs

Allows for acquisition of knowledge, skills and attitudes

Allows for direct observation of performance

Allows for identification of problems and corrective measures throughout the process


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• Limits Difficult to find a teaching setting equivalent to the

candidate’s practice setting

Difficult to teach clinical follow-up skills for chronic problems if the training period is short

Very costly

Problems identifying clinician instructors

Success somewhat dependent on the expertise of the clinician instructor

Motivation of the candidate is essential

Requires a potential for rehabilitation

Practical tips for clinical training

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• Physician candidate must have full licence

• Temporary hospital privileges for the trainee if required

• Adequate malpractice insurance

• Pre-training meeting with the candidate and the instructor to:

1. Review the objectives

2. Review the educational process

• Schedule

• Number of patients

• Different clinical settings (in-patient ward, emergency room, surgical ward, out-patient ward, etc.)

• Direct or AV observation/case discussion

• Academic sessions : journal club, lectures, etc.

Practical tips for clinical training

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3. Review the evaluation process and daily feedback

4. Discuss legal obligations of the candidate and of the instructor

• Trainer is the treating physician (responsable for the patient)

• Trainer must write an evaluation report but the final decision is made by the CMQ

5. Training period may be shortened if:

• Objectives have been achieved before the end of training

• Objectives are not achievable within the allotted training period

6. Process can be humiliating for the candidate

7. Instructor/trainer can be helped by colleagues

8. A financial agreement is signed by three parties

In your context:

Who refers practicing

physicians for remediation?

Who are they?

• Male or female

• General practitioners or specialists

For what kinds of problems are they

referred?

At the CMQ:

Who are the candidates?


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1. Reentry Return to practice

Change of scope of practice

2. Performance problems Behaviour or professionalism

Clinical problems acquired secondary to: physical health, cognitive impairment, substance abuse, mental health

Performance problems for no specific reason except:

Age

Lack of CPD

Money-driven practice


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3. Assessment process

Physical exam

Neurocognitive testing

Entry questionnaire (demographics, practice profile)

Knowledge test

Clinical assessment: Mini-CEX or direct observation, OSCE, SOI

13%

87%

Candidates 2003-2013 N=408 physicians

SEX Active physicians 2008-2009*

N=17574 physicians

41% 59%

p < 0.0001

Who are the candidates with clinical performance

problems?

* Midpoint of the analysis period

Between 2003 and 2013, 408 physicians undertook a total of 465 remedial activities due to performance problems


problems?


AGE

< 50 50-69 ≥ 70

49% 46%

6%

Active physicians 2008-2009* N=17574 physicians

< 50 50-69 ≥ 70

23%

53%

25%

p < 0.0001 * Midpoint of the analysis period


SPECIALTY Active physicians 2008-2009*

N=17574 physicians

p < 0.0001

* Midpoint of the analysis period


problems?

SPECIALTIES

Candidates 2003-2013 N=144 specialists


problems?

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• ♂ 46 years old, emergency physician

Problems with MSK clinical evaluation and diagnosis

5 days training in MSK in a physical setting

• ♂ 60 years old, general practitioner

Problems with follow-up of chronic health problems and laboratory results

Chart-stimulated recall tutorial for general practitioners

• ♂ 75 years old, anesthesiologist in university teaching hospital

Problems with emergency situations

2 days training in emergency anesthesiology in a high fidelity simulation center


problems?

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♀ 48 years old, general practitioner, hospitalist

Problems with the clinical assessment and treatment of acute

care inpatients

40 days clinical training on a hospital in-patient ward

♂ 60 years old, radiologist in community hospital

Problems with interpretation of mammograms

5-day "bootcamp" in mammography


problems?

In your context:

Do you collect data on your

success rate?

At the CMQ:

What is our success rate?

Tutorial and clinical training programs 2003-2013 N=465 activities

What did they do?

What did they do?

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Clinical training programs: 280

Tutorial programs: 185

Part time: 165 (59%)

Full time: 115 (41%)

No limitation: 202 (72 %)

Limitation: 78 (28 %)

Fields of remedial activities Family doctors - 2003-2013

TOTAL: 306 activities

Family medicine including hospitalization

248 Gynecology, women health and VPT 3

Geriatrics and long-term care 21 Anesthesiology 2

Emergency medicine and intensive care

15 Pediatrics 1

Obstetrics including ultrasound 6 Radiology 1

Doctor-patient relationship 4 Palliative care 1

Surgical specialties 3

TOTAL 306

What did they do?

TOTAL: 159 activities

Family medicine incl. hospitalization

33 Surgical emerg. in gynecology + C-section 7

Medical specialties incl. endoscopy

29 Gynecology and women health incl. VPT 7

Mental health and psychiatry 22 Obstetrics including ultrasound 6

Pediatrics 13 Emergency medicine and intensive care 5

Radiology 12 Anesthesiology 3

General surgery 10 Doctor-patient relationship 2

Surgical specialties 9 Geriatrics and long-term care 1

TOTAL 159

Fields of remedial activities Specialists - 2003-2013

What did they do?

RESULT OF ACTIVITY

*Other: interrupted activities (sickness, death) and ongoing activities

2003-2013 : 465 activities

Who passed? Who failed?

% SUCCESS* ACCORDING TO AGE

< 50 50-69 ≥ 70

*Excluding “partial success” and “other” categories

N=432 p < 0.0001

90/93

194/231

66/108


% SUCCESS* ACCORDING TO SPECIALTY

226/281 124/151



N=432 p = 0.764

% SUCCESS* ACCORDING TO REASON FOR REMEDIATION



N=738 p = 0.0002

Questions/avenues of reflection

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• How can we explain the lower success rate

• … of physicians ≥ 70 years of age?

• … of physicians who are referred for remediation due to performance problems?

• How can we improve our educational interventions to help these physicians succeed in their remediation activities?

What are the key factors

for successful remediation?

Factors for successful remediation

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A. Candidate's factors

• Health

• No substance abuse

• Good physical health

• No mental health problem

• No cognitive impairment


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A. Candidate's factors

• Behaviour

• Professionalism

• Leadership, team work

• Motivation to change, receptivity

• Time management

• Communication skills


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A. Candidate's factors • Social/demographic

• Age

• Financial situation

• Language

• Working environment

• Job satisfaction

• Learning capacity • Ability to develop strategies for learning

• Problem-solving capacity


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B. Educational factors

• Supervision/teacher

• Clinical expertise

• Excellent teaching skills

• Good understanding of the candidate's needs

• Leadership

• Good communication skills

• No judgement/acceptance of the candidate's condition

• Ability to listen

• Expertise in evaluation/assessment


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• Educational environment

• No burden or pressure (educational climate)

• Meaningful context adapted to candidate's practice

• Sufficient clinical exposure


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• Process

• Individualized remediation plan

• Learning objectives • Specific

• Measurable

• Achievable

• Results-oriented

• Realistic time frame


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B. Educational factors • Process

• Holistic approach • Knowledge

• Clinical skills

• Communication skills

• Professionalism

• Educational tool • Adapted to the candidate's needs

• Well structured

• Adequate length

• Clinical exposure


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C. Administrative factors • Recognized and validated process

• Regulatory leverage

• Accreditation system

• Pre, per and post meetings between candidate and supervisor

• Availability of the CMQ personnel responsible for supporting the supervisor • Good explanations of objectives, obligations and

mandate of the educational activity

• Financial guidance or framework

Factors for successful remediation of aging physicians

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• Older physicians need more time to learn

• No multitasking during educational activity

• Teach/learn: the essentials

• Repeat new knowledge more than once

• Develop learning strategies that are not based only on memory skills

• Provide relevant clinical context

• More written documents than verbal instruction

• Shorter learning periods (half-day or shorter day)

Why use medical school teaching sites

and medical school professors?

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Advantages • Experienced and skilled clinicians

• Experienced and skilled professors/teachers

• Experienced and skilled evaluators/assessors

• Teaching sites are used to having students, clerks, residents and fellows around

• Well-structured academic settings

• Good clinical and educational resources

• Exposure to a large variety of clinical problems

• Contact with young residents and fellows

Why use medical school teaching sites

and medical school professors?

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Limits

• Professors/teachers not used to teaching elderly students/residents

• Clinical setting may have more extensive resources than the candidate’s clinical setting

• Candidates are usually slow learners

At the CMQ:

What are the impacts of

our remediation process?

Does remediation improve performance?

% satisfactory scores at peer review before and after remediation

* Only remediation activities with a peer review before AND after are included in this analysis.

N=136 activities*

All differences are significant

(p<0.05)

Prescription by the Professional Inspection Committee after a peer

review

Satisfactory quality of practice

Non satisfactory quality of practice

Level 3

Remediation, limitation, retirement

Level 2

Recommendations +

Control visit

Level 1

Recommendations

Level 0

No action, satisfaction letter

Follow-up after remediation

408 physicians with clinical performance problems

No planned control visit 134 (40%)

* For physicians who undertook more than one remedial activity, only the last one is considered.

Planned control visit 200 (60%)

Failure 52 (13%)

Partial success

11 (3%) Other

11 (3%)

Result of remedial activity*

Success 334 (82%)

Successful activities 334



Control visit not done 57 (28%)

Control visit done 143 (72%)

Control visit to come 41 (72%)

Retirement, resignation, radiation, limitation, death

13 (23%)

Control visit cancelled 3 (5%)

4 (3%)

63 (44%)

24 (17%)

52 (36%)

36% of physicians (52 out of 143) had a

non satisfactory control visit

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Successful activities 334


Control visit done 143 (72%)

22 clinical training activities

30 tutorial activities


4 (3%)

63 (44%)

Result of control visit

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2

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24 (17%)

52 (36%)

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36% of physicians (52 out of 143) who had a control visit after a

SUCCESSFUL remediation ended up with a

NON SATISFACTORY control visit and a prescription for

ADDITIONAL REMEDIATION

Why

Reasons for unsatisfactory evaluations in practice six months

to one year later

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• Old habits come back faster than new knowledge/skills

• Evaluation tool in clinical context different from educational tool in educational setting

• Training program affected by Lima syndrome

• Poorly done needs assessment

• Clinical context with more pressure and burden than during the remedial educational activity

• Isolated practice with lack of CPD


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Interviews with physicians

Challenges: "It's more difficult to learn when you are

60 years old than when you are 25 years old"

"Old habits come back faster than new notions"

"The cost of refresher training is a barrier, since it is usually assumed by the physician"

Key message

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Remedial interventions can and should be tailored to address specific physicians'

problems and needs

joint conference of ipac cpe 4th 6 september 2014 th...

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