Legal Considerations in the Remediation and Dismissal of Graduate Medical Trainees

• DOI: 10.4300/jgme-d-17-00813.1
• Publication Date: 2018-06-19T16:08:55Z
• Authors: Cedric Lefebvre; Kelly Williamson; Peter Moffett; Angela Cummings; Beth Gianopulos; Elizabeth Winters; Mitchell Sokolosky
• Keywords: Specialty; Promotion (chess)

Some percentage of residents and fellows across all specialties require remediation during training. Graduate medical education leaders must navigate steps to optimize resident learning acquisition skills, preserve patient safety, maintain the standards specialty.1–3 Standardized approaches performance management are available for program achieve favorable results.4–9 In 2015–2016, 1110 129 720 (0.86%) left or did not successfully complete their training program, including 843 who withdrew, 249 were dismissed, 18 training.10 The potential legal implications successful unsuccessful often overlooked. An understanding landscape surrounding process is important protecting stakeholders, trainees.A systematic approach with use consistent language important, as agreement on terminology by parties. Remediation any additional training, supervision, assistance above what typical in specialty.6 Two levels widely accepted: informal formal.7 Informal directed at improving part clinical a subset learners. It generally managed typically reported future reports trainee. Formal based decision that conduct learner falls short requirements. This may include efforts remediation. Unsuccessful formal has long-standing consequences further remediation, non-promotion, probation, even dismissal. be reference letters trainee, when completed successfully. Designated Institutional Official notification should occur cases advisable some cases.Probation constitutes kind last chance trainee correct unacceptable performance. When making place review institutional policies confirm due trainees. key note program's responsibility remediate trainee's does supersede its duty protect patients from harm.11 Therefore, dismissal, nonrenewal contract, and/or non-reappointment necessary if probation fails, egregious occurs. Probation status licensing boards employers.To specialty, programs prepared withhold credentials those unable meet minimum acceptable criteria.11,12 Annually, small number trainees but deemed have met criteria entry into unsupervised practice recommendation eligibility board certification examination specialty subspecialty.Residents unique position they hospital employees learners simultaneously. They expected perform day-to-day care tasks required them, and, concurrently, demonstrate progression educational curriculum. Training prepare after graduation. Human resources do adequately address complexities this employee/learner situation.When identifies deficiencies knowledge, professionalism, another competency, it intervene remediate. If unsuccessful, removal indicated. Disciplinary interventions negative assessments affect attainment professional goals employment. Legal questions can arise both remediation.A resident's claim residency legally viewed “property interest deserving appropriate before removed.”13 To capricious arbitrary removal, Accreditation Council Medical Education (ACGME) requirements specify sponsoring institutions policy provides upon suspension, nonrenewal, institution provide fellow written notice intent contract renewal promotion withheld.14 ACGME Common Program Requirements charge director ensuring compliance mandates raise grievance benefit process.15Remediation disciplinary action follow process, course documented detail.12,16 Trainees given deficiencies, an opportunity evidence, advocate themselves.13,17 avail themselves appeals processes. However, afforded considerable discretion regarding intervention, hearing law.17 Courts long recognized qualification universities settle academic issues.18 Collaboration among resident, director, Clinical Competency Committee, Official, human resources, counsel latter stages (remediation, dismissal).If evaluative comments made without malice restricted objective appraisals performance, will likely unsuccessful. Case law supports educators' critical evaluation abilities. Such protected libel because component evaluation, gives implied consent evaluated enrolling program. Furthermore, Kraft v William upholds dissemination information within institution. faculty share such intraschool publication defamation claims common privilege learner.19 was later qualified only communications malice.20It unlikely recover damages record containing shared outside parties good faith. Unprofessional other problematic behaviors school associated subsequent state boards.21–23 State credentialing departments issue increasingly detailed inquiries about graduates' histories.24 Educators bound ethical obligation truthfully report (when solicited) reference, forms, documents. reporting career employment eligibility. could potentially sought he she believes unwarranted inaccurate, disclosure his her improper. defend clear management. Written acknowledgment occur, well contemporaneous documentation such, also crucial.24 There no precedent date restricts faith inquiry. disclosing events inquiring parties, prudent seek scope phrasing disclosures. adverse actions result changes physician's staff privileges. consult ensure mandatory reporting. Unsolicited history legitimate avoided.12 issued statements student Association American Colleges, US Court Appeals considered them stigmatizing restricting student's freedom pursue opportunities.17While resulting dismissal poses possible liability, solid ground. determined distinction exists between postgraduate continuing degree-granting requiring achievement granting certificate.19 A institution, therefore, breach withholds certificate work satisfactorily. ability determine credentials, prerogative certificates met.16,19 decisions just cause, accordance policy, reasonably expect upheld.11,12,16A capitulation resignation. tempted resign effort avoid action. While option attractive expedites closure matter, wary allowing resignations unethical occurred. purpose providing truthful employers' patients. Allowing resignation established impedes purpose. instances personal hardship interest, most action.Faculty supervise held liable negligent injury caused training.11,12,25 prevent harm necessitate poorly performing delivery substandard wait until occurs terminating privileges trainee.26Successful completion implies graduate competent field medicine, our knowledge there published case suggest injuries ultimately upheld institutions' authority determining eligibility, been reluctant recognize complaint malpractice litigation claims.27,28Courts refused tort malpractice, current sufficient grounds against malpractice.12,25,29–44If exhibits concerning behavior stemming matter condition, deliberate taken individual Generally, directors limit evaluations attempt diagnose condition. direct threat perceived, relieved responsibilities. administrative leave absence helpful collect strategize next steps.According Equal Employment Opportunity Commission, employer reasonable belief employee's essential job-related duties impaired, employee make disability-related submit examination.45 cannot forced treatment, securing treatment fitness individual's responsibility.24 fit returning duty.When disability discovered collaborating officials familiar Americans Disabilities Act. (employee) usually initiates request accommodation; however, obvious apparent, explore accommodations. discloses requests accommodation, initiate interactive identify accommodation.Job restructuring, modified scheduling, reassignment accommodations many environments.45 these alterations present challenges settings. need accommodation causes undue hardship. Factors cost nature type, structure, function employer's operation.45 leadership requested compatible which reflect demands specialty. consulted circumstances consideration Act.Standardized, effective success maximize safety. Familiarity adherence enable programs, trainees, (see summary box).