A notice of deficiency should define the expected acceptable behavior, timeline for improvement and consequences for noncompliance, according to a governance and empowerment strategy developed for surgical residents. Also, the authors recommended that the faculty should note and address systems problems that unintentionally reinforce and thus enable unprofessional behavior.

“Complaints, particularly by new residents, should be investigated and addressed promptly through a process that is transparent, fair, and reasonable,” wrote the authors, who empahsized the importance of early intervention.

With this paper, published in the July issue of the Archives of Surgery, Hilary Sanfey, MB, BCh, from the departments of surgery at Southern Illinois University School of Medicine in Springfield, Ill., and colleagues sought to develop an evidence-based approach to identify, prevent and manage surgical residents with behavioral problems.

The American College of Surgeons and Southern Illinois University’s department of surgery hosted a one-day think tank to develop strategies for early identification of problem residents and appropriate interventions. Participants read a selection of relevant literature before the meeting and reviewed case reports.

During the meeting, participants took part in short didactics on institutional and legal approaches to problem residents, followed by a brainstorming session using the nominal group technique to identify potential strategies for remediating problem residents. The nominal group technique is a structured process for generating numerous ideas.  

Meeting organizers also prepared two cases of problem residents based on structured interviews conducted with surgery program directors during their research. Both cases had characteristics found in many problem residents and were discussed in detail to elucidate common themes as a platform to making recommendations for remediation.

Early identification and prevention of behavioral problems is integral. “Because behavioral problems are frequently identified early in training, the first six-month review is a time for critical evaluation of new residents,” wrote Sanfey and colleagues. But that period is not the only opportunity for remediation. "Any problem arising at any time should be brought to the attention of the program director for full investigation and a documented action plan with an end point for further evaluation.”

In an internal medicine study that the authors referenced, 60 percent of program directors identified problem residents through critical incident reports (JAMA 2000;284[9]:1099-1104). In 75 percent of those cases, program directors first became aware of problem residents through verbal complaints from faculty, and only 31 percent identified a problem resident from a written evaluation.

Once a problem is suspected, the resident should be provided with a notice of deficiency that defines the expected acceptable behavior, the timeline for improvement and the consequences for noncompliance. Also, he or she needs to understand through self-reflection that such behavior is unacceptable and detrimental to the resident, the program and patients.

“The responsibility for behavioral change rests with the resident, but the program has an obligation to set clear expectations and supply appropriate surveillance, mentorship, and timely feedback,” the authors wrote.

If self-reflection or remediation fails to achieve the desired result, Sanfey et al said that program directors must follow through on the previously discussed consequences of probation, failure to promote, or dismissal. Failure to enforce consequences has a negative effect on the behavior and morale of all residents and the care delivery system.

“The best way to ensure that decisions are not arbitrary or capricious is to use a clinical competency committee,” they wrote.

The authors concluded that the next step will be to conduct a series of workshops with program directors to promote a uniform evidence-based approach at a national level to the problem residents.