Standardized Letters of Concern and Remediation Contracts: Templates for Program Directors

Abstract

Background

Remediation of the struggling resident is a universal phenomenon, and the majority of program directors will remediate at least 1 resident during their tenure.

Objective

The goal of this project was to create a standardized template for program directors to use at all stages of remediation.

Methods

Between 2017 and 2018, the Council of Residency Directors in Emergency Medicine (CORD-EM) Remediation Committee searched for best practices in the medical literature and compiled a survey that was e-mailed to the CORD-EM listserv. After reviewing all information, a standardized remediation contract was created, reviewed by legal counsel, and distributed to members.

Results

Forty-two percent (110 of 263) of program directors or assistant program directors on the CORD-EM listserv answered the initial survey and provided guidance on current remediation practices. The committee created formal and informal standard remediation contracts as both fillable templates and alterable documents. These were reviewed by CORD-EM general legal counsel and approved by the CORD-EM Board of Directors for distribution. The project took approximately 20 hours to complete over 8 months and involved a cost of $480 for legal fees.

Conclusions

With program director input and legal counsel review, the CORD-EM Remediation Committee produced standardized remediation contracts, which can be used by all emergency medicine programs after comparison to local institutional policy and local legal review. This process was feasible and can be replicated by other specialties.

Introduction

Resident remediation is a universal phenomenon, and program directors will likely remediate at least 1 resident during their tenure. One study estimated that 31% of general surgery residents will undergo remediation,¹ and a survey of emergency medicine program directors showed that in the last 3 years approximately 90% of programs had at least 1 resident on remediation.²

There are a variety of terms used for the spectrum of remediation, including less formal stages such as letters of concern or professional development plans, and the more formally recognized remediation and probation.³ A recent effort has been made to standardize the terminology of remediation with phases progressing from informal remediation (typical warning stage with only program-level involvement), formal remediation (involving the graduate medical education [GME] institutional level), probation, and termination.⁴ Regardless of the phase, documentation is important and demonstrates due process.^5–8 There are a variety of elements that have been suggested as best practice to include in the letters, such as a statement of the issue, direct observation, detailed plan for remedy, timeline for completion, measurable outcomes, and statement of consequences.^5,6,8 There are also elements that may have legal ramifications, including a statement indicating the possibility of reporting to medical boards as well as ensuring adherence to institutional due process.⁷ With more than 11 000 Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the 2018–2019 academic year, the creation of standardized templates may be useful to new program directors.⁹

The goal of this project was to create not only a standardized template for use at all stages of remediation available to emergency medicine program directors, but also one generalizable to program directors across specialties.

Methods

The CORD-EM Remediation Committee was directed to investigate current best practices in remediation contracts. Themes from a literature search were compiled and a survey was created to examine which themes were expressed in practice by the respondents (provided as online supplemental material). The survey asked for terminology used during informal stages of remediation and disposition of these documents once that phase of remediation was complete. Respondents also selected which elements should be incorporated into all letters (choices included a statement of the issue, observations supporting the issue, detailed plan for remediation, timeline for completion, measurable outcomes, and statement of consequences). Besides free text comment boxes for all questions, there was an option for respondents to upload sample remediation contracts that were analyzed similarly to the free text comments. The inclusion plan for the responses was as follows: the top 2 responses (absolute count) for multiple-choice questions, any answer choice selected > 75% of the time for multiple selection questions, and any free text comments that all survey authors agreed warranted inclusion in the final template. The survey was created by the authors, tested for clarity among the committee members, and modified. The survey included 5 multiple-choice questions, 1 multiple selection question, and 1 free text question (provided as online supplemental material).

This project was considered exempt by the Virginia Commonwealth University Institutional Review Board.

Results

In the fall of 2017, this survey was sent to all members of the CORD-EM listserv via e-mail. The survey was completed by 110 program directors or assistant program directors in emergency medicine (42%, 110 of 263 listserv members) with most having been involved in informal improvement plans (94%, 103 of 110) and formal remediation experiences (80%, 88 of 110). Terminology varied for informal stages of remediation with the most common responses being letter of concern (31%, 34 of 110), corrective action plan (23%, 25 of 110), and professional development plan (20%, 22 of 110; Table). Sixty-three percent of respondents (69 of 110) kept informal contracts in files at the program level and forwarded to GME if the resident went on to formal remediation, while 25% (28 of 110) reportedly never sent them to GME. Using our previously defined inclusion plan, a list of required elements in all remediation contracts was identified (Table).

Table.

Survey Results Utilized in Template Creation

Survey Element	No. (%)	95% CI
Terminology used for informal remediation (N = 110)
Letter of concerna	34 (31)	23–40
Corrective action plana	25 (23)	16–32
Professional development plan	22 (20)	14–29
Pre-remediation plan	7 (6)	3–13
Other	22 (20)	14–29
Essential elements for remediation letters (N = 109)
Statement of the issueb	108 (99)	95–100
Observations/evaluations supporting the issueb	94 (86)	78–92
Detailed action plan to remedy the issueb	102 (94)	87–97
Timeline for completion of activitiesb	104 (95)	89–98
Measurable outcomesb	96 (88)	81–93
Statement of the consequences of not remediatingb	105 (96)	91–99
Reference to due process policy of institutionc	N/A	N/A
Acknowledgment that observations are expert opinions of educatorsc	N/A	N/A
Disposition of informal remediation letters (N = 110)
Remains in local file and progresses to GME if needed for formal remediationa	69 (63)	53–71
Remains in local file and then destroyed (never goes to GME)a	28 (26)	18–34
Immediately forwarded to GME	3 (3)	1–8
Other	10 (9)	5–16

Abbreviations: CI, confidence interval; N/A, not applicable; GME, graduate medical education.

^aIncluded in templates (top 2 answers).

^bIncluded in templates (> 75% selected).

^cIncluded in templates (free text entry that 100% of committee agreed was relevant).

A template was created that allows programs to customize aspects of the contract without altering the essential elements (Figure). Utilizing our previously described cutoffs, the template included the top 2 answers for preferred terminology of informal remediation (letter of concern and corrective action plan), and since the letter was designed for formal remediation or probation, these options were included in the template as well. Similarly, the disposition of the letter was built to allow selection between the top 2 choices (kept locally and destroyed if no further action or kept locally and sent to GME if remediation progressed). Free text entries were built into the letter for areas requiring resident-specific information (statements of issue, observations, and remediation activities). These contracts were reviewed by CORD-EM general counsel and edited. Current versions of these contracts in both template and freely alterable forms are available on the CORD-EM website (www.cordem.org). Ongoing assessment of the letters continues with a feedback section on the website.

Figure.

Letter Template

The overall process involved approximately 20 hours of time, including survey generation, results analysis, generation of the sample letters, and committee review. The cost of the project was $480 billed for general counsel document review and telephone conferencing. The CORD-EM website is supported by administrative staff who were able to load all of the letters onto a preformatted website. The project spanned 20 hours over 8 months.

Discussion

More than 90% of responding emergency medicine program directors have participated in informal or formal remediation activities. Using input from these program directors and a consensus approach by the committee, flexible online templates for informal and formal remediation, reviewed by CORD-EM legal counsel, were developed and disseminated over an 8-month period.

Program directors across specialties struggle with remediation. In 2008, Ratan and colleagues¹⁰ published an approach to remediation as well as a suggested remediation letter for use by obstetrics and gynecology programs. The approach includes elements of our current work such as inclusion of specific observations, measurable outcomes, and a statement of potential repercussions. Since remediation is a continuum from the informal stages all the way up through probation and termination, we included check box options for the consequences of failed progression at all stages. This allows the resident to look ahead and realize that while termination may not be selected as an outcome from the first informal remediation, it is a possibility for later stages and helps to ensure earlier stages of remediation are taken seriously while advertising repercussions residents may never anticipate (reporting to licensing authorities).

There are certain elements of remediation that have legal ramifications. A reference to the due process policy of the sponsoring institution helps to conform with the ACGME requirement to ensure due process.¹¹ Ratan and colleagues¹⁰ also included reference to due process and institutional polices and suggested involvement in legal counsel early in the process. A similar theme is noted in the radiology literature where Wu and colleagues¹² described a comprehensive remediation approach with institutional and legal involvement. Our letters mirror these suggestions with reference to the institutional due process policy and a statement (when the template is downloaded) that refers users to consult with their own legal counsel. A statement that the observations are the “expert opinion of educators” may be useful in legal disputes. Lefebvre and colleagues⁷ suggested this theme, and it was confirmed as a free text response in our survey where 1 respondent had successfully defended a libel suit brought by a resident.

A project of this scope would be feasible for other organizations to recreate. The only cost associated with the project was for legal review and this was paid by CORD-EM (a national organization with membership dues). Other specialty societies would likely have similar resources. For individual GME offices and program directors there may be a cost associated with local legal review unless in-house counsel is provided by the institution. By starting with the current work and editing only for conflicts with local policy or laws, it seems reasonable to believe the cost would be similar or less than our initial legal fees.

The work is limited in that it represents consensus opinion from a single specialty; however, with similar themes noted across specialties, it seems reasonable to believe this represents a starting point. Because the survey from which the final templates were derived had no evidence of validity, respondents may not have interpreted questions as intended, which could result in omission of key elements. Results of using the templates, including acceptability (to faculty and residents) and remediation success, are not yet clear.

Future efforts should evaluate utilization of templates and feedback from users to maximize the value of standardized letters of concern and remediation contracts to GME leaders.

Conclusions

The CORD-EM Remediation Committee has created standardized remediation contracts as an aid for program directors, based on background research, consensus practice, and legal review.