Remediation required substantial resources but was successful for 90% of learners. Future studies should compare remediation strategies and assess how to optimize faculty time.

Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors' three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

BACKGROUND:Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm.OBJECTIVE:To evaluate a Hospitalist‐run Acute Care for the Elderly (Hospitalist‐ACE) service.DESIGN:Quasi‐randomized, controlled trial.SETTING:Urban academic medical center.PATIENTS:Medical inpatients age ≥70 years.INTERVENTION:Hospitalist‐ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum.MEASURES:The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls.RESULTS:One hundred twenty‐two Hospitalist‐ACE patients were compared to 95 usual care patients. Hospitalist‐ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of “Do Not Attempt Resuscitation” orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist‐ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30‐day readmission rates (12% vs 10%, P = 0.50).CONCLUSIONS:A Hospitalist‐ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed. Journal of Hospital Medicine 2011;6:313–321. © 2011 Society of Hospital Medicine

INTRODUCTION:There is no widely accepted structured, evidence based strategy for the remediation of clinical reasoning skills. AIM: To assess the effectiveness of a standardized clinical reasoning remediation plan for medical learners at various stages of training. SETTING: Learners enrolled in the University of Colorado School of Medicine Remediation Program. PROGRAM DESCRIPTION: From 2006 to 2012, the learner remediation program received 151 referrals. Referrals were made by medical student clerkship directors, residency and fellowship program directors, and through self-referrals. Each learner's deficiencies were identified using a standardized assessment process; 53 were noted to have clinical reasoning deficits. The authors developed and implemented a ten-step clinical reasoning remediation plan for each of these individuals, whose subsequent performance was independently assessed by unbiased faculty and senior trainees. Participant demographics, faculty time invested, and learner outcomes were tracked. PROGRAM EVALUATION: Prevalence of clinical reasoning deficits did not differ by level of training of the remediating individual (p=0.49). Overall, the mean amount of faculty time required for remediation was 29.6 h (SD=29.3), with a median of 18 h (IQR 5-39) and a range of 2-100 h. Fiftyone of the 53 (96 %) passed the post remediation reassessment. Thirty-eight (72 %) learners either graduated from their original program or continue to practice in good standing. Four (8 %) additional residents who were placed on probation and five (9 %) who transferred to another program have since graduated. DISCUSSION: The ten-step remediation plan proved to be successful for the majority of learners struggling with clinical reasoning based on reassessment and limited subsequent educational outcomes. Next steps include implementing the program at other institutions to assess generalizability and tracking long-term outcomes on clinical care.