The time occasionally comes for leaders in radiology to address residents who need remediation. Perhaps the resident is failing to hit certain milestones, acting unprofessional, or something else entirely.

Jiajing Liu, of Tufts University School of Medicine in Boston, and colleagues wrote about such situations for an article recently published in the American Journal of Roentgenology.

“Early identification of residents who need remediation is important because formal remediation is successful in 78–90 percent of cases,” the authors wrote. “Because residents who need remediation rarely identify themselves, program directors must use a variety of tools to identify them, including examinations, faculty evaluations, and feedback from colleagues and other staff. Residents are also understandably reluctant to speak unfavorably about their peers, and the American Board of Radiology core examination does not take place until the end of year 3. Therefore, most signs that a resident is struggling come from faculty evaluations and the program director's own interactions with the resident.”

This interaction between a resident and his or her program director is so important, Liu et al. developed a list of specific things directors should consider before speaking with the resident:

1. What, exactly, is the problem?

“Because vague problems beget vague solutions, it is critical to specify exactly what the problem is,” the authors wrote. “For example, instead of informing a resident that he or she is ‘under-performing,’ the more specific ‘you are reading an average of five CT scans a day while your peers are averaging 10 per day’ clearly conveys the issue.”

Liu et al. added that specificity is also crucial when discussing areas residents may need to spend a little more time studying. “Learn more,” for instance,  is not as helpful as, “study this specific thing.”

2. Does the resident understand? Does he or she know there is a problem at all?

Maybe the resident understands the situation, but doesn’t necessarily realize it is an issue. Or maybe they have excuses they think justify their performance.

Liu and colleagues explained that residents should be given an opportunity to describe the problem, because it can reveal a great deal about the resident’s mentality and how things can be corrected.

“Self-reflection is a large part of the remediation process, and this could be the first time during residency that the resident has done any self-reflection,” the authors wrote.

3. Do I know or does the resident know what is causing the problem?

This question is especially helpful when a resident is meeting expectations and then suddenly begins to struggle mightily. If the root of the issue can’t be determined, the authors recommended starting with the hospital’s physician wellness program.

4. Do I know or does the resident know how to fix this problem?

A plan of remediation should always be smart, but it should also be SMART (specific, measurable, achievable, realistic, and timed). These plans are often developed during one-on-one discussion between the director and the resident, the authors explained, and if a plan doesn’t come together, that’s when outside help is sometimes required.

5. Does this require additional help from other faculty members or a psychological/psychiatric evaluation?

Directors have people they can turn to when meeting with the resident doesn’t seem to do the trick. A familiarity with these different options can prove to be valuable.

“The office of graduate medical education may already have algorithms in place and have much more experience in dealing with troubled residents,” the authors wrote. “The employee health department may also offer counseling or provide residents with referrals.”