In this systematic review, the authors take an in depth look at remediation: how is supposed to work, who it is used for, as well as the various situations in which it is used and the diverse outcomes. They do their research using a methodology new to Linda – curious what it is? Listen in to find out!
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KEYLIME SESSION 319
Reference
Price T, G Wong, L Withers, et al. 2021. Optimising the delivery of remediation programmes for doctors: A realist review. Medical Education. 00:1–16.
Reviewer
Linda Snell (@LindaSMedEd)
Background
Theory-led research should deliver findings at a level of abstraction whereby they are transferable to a range of interventions, while being close enough to actual practice to be relevant to those who plan and deliver interventions.
One such intervention is remediation of physician performance: process that seeks to address underperforming docs to return to safe practice, is a crucially important area of medical education. However, there is limited evidence for the particular models or strategies employed: 1 thematic & 3 systematic reviews highlight a lack of research for a firm theoretical base to underpin remediation interventions.
What we know: researching remediation is challenging as it is contextual, based on attributes and skills of colleagues, resources, and organisational culture. Remediation covers a broad array of interventions, occurring across a range of settings and at different career stages of a doctor’s career and for practicing docs occurs outside formal educational settings. The issues being addressed are wide-ranging, e.g. professionalism, behaviour vs knowledge or skills. It has been reconceptualized as ‘remediation towards supporting practice change’
Purpose
“to address the complexity of remediation for practicing doctors by developing a theory of how remediation is supposed to work, for whom and the contexts that lead to different outcomes.”
Key Points on the Methods
A realist review is a theory-driven interpretive technique to make sense of heterogeneous (qual, quant, MM) evidence about complex interventions; it focuses on understanding mechanisms by which an intervention works (or fails), providing an explanation, as opposed to a judgment about how it works. Achieved by developing theories to explain how, why, in what contexts, for whom and to what extent interventions ‘work’. A relatively new knowledge synthesis method, however it does have standards (RAMESES). Uses frame of CMO- context – mechanism – outcome.
10 person research team, diverse expertise and perspectives. Also a 12-person stakeholder group consulted iteratively to provide subject knowledge for theory, for dissemination plans, and for generation of feasible recommendations.
Authors chose to look at practising doctors, as the stakes of failure are high and it is an under-researched area; they defined ‘practising doctor’ as any doctor practising medicine who has completed medical school and includes those in training and consultant or attending physicians.
Searched usual databases, grey lit, & did purposive supplementary searches. Included English language on the remediation of practising doctors, all study designs, all health care settings and all outcome measures. Coding looked at barriers and facilitators to remediation, strategies used by programmes and processes facilitating change.Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context–mechanism–outcomes (CMOs).
Key Outcomes
4500 papers screened – after exclusion/inclusion 141 records included.
64% North American, most in past 10 years
Variety of study designs, paper types, individuals studied, topic being remediated, programme type, outcome
29 CMOs identified and a theory developed.
Remediation programmes are effective when insight and motivation are developed and behaviour change reinforced.
-insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively.
-motivation can be enhanced by involving the doctor in remediation planning, correcting causal
attribution, goal setting and destigmatising remediation.
-sustained change can be achieved by practising new behaviours and skills, and through guided
reflection.
Key Conclusions
Multimodal assessment used to give useful feedback.
Identify the problem but also identify the cause of the problem.
Focus on the behavioural aspects of change that are required for learning to take place vs an educational model.
A lack of high-quality research on the subject, mainly from North America, which may limit its applicability.
Authors able to link practical suggestions to each CMO.
“Remediation can work when it creates environments that trigger behaviour change mechanisms.”
Spare Keys – other take home points for clinician educators
Remediation complex, no magic bullet!
A new methodology for me!
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