By: Judith Godschalx (@JAGodschalxDekk) and Walther van Mook (https://www.linkedin.com/in/walthervanmook/?originalSubdomain=nl)
Coming from the same common trunk, all medical graduates acquire many skills, experiences, and cognizance. Taught by teachers of diverse backgrounds and different specialties, they will eventually integrate what they have learned into practice. Unfortunately, not all of them will develop into the specialist of their primary preference. Seldomly do program directors decide to dismiss a resident from a postgraduate medical training program prematurely. Why does a program director make such a decision? Honestly, most of the time, we simply don’t know, as program directors’ decisions remain confidential due to residents’ privacy protection unless the resident disputes the decision. Since 2005, the Dutch national conciliation board has been preserving the judicial cases related to these disputed decisions. In the same year, the CanMEDS competency framework1 was introduced to scaffold assessment in postgraduate medical education in the Netherlands. The law cases were anonymously published online from 2011 to 2021. These cases form a collection of extensive and detailed descriptions of arguments used by residents and program directors about whether or not to continue training. Such a law case collection thus is an extraordinarily rich research resource because these law case descriptions explicitly name and explain the residents’ CanMEDs competency deficiencies according to their program directors.
Specifics to specialties
We wondered how program directors of various specialties considered residents’ deficiencies in CanMEDs competencies. Which competencies of the CanMEDs’ flower, illustrated with petals, could not be mastered, could not be remediated, and remained rudimentary, yet are of utmost importance for the specialty? Across medical specialties, ³ 70% of 116 dismissed residents could not master at least one CanMEDS competency. Overall, the most common deficient domains were medical expert, communicator, and professional, but deficiencies differ between specialties.2 All dismissed surgery residents were considered deficient in medical expertise: insufficiencies of operative skills. Of course, one would expect a surgeon in the making to manage how to cut and stitch. Medical expertise, on the contrary, was fine for most dismissed psychiatry residents. Their program directors complained about incompetence in communication, expecting them to know how to talk and listen on a multitude of levels.3 Communication in psychiatry might be a specific form of medical expertise required for diagnostics and psychotherapy, demanding inter-personal-connection, comfort, compassion and confrontation.4 In the supportive specialties, e.g. consulted by others for diagnostic purposes such as radiology and pathology, dismissed residents were more commonly deficient in scholarship, which is a reproach particularly not raised to residents in family medicine and nursing home care. Instead, these latter groups of residents were more frequently deemed unprofessional.5 The differences in deficiencies by specialty may require root-cause-analysis, targeted remediation, or future selection of residents better matching the specialty.
So far, the research results based on case law meet our profound preconceptions about colleagues of different specialties. Nevertheless, the case law displays program directors’ emphasis on assessing specific competencies, and possibly reveals factors inherent to specialty. For example, in surgery, dismissal occurs later in residency compared to other specialties.6 This may allow late bloomers to come up roses. Or documentation of feedback from supervisors and resident progress meetings might be less frequent, comprehensive, or accurate. On the other hand, the supervising surgeons provide feedback immediately in the operating theatres during surgery.7 In the later years of training, with the residents’ increased independence, the consequences of deficiencies in surgical skills become more readily apparent for patient care, requiring intervention by the program director. Family medicine historically attributes a significant level of institutional attention to assessing professionalism.8 This sows the seeds for explicitly distinguishing deficiencies in aspects of professionalism from aspects of communication and recognizing and remediating flaws in professionalism early,9 and thus to nip incompetencies in the bud. However, clear and respectful communication is essential to professionalism in several specialties.10 Overlap of residents’ deficiencies (such as professionalism, communication, and medical expertise) may indicate that these residents generally perform poorly, while their program directors named only some of their most prominent deficiencies.
Harvest the fruits
What do the studies using case law add to the botany of the CanMEDS flower? Dismissed residents who disputed their dismissal decision were considered deficient in diverse, overlapping CanMEDS competency domains, differing according to specialty. Specific deficiencies, such as professionalism, might contribute to deficiencies in numerous CanMEDS competencies, which are intertwined. Perhaps we could trace numerous of these deficiencies back to professionalism acting as an overarching (meta)competency domain affecting deficiencies in several other CanMEDS competencies.11 So, however interesting the importance program directors place on specific resident competencies at crucial moments, such as: assessing aptitude and deciding on a dismissal; we should be wary of reductionism. Many petals constitute a beautiful flower, which we should worship, for flowers are the pledges of fruit. – So, don’t pluck the petals.
About the author:
Judith Godschalx, MD, LLM, LLB, BA IS A PSYCHIATRIST AT THE FLEVOHOSPITAL ALMERE FOR GGZ Central, THE NETHERLANDS. SHE TEACHES AND SUPERVISES RESIDENTS IN PSYCHOTHERAPY, HOSPITAL CONSULTATION and MANAGEMENT. SHE IS A MEMBER OF THE DUTCH CONCILIATION BOARD, WHICH DECIDES ON DISPUTES BETWEEN RESIDENTS and PROGRAM DIRECTORS. SHE is A FORMER PROGRAM DIRECTOR OF HOSPITAL PSYCHIATRy FOR RESIDENTS IN PSYCHIATRY AND FAMILY MEDICINE.
WALTHER van MOOK, MD, PHD IS AN INTERNIST-INTENSIVIST AND POSTGRADUATE DEAN AT THE Maastricht univerisity MEDICAL CENTER, THE NETHERLANDS. He is professor of PROFESsional development AT MAASTRICHT UNIVERSITY THE NETHERLANDS. HE IS DEPUTY PROGRAM DIRECTOR OF INTENSIVE CARE.
- Frank JR. 2005. The CanMEDS 2005 physician competency framework. Ottawa: the Royal College of Physicians and Surgeons of Canada.
- Godschalx-Dekker JA, Gerritse FL, Mook WNKA van, Luykx JJ. Do deficiencies in CanMEDS competencies of dismissed residents differ according to specialty?Med Teach. 2023;45(7):772-777, doi: 10.1080/0142159X.2023.2166477.
- Godschalx-Dekker JA, Mook WNKA van. Dismissed psychiatry residents who appeal: exploring unprofessional behavior.Acad Psychiatry.February 28th 2023, doi: 10.1007/s40596-023-01746-0.
- Godschalx JA. Voortijdige beëindiging van de opleiding tot psychiater in Nederland. [Premature dismissal of psychiatry residency training in the Netherlands] Tijdschr Psychiatr. 2021;63(11):789-795.
- Godschalx-Dekker JA. Uitval door ongeschiktheid voor ouderengeneeskunde.Tijdschrift voor Ouderengeneeskunde. 2021;46(2):2-9.
- Godschalx-Dekker JA. Abstract: Geschillen tussen AIOS en opleider over de beëindiging van de opleiding tot anesthesioloog.Nederlands Tijdschrift voor Anesthesiologie. 2021;34(4):5.
- Cantillon P, Grave W de, Dornan T. The social construction of teacher and learner identities in medicine and surgery.Med Educ. 2022;56(6):614-624, doi: 10.1111/medu.14727.
- Vermeulen MI, Kuyvenhoven MM, Groot E de, Zuithoff NP, Pieters HM, Graaf Y van der, et al. Poor performance among trainees in a Dutch postgraduate GP training program.Fam Med. 2016;48(6):430-8.
- Barnhoorn PC, Nierkens V, Mak-van der Vossen MC, Numans ME, Mook WNKA van, Kramer AWM. Unprofessional behaviour of GP residents and its remediation: a qualitative study among supervisors and faculty.BMC Fam Pract. 2021;22(1)249, doi: 10.1186/s12875-021-01609-3.
- Martinez W, Pichert JW, Hickson GB, Braddy CH, Brown AJ, Catron TF, et al. Qualitative content analysis of coworkers’ safety reports of unprofessional behavior by physicians and advanced practice professionals.J Patient Saf. 2021;17(8):e883–9, doi: 10.1097/PTS.0000000000000481.
- Luijk SJ van, Mook WNKA van, Oosterhout WPJ van. Het leren en toetsen van de professionele rol. [To learn and assess the professional role.]TMEO. 2009;28(3):107-118, doi: 10.1007/BF03081768.
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