We have developed a programme theory of what is working in remediation to improve patient safety and reduce attrition of the medical workforce. As already noted, we did not seek to repeat what is already known about how doctors learn. Rather, we sought to understand what it is that makes remedial interventions unique, and to develop a model that helps us understand how improvements in performance or behaviour occur under these conditions. Indeed, the uniqueness of remediation has recently been characterised as a ‘wicked problem’, in the sense of the term used by design theorists Rittel and Weber.146 In this sense, wicked problems are described as such because they are difficult or impossible to solve because of the many environmental factors involved and the interconnectedness of the many smaller problems of which they are comprised.12 Others have described remediation as a ‘Gordian knot’ because of the difficulties associated with unravelling how it works.147 Remediation suits such a characterisation, and a further challenge for conducting an evidence review of remediation is that, in large part because of its ‘wickedness’, there is a paucity of information on what is working when it works.11,25
However, the realist review approach that we have employed has sought to tackle this issue head on. Rather than conduct a descriptive or narrative synthesis of existing evidence, which we know has thus far produced a limited understanding of remediation,25 the realist approach has allowed us to draw on a wider range of literature and the guidance of a stakeholder group. The process of building CMOcs is one of theory building, whereby causal explanations for what is working (or not working) are built, refined and tested. This has allowed us to go beyond a scant literature that is not theoretically rich to develop an explanation of what is happening in a remediation programme to produce its effects, for whom and in what contexts. The overall programme theory is presented in Figure 3.
Before providing a narrative explanation of our findings in relation to our programme theory, it is important to note what a programme theory is and what it is not. The word ‘theory’ can be used in different ways, and here we mean theory in the sense described by Klee:148
A theory is an attempt to organize the facts – some ‘proven’, some more conjectural – within a domain of inquiry into a structurally coherent system.
Our programme theory is a ‘theory’ in the sense described by Klee,148 because the processes it describes were inferred through our analysis of the existing literature, subsequent discussions with the stakeholder group and through drawing on substantive theories to provide an abstracted description of the processes that occur in a programme to produce its effects. We propose that this is the best fit theory, at this time, based on the data available. Programme theories are never completely finished products to the extent that any subsequent data from new research should always be viewed as an opportunity to modify, develop and refine the programme theory.
The programme theory for remediation is the sum of the CMOcs that have been described in Chapter 3. Each CMOc represents an explanation of what is happening in different parts of the programme to create particular outcomes. The outcomes are not always, or even usually, the outcomes that are described in a particular study. Often, the outcomes described in a study will relate to quantifiable measures, such as subsequent examination performance or attrition rates from the programme. These measures are important, but they do not tell us much about how the intervention is working and what processes are happening along the way to get there. Rather, as described in the Chapter 3, Results of the review, in a realist review these more intermediate outcomes are deduced from developing an understanding of what it is that needs to happen at different stages for an intervention to produce its effects.
Summary of main findings
Conceptualising remediation
Remediation is not a straightforward educational intervention, as the issues being addressed can be wide-ranging, often related to behaviour rather than knowledge and skills, and because of the negative connotations that surround it. Moreover, remediation for practising doctors, as opposed to medical students, often occurs outside formal educational settings. Therefore, in line with Bourgeois-Law et al.,12,13 we have conceptualised remediation for practising doctors as ‘supporting practice change’ as opposed to ‘redressing gaps in skills and knowledge’.12,13
Although educational processes are clearly central to what is going on in remediation, in developing a programme theory of what is working, in what contexts, for whom and to what extent, we have focused on what is happening to create the environments where those educational processes can function. Doctors are, generally, academically able (i.e. high academic achievement is a prerequisite to enter medical school in the first place, and medical school curricula are stringent and assessment processes usually very robust). However, remediation often does not work, because of a number of identifiable barriers (i.e. lack of insight and motivation, negative emotions towards the process, isolation and denial). These barriers are more behavioural than educational.7 In this sense, remediation works when the intervention is able to change the context to overcome these barriers and engage doctors in activities that facilitate a change in practice.
Therefore, this programme theory highlights the processes that occur to induce the behaviours that can create those learning opportunities. Theories of behaviour change, in particular the transtheoretical model, incorporate a temporal dimension that disaggregates the behaviour change process into contemplation, preparation and outcome phases.149 This temporal disaggregation was useful in mapping outcomes as, although remediation is by no means a linear process, there are some outcomes related to insight that logically precede other aspects of changes in practice. Moreover, the focus on attitudes, subjective norms and perceived behavioural control in the theory of planned behaviour helped us to understand and tease out the mechanisms that operate to induce insight and motivation, and facilitate practice change.150
How remediation programmes work to develop insight
As depicted in our programme theory, remediation works when it induces participants to develop insight. Insight here refers to those outcomes in which a doctor is ready to explore feedback on their performance and accept any highlighted divergence between their own perceptions of their performance and the feedback that is presented. The intervention strategies that help produce insight relate to the environment created and the framing of feedback. A supportive environment, with confidential discussions and someone who provides advocacy and emotional support, will help invoke psychological safety that may lead to trust and, subsequently, a readiness to explore feedback. If feedback is then framed in a supportive and effective way (i.e. juxtaposition, specific data from multiple sources, affirmation and relatable normative frameworks) then further mechanisms of affirmation, dissonance and normative enticement may be triggered, which may lead to the remediating doctor validating the feedback that is presented to them. This is because they feel safe enough to explore the feedback and because that feedback has been presented in a way that is not threatening, but in a way that highlights the problem effectively and shows the discrepancy between actual and perceived behaviours.
This process is not linear and may continue to operate throughout the remediation process, moving from intervention strategy, to mechanism, to intermediate outcome and back to intervention strategies. This is depicted in the programme theory by the spiral situated alongside the categories of outcomes (see Figure 3). At some point remediation may cease to work–perhaps if the doctor does not feel safe or if the remediation is not framed effectively. In such cases, the mechanisms of denial or rejecting the norms of the profession may lead to outcomes of distrust or isolation. In which case, if the remediation programme is to work again, more facilitative environments need to be created.
How remediation programmes work to motivate remediating doctors
In our programme theory, a remediating doctor must be motivated to engage with the process. Strategies aimed at developing intrinsic motivation include doctor involvement in remediation planning, correcting causal attribution, effective goal-setting and destigmatising remediation. When these strategies are employed, perceptions of control, self-efficacy and self-awareness may function as mechanisms to induce intrinsic motivation. Alongside this, clarity in terms of the potential outcomes of the process may trigger an evaluation of costs and benefits. Although insight logically precedes motivation, once some motivation has been induced, the processes may function alongside the insight mechanisms, with each process enforcing the other.
How remediation works to facilitate practice change
Remediating doctors need, at some point, to learn new skills and behaviours to effect behaviour or performance change. In many cases, this will relate to standard educational interventions and we have not sought to develop programme theories for such tried and tested educational models. However, the environment in which remediating doctors learn new behaviours and skills in a remediation programme may be much more restricted than general continuing medical education.
Practising new skills or behaviours in simulated environments may be an important aspect of a remediation programme. This applies to professionalism issues, such as boundary violations, as well as more straightforward educational processes. However, when simulated practice is not possible, then reflection on experiences in the workplace may serve the same purpose. A doctor may be tasked with specific behaviours to practise and, through a coaching process, can reflect on the success or otherwise of these processes when they meet with their coach.
Guided reflection is likely to be important at all stages of a remediation programme. Written reflections may be useful, but their value could be undermined if they are summatively assessed. Face-to-face meetings with a skilled coach will enable the coach to elicit reflection and ask probing questions. Guided reflection may also work better when it is facilitated by someone external to the organisation, so that difficult questions can be asked without the perception of any implied threat.
Other contexts that impact on remediation
In realist explanations of an intervention, the interventions work when they manipulate the context to create the opportunities and resources to induce change. Not all remediating doctors would need to engage with every intervention strategy for the same length of time. There will be individual contexts and contexts related to the setting that will impact on how remediation works.
The individual context includes the stage in a doctor’s career, as this will influence the extent to which undergoing remediation results in a loss of autonomy and the subsequent likely barriers to intervention. The other individual contexts here relate to the negative emotions and fear attached to a remediation process, which can lead a remediating doctor to deny that there is an issue to be addressed. Related to this is a doctor’s professional identity development, which will impact on their learning, and their motivation and engagement with remediation. The setting context relates to the work environment, which may determine how safe a doctor feels to engage in remediation and the stigma attached to remediation.
Comparison with existing literature
Bourgeois-Law et al.12 have noted that conceptualisations of remediation have tended not to differentiate between trainees and those doctors who are consultant-level (i.e. attending-level) physicians. They argue that consultants and attending physicians operate in a more autonomous environment as opposed to the educational environment surrounding trainees. As such, remediation for consultants and attending physicians entails a much greater loss of professional autonomy, particularly if that remediation entails a return to supervised practice.12
This review of the literature supports Bourgeois-Law et al.’s12 assertion that in remediation studies little consideration is given to this difference. The majority of the literature uncovered in the formal search (66/114) focused on doctors in training, with only 11 studies focusing specifically on consultants, GPs and attending physicians. Out of the remaining 36 studies that included both categories, little or no consideration was given to the different contexts in which these doctors operate. Stakeholders strongly supported this assertion about the importance of autonomy (and the loss thereof) in a remediation process. However, in our review, we have also, in a number of ways, moved beyond this binary distinction and have developed a more nuanced understanding of the importance of a doctor’s operational autonomy in determining how remediation works. As noted by our stakeholders, a binary distinction between doctors practising independently and those in training may be an oversimplification. Autonomy increases incrementally throughout a medical career and, for example, the step from a senior trainee to a consultant may not be as great as that from a junior trainee to a senior trainee. We have therefore developed a programme theory that is sufficiently transferable to remediating doctors whatever the stage in their career, from medical school graduation to consultant level. We have identified that is not simply the stage of a doctor’s career that is either a barrier or a facilitator, but the loss of autonomy experienced (see Table 2, CMOcs 14 and 15).
The last systematic review to develop a model for remediation was conducted by Hauer et al. in 2009.11 Broadly speaking, the model advocated by Hauer et al.11 was akin to a medical model of treatment (i.e. assessment, diagnosis, intervention and follow-up) (Figure 4).
FIGURE 4 Hauer et al.’s11 model for remediation of physicians across the continuum of medical education. (Figure not reproduced here; see the original article.)
Our findings do not contradict Hauer et al.’s11 model, but they develop considerably greater detail on what some of these processes might look like in a successful programme. The use of multimodal forms of assessment, highlighted by Hauer et al.,11 is widely supported in the literature returned in this review.47,62,115,119,144,151–153 This assessment serves a number of functions. As noted by Hauer et al.,11 a central purpose of assessment in remediation is to aid the accurate diagnosis and understanding of the concern. However, we suggest that multimodal assessment should also be used to gather specific and direct feedback that is more likely to be validated by a remediating doctor. Our findings in relation to the stigma of remediation and influence on professional identity suggest that it is important to evaluate organisational issues that may have an effect on how a remediating doctor reacts in a particular work setting, and may point to the need to instigate organisational changes to facilitate a more effective remedial environment. The assessment of the workplace environment is not common in remediation assessment processes, with the UK’s Practitioner Performance and Advisory service (formerly the National Clinical Assessment Service) being a notable exception.5 Importantly, research by the same organisation found that, although only a minority of referrals noted problems in the workplace environment, the majority of assessments found workplace to be an important contributing factor to performance or behavioural problems.154 The need to consider the importance and impact of organisational problems in remediation has been highlighted in a number of papers, and our findings would support this approach.155–157
Diagnosing a deficiency–the next stage in Hauer et al.’s11 model–is central to remediation. Our research suggests that identifying the manifest problem itself may be a slightly different endeavour from identifying the cause of the problem. Identifying the cause of the problem, which will allow a remediating doctor to develop self-awareness and a sense of control, means that guided reflection with a coache/mentor can help engender insight and a sense of control and self-efficacy. Developing an individualised remediation plan should be, we suggest, an activity undertaken with the remediating doctor, if possible, affording the greatest opportunity to enable input into the process.
We would agree with Hauer et al.11 that coaching and mentoring has an important role in a remediation process. What we have added via this realist review is how coaches and mentors are an integral part of the remediation process. The importance of developing insight is not really captured in Hauer et al.’s11 linear model of remediation, and we have argued here that it is absolutely central to the remediation process. The way in which coaches or mentors frame feedback and whether or not they create an environment in which a remediating doctor is able to feel safe and be candid about their thoughts and feelings, is central to whether feedback is likely to be accepted or rejected, and whether or not that feedback will engender the self-efficacy and sense of control needed to motivate a doctor to complete a remediation programme. Coaches and mentors should be trained and focused on the provision of support and guiding reflections, and may be most effective when they have no role at all in any decisions on the progress of the remediating doctor. This accords with an increasing recognition of the importance of reflection in medical education.158,159
Remediation is often viewed in terms of an educational model,12,25 and our focus here has been on the more behavioural aspects of change that are required for learning to take place. We are not the first to argue that remediation should be understood in this way. Prescott-Clements et al.7 developed a model for assessment in remediation similarly rooted in concepts of behaviour change. We have used this same conceptualisation to build a more detailed theory about the processes that occur throughout a remediation programme to produce its effects.
Our programme theory addresses the questions of why, how, and in what contexts remediation works. Our answer to this aspect of the question uses a behaviour change approach to describe the way in which remediation interventions change the contexts to create insight, motivation and practice change–stages that we argue are essential to successful remediation. In terms of ‘for whom?’, we have noted that a doctor’s career stage may be an important factor, and that those who practise with more autonomy and away from educational cultures associated with training grades may find remediation more challenging. This fits with how we think remediation works, but the stage of a doctor’s career is only explicitly referred to in one scoping review paper.12 Some studies have also pointed to the difficulties in remediating older doctors in particular,7,95,110,160,161 but there was not enough evidence in the literature to integrate this into the programme theory. Similarly, we acknowledge that gender, culture, or medical specialty may all be relevant factors, but, once again, because of the absence of data in the documents included in our review, we were unable to further elucidate these factors.
The aspect of the question ‘to what extent’ is not about producing a summative judgement of remediation programmes. Rather, in our review, it is meant to be much more explanatory than judgemental in its focus, and to develop an understanding of remediation in depth. In fact, we do not think it is possible from this literature to produce any kind of summative judgement, as there is too much variation in multiple aspects of the delivery of remediation, the setting and the characteristics of the remediating doctor. Indeed, this variation is the reason why we chose a realist review approach, so that we could start to understand the differential impacts (i.e. the ‘to what extents’) of remediating programmes. To do this, we picked apart the remediation process, as illustrated by our CMOcs.
Our programme theory and embedded CMOcs show that, although there is a final desired outcome, namely patient safety, there are also many other intermediate or more proximal outcomes that need to be ‘achieved’. Our CMOcs set out when (and in what contexts) these are likely to occur, but we cannot quantify the likelihoods, as the data needed to do so were not available in the included documents. This is not surprising, as none of the included documents had set out to measure these intermediate or more proximal outcomes. More primary research is needed to evaluate whether or not these intermediate or more proximal outcomes are achieved.