Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Aim

The REalist SynThesis of dOctor REmediation (RESTORE) review aimed to identify why, how, in what contexts, for whom and to what extent remediation interventions work for practising doctors to restore patient safety. The review was structured around the following objectives and review questions.

Objectives

• To conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.

• To provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.

Review questions

• What are the mechanisms by which remediation interventions work to change the behaviour of practising doctors to produce their intended outcomes?

• What are the contexts that determine whether or not remediation interventions produce their intended or unintended outcomes?

• In what circumstances are these remediation interventions likely to be effective?

The next chapter provides a detailed description of the methods utilised in the review. Chapter 3 presents the results, followed by the discussion in Chapter 4. Finally, the conclusions and recommendations are presented in Chapter 5.

Formal search

In step 2, the goal was to find a body of relevant literature to further develop and refine the initial programme theory developed in step 1. The searches were designed, piloted and carried out by AW, an experienced information specialist with expertise in carrying out searches for realist reviews. AW used MEDLINE (via Ovid) to develop the search strategy. An iterative process was adopted, whereby search terms were added, removed and refined to achieve a balance of sensitivity and specificity in the results. The overall aim was to capture a broad range of relevant literature while minimising irrelevant literature.

As the search developed, sample sets of results were screened by TP and NB. This facilitated the selection of relevant search terms. In addition, highly relevant studies that had already been identified by the review team through their own personal libraries were used to test the search strategy (i.e. if these papers were returned in a particular search it confirmed the effectiveness of the search). The final search strategy used a range of search terms for the concepts ‘remediation’, ‘performance’ and ‘doctors’, which were combined using the AND Boolean operator (see Appendix 1).

The following databases were searched on 4 June 2018: MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Health Management Information Consortium (HMIC) (via Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (via EBSCOhost), Education Resources Information Center (ERIC) (via EBSCOhost), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest) and Database of Abstracts of Reviews of Effects (DARE) (via the Centre for Reviews and Dissemination). The search syntax and indexing terms were amended where needed from the original MEDLINE for use in these databases.

The search results were exported to EndNote X7 (Clarivate Analytics, Philadelphia, PA, USA) and deduplicated using the ‘find duplicates’ function. The search strategies for the main database search are reproduced in full in Appendix 1.

Additional searches

Although we conducted a grey literature search in the main search using HMIC, following a discussion with our third stakeholder group, where some of the stakeholders highlighted the relevance of some key grey literature, we decided to do a subsequent search specifically to identify grey literature. Searches for grey literature were conducted on 25 June 2019. The following databases/websites were searched: Google Scholar, OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. The databases were searched with free-text keywords and controlled vocabulary where appropriate, using terms such as remedi*, reskilling, and retraining, combined with the concept of doctors.

Citation searching was undertaken, including searches of the reference list of all included documents and ‘cited by’ searches of certain papers that were particularly rich in terms of building the programme theory. The ‘cited by’ searches were undertaken using Google Scholar. Stakeholders were also asked to identify any literature they thought relevant. Any literature identified through grey literature searching, citation searching and via stakeholders that satisfied the inclusion criteria were included in the review.

The supplementary searches were purposive and undertaken on an ad hoc basis, as and when more data were needed on specific theories regarding different aspects of our programme theory of how remediation is supposed to work (e.g. insight, dissonance, psychological safety, feedback and behaviour change). Google Scholar was searched using topic keywords. Once relevant references were found, backwards and forwards citation searching techniques were used to identify further relevant papers.

Providing safe spaces and using advocacy to develop trust in the remediation process

As remediation is a threat to a doctor’s professional identity, and may also be perceived as a threat to their career, feelings such as anger and mistrust may prevent a doctor from even engaging with negative feedback on their performance or behaviour. 51 A recurring theme in the literature is that a remediating doctor is more likely to be ready to explore and to validate others’ perceptions of their behaviour or performance if they have trust in the people involved in remediation and trust in the process of remediation itself.

The actual word ‘trust’, although used on occasion,52,53 does not appear frequently in the returned literature. However, the idea of developing trusting relationships is implicit in a number of papers. 49,50,52,54–62 Trust also emerged as an important theme in the stakeholder meetings. To develop this relationship, the literature points to features of remediation programmes that might bring about trust. In particular, the literature noted the importance of developing safe spaces and using advocacy to engender trusting relationships.

The literature describes the need to create a ‘safe space’ in which a confidential discussion can take place, without fear of sanction or judgement. 49,52,54,55,57–62 A safe space is important because remediating doctors usually fear the consequences of being identified as needing remediation. One aspect of creating a safe space is to provide assurance of confidentiality. The literature refers to conversations in a remediation process that are not only confidential, but allow the remediating doctor the opportunity to express negative emotions, such as anger and shame, that might be invoked by being identified as needing remediation. 44,54 Our stakeholders suggested that this provision of confidentiality may also facilitate the remediating doctor to express any mental health issues that may not have come to light.

Trust can also be developed through building personal relationships during the process of remediation. Sometimes, such a relationship is described in the context of a coaching model53–56,59,60,63–66 and elsewhere in terms of a mentoring programme. 44,48,49,55,63,67–75 Regardless of the term used, a key focus in the literature is that someone in the remediation programme takes on the role of being an advocate for the remediating doctor.

Advocacy is described as offering ‘unconditional positive regard’76 in the context of a one-to-one relationship in a remediation programme. Empathy and validation are key to this role,75 which has been described as a ‘therapeutic relationship’. 77 In practice, this may mean empathising on specific issues, such as working conditions being very challenging, and acknowledging that others have similar struggles,55 or that behavioural norms have changed since the remediating doctor did their training. 76 Shapiro et al. 53 point to the importance of validating a doctor’s good motivations, even if the ultimate goal is to reach a point where the remediating doctor understands that they were not acting in a way that was compatible with this motive. 53

The person performing this advocacy role may be a senior doctor76 or a peer55,71 in a role labelled as either coach, mentor or other. A key point noted in a number of papers is that advocacy is deemed to be most effective when the individual fulfilling this function has no role in the summative evaluation of the remediating doctor or the final outcome of the process. 54,56,76 The advocate does not necessarily have to be intimately involved with the delivery of the remediation programme, but should be familiar with the case. 78 Our stakeholders suggested that this individual should be someone who is chosen by the doctor. Having this supportive relationship and non-judgemental encouragement allows for trust to develop, which, in turn, means that the remediating doctor is more likely to engage in the process and be ready to explore concerns about their performance or behaviour.

Realist analysis of providing safe spaces and using advocacy to develop trust in the remediation process

Extract 1 (Box 2) is typical of the way in which insight is addressed in the literature (i.e. a lack of insight is a barrier to remediation, but is potentially remediable). The emphasis on the importance of insight was mirrored in the stakeholder group discussions, in which a lack of insight was unequivocally associated with failure in remediation. The link between establishing safe spaces because of the reactions and vulnerability of the remediating doctor is drawn from data such as those in extracts 2–6 (see Box 2) and was verified explicitly in the stakeholder group discussions. The stakeholder group, both within meetings and in later e-mail exchanges, also emphasised the importance of trust as an important outcome when someone feels psychologically safe.

Therefore, CMOc 1 establishes the context that remediation is feared by those who engage in the process and that they will not engage if they do not feel psychologically safe (Table 3). CMOcs 2–4 refer to the role of psychological safety as a generative mechanism that leads to outcomes of trust and, because there is trust, a readiness to explore performance or behavioural concerns. Only one paper41 that was returned in the remediation literature search explicitly mentions psychological safety (see Box 2, extract 7). Psychological safety was examined as a concept at the suggestion of a member of the review team. We subsequently conducted a supplementary literature search to examine whether or not the concept was appropriate to help understand the causal mechanisms at work in building trusting relationships.

The literature returned in the supplementary search showed that psychological safety was specifically concerned with developing trust within the contexts where perceptions of risk and fear are prevalent. Extract 3 (Box 3), from the most recent study83 we could find on psychological safety in medical education, also discusses its importance in relation to building relationships of trust. This focus on overcoming perceptions of risk and threat is well suited to the environment of remediation and provides a credible explanation of how intervention strategies can create the contexts that lead to trusting relationships in a remediation programme, in turn leading to a readiness to explore a problem. As a mechanism, psychological safety describes a process in which the opportunities and resources provided by the programme (i.e. the provision of a safe space and the advocacy role) alter the reasoning of individuals, enabling them to take the psychological risk of exploring their performance or behaviour.

These CMOcs identify the different contexts that can facilitate psychological safety, including a confidential and safe space for discussion and support provided by advocacy. Some papers note that part of this advocacy role may be acknowledging a doctor’s intentions and professional motives. Extracts 8–15 (see Box 2) imply that a more psychologically safe environment can be created with such validation, and this has informed the contexts noted in CMOc 2.

For CMOcs 3 and 4, we assert that the advocacy role may be most effective when this individual has no role in summative judgements about the performance of the doctor, and this point is explicitly noted in the literature (see Box 2, extracts 16–19). Although not developed in the literature, the notion of trust here offers a reasonable explanation (i.e. if someone is feeling judged then it is likely to be more difficult for them to build a trusting relationship and feel that they are being validated). This was also noted in stakeholder group discussions.

If a remediating doctor is ready to explore a potential behavioural or performance concern, and there is enough trust to validate others’ perceptions and judgements, a further aspect of developing insight is to accept the need to improve performance or change behaviour. 84 The acceptance comes when a remediating doctor realises that their behaviours or performance do not meet the standards that they consider to be important to the practice of medicine. However, as noted above, the fear and anger that accompany remediation may mean that, rather than accept these standards, a remediating doctor may just reject them or reject the feedback itself. Therefore, the important question is how can feedback be delivered in such a way that a remediating doctor accepts that they must improve their performance or change their behaviour?

Framing feedback 1: juxtaposition

One strategy is to use the remediation process to elicit the remediating doctor’s own ideas about what makes a good doctor, and then compare their own behaviours to these standards. One ethics remediation programme in the USA starts by asking all participants on the first day of the programme to describe the ‘ideal healer’. On the second day of the programme the participants describe their own actions and are presented with their previous ideals. 85,86 The authors expressly stated that the purpose of these programmes is to create a ‘professional dissonance’ or ‘ethical discomfort’85 that can be reconciled through an acceptance that the remediating doctor’s behaviour does not conform to the expectations of either the profession or the remediating doctor’s idea of what constitutes a good doctor. As these values come from the remediating doctor, rather than an external source, they may be perceived as being more authentic and less challengeable.

Acceptance may also occur when a remediating doctor’s own perceptions of their performance or behaviours are juxtaposed with the perceptions of trusted colleagues. Samenow et al. 79 describe a university hospital’s professional behaviours remediation programme. The first part of the programme for a referred doctor involves collecting feedback on behaviour from different members of staff. Similar to the aforementioned ethics remediation programme, the express purpose is to create a ‘disorientating dilemma’ where the remediating doctor contrasts their own perceptions of their behaviour with that of their colleagues. Another version of the juxtaposition strategy is to use video simulations in which actors act out unprofessional behaviours. The remediating doctor views a number of simulations, the last of which (unbeknown to them) has been specifically devised to show behaviours similar to their own behaviours. 65 Again, the purpose here seems to be contrasting their views on professional behaviours with their own behaviours.

Realist analysis of framing feedback using juxtaposition

Dissonance as a mechanism appears quite explicitly in the literature. In Box 4, extracts 2 and 3 discuss this in almost realist terms. In describing the disorientating dilemma or ethics discomfort that is induced through the strategy of juxtaposition, the authors offer a causal explanation of the way in which change can occur. This is based on the premise that the remediating doctor must accept the need to change performance or behaviour, which is noted or implied throughout much of the literature. This was also a continuing theme in stakeholder group discussions. Similarly, in extract 4, a process of guided reflection is used to enable the remediating doctor to compare their own actions with how they were perceived by others.

Context–mechanism–outcome configuration 5 (Table 4) describes the process whereby strategies that create this juxtaposition invoke change through dissonance. The outcome created here is the acceptance of the discrepancy between their own and acceptable behaviours.

Framing feedback 2: specific data from different sources

Gaining insight from accepting feedback is important at all stages of remediation. Initial presentation of feedback may be part of what Papadakis et al. 58 have termed the ‘feedback conversation’. 58 As remediation progresses, feedback and reflection on new skills and progress will create more insight and more progress. Trust may then link into feedback, in that the remediating doctor may react more readily to the feedback received if they have a trusting relationship.

A frequently identified barrier to successful remediation is the negative emotions of the remediating doctor throughout the remediation process. 49,51 In the remediation environment, therefore, providing feedback does not mean that feedback will automatically effect behaviour change. 55 Rejecting feedback may be likely throughout remediation. One of the contexts that may lead to a rejection of feedback is when a doctor perceives that accepting the feedback is a threat to their career or their professional identity. 51 There are a number of strategies within the literature that are used to manipulate the context within remediation programmes to mitigate or ameliorate these emotional barriers to engaging in remediation.

A relatively common argument in the literature (and one that also arose in the stakeholder group) is that feedback needs to be as clear and as specific as possible so that it might not be so easily dismissed or discredited. In particular, the feedback should be articulated in ways that are unambiguous and objective. 52,63,65,71,88,89

This is particularly challenging when the issue is a behavioural one, as specific and direct feedback is difficult to gather. However, it is also particularly important, as receiving feedback that is non-specific may be interpreted by the remediating doctor as being victimised by the organisation or specific individuals within it. This raises the issue of the role of soft intelligence (i.e. an ear to the ground) within remediation programmes. The literature suggests that soft intelligence may be particularly useful in gaining a better understanding of the nature of performance or behavioural concerns and, therefore, help tailor a remediation programme appropriately. 50,52,56,66,67,69,73,79,87,89–93 However, such data may be less useful in invoking behaviour change for the participant, given the importance attached to specific and unambiguous feedback.

In addition to having specific data, remediating doctors are more likely to validate feedback when it is derived from multiple sources. 42,46,52,58,79 Although the reason for this is not really described in the literature, it seems logical that feedback is much more difficult to deny if it comes from a range of sources. Patient feedback may be particularly useful, as provision of safe and effective care is central to medical professional identity (see Framing feedback 3: affirmation, normative frameworks and feedback standard discrepancy).

Realist analysis of how specific feedback from different sources can lead to acceptance

Context–mechanism–outcome configuration 6 is derived from a substantial body of literature that suggests that feedback is more effective when it is specific (Table 5). This is clearly supported in Box 5, extracts 1–3, whereas extract 7 notes that feedback in the absence of specific data may be unconvincing. The importance of a variety of sources of feedback is noted in a number of the extracts (see Box 5) and was strongly supported in stakeholder group meetings. Validation describes a simple but important mechanism whereby, once the feedback is recognised as a legitimate and accurate description of behaviour, the remediating doctor will logically recognise the discrepancy between their own perceptions of their performance or behaviour, and others’ perceptions.

In CMOc 7, this outcome of the gap between the remediating doctor’s perceptions and the actual behaviours or performance becomes the new context that triggers the mechanism of dissonance. CMOc 8 describes what happens when feedback is not framed in this way and therefore becomes perceived as a generalised judgement on the remediating doctor as a person. Denial (discussed in more detail in Realist analysis of framing feedback: affirmation, normative frameworks and feedback standard discrepancy) is the remediating doctor’s way of reconciling the uncomfortable professional dissonance they experience.

Framing feedback 3: affirmation, normative frameworks and feedback standard discrepancy

Having specific feedback from multiple sources may be important for that feedback to be validated, but it may not be enough, given the emotional barriers associated with engaging in remediation. The literature points to a number of other framing strategies. If a doctor gets feedback that does not fit with their professional identity, a state of acute identity dissonance may be alleviated only through denial of the feedback itself. 57 Some intervention strategies appear specifically directed at framing feedback in such a way that it protects the professional identity of a doctor being remediated, namely affirming the remediating doctor’s strengths, framing discordant data in accordance with relatable normative frameworks, and presenting feedback in a way in which the gap between actual and perceived standards is neither too big nor too small.

Affirming a remediating doctor’s strengths may increase the chances that any corresponding negative feedback is validated. 50,94,95 Moreover, care should be taken to ensure that the feedback is delivered in a way that is not judgemental or demeaning. 50 The important point here, as noted above, is that feedback that undermines a doctor’s professional identity may result in rejection of that feedback.

It may also be important to frame feedback according to norms that a doctor can relate to and that are congruent with their professional identity. For example, respect for colleagues may be a difficult normative reference to grasp if the remediating doctor thinks that they are motivated by appropriate norms. However, doctors may find it easier to relate to normative frameworks around patient safety. 52 In other words, if possible, it may be useful to ‘honor the intent’ of the remediating doctor, while pointing out that the behaviour poses safety risks. 53

In our stakeholder meetings there was discussion on the importance of framing feedback so that it seems manageable. It may be important to deliver feedback in a way that encourages perspective, conveying to the doctor that the issue to be addressed is one part of their practice and not their practice in its entirety. The discussions included suggestions that effective coaching can be used to remind a doctor that they have already achieved a great deal by getting through medical school and have proven themself to be a capable practitioner.

Realist analysis of framing feedback: affirmation, normative frameworks and feedback standard discrepancy

The context for CMOc 9 is the fear that characterises remediation (Table 6). Denial functions here as the mechanism, as it is a way for the remediating doctor to reconcile what we previously described as uncomfortable professional dissonance without accepting the feedback on their performance or behaviour. Citation searching from one of the returned papers96 pointed to some of the wider literature on denial in the medical education literature. This suggests that denial may take different forms (i.e. denial of the feedback or denial of the standards to which they are being held). This fits with the remediation literature, which discusses situations where there may be denial of the veracity of the feedback itself (i.e. ‘I don’t believe this feedback reflects my performance or behaviour’)55 or a denial of the standard, or even the values, of the profession to which those standards pertain. 57,96,97 Denial has been posited as a mechanism that explains non-engagement or superficial engagement with remediation. Box 6, extracts 1–4 offer examples of the different types of denial that might take place in remediation.

Context–mechanism–outcome configuration 10 explains that affirmation, which has been identified as a mechanism in other realist research on doctor performance,101 may be a process that helps protect professional identity. This was discussed in the stakeholder group and is supported by Box 6, extracts 5–7, which suggest that some positive feedback, and affirmation of a remediating doctor’s strengths, can be helpful in remediation. This is a tentative CMOc, as the literature does not discuss this in much detail.

Context–mechanism–outcome configuration 11 concerns the degree of variance in feedback. This was informed by stakeholder group discussions on the need to make remediation seem ‘manageable’ and to deliver feedback in a way that did not make the process seem overwhelming. In the wider literature on feedback, the gap between the data provided in the feedback and the accepted standards is known as the ‘feedback-standard discrepancy’. 96 Again, the use of coaches and advocacy may be important in conveying this. This links to CMOc 6, where specific feedback is important because it is less likely to be seen as a generalised judgement about a doctor’s performance and more likely to allow for the identification of achievable improvements. If a remediating doctor feels that the remediation is manageable, then the mechanism of dissonance, rather than denial, is more likely to be triggered.

Context–mechanism–outcome configuration 12 develops a causal explanation for how a doctor can be motivated to align their performance or behaviours with those of the profession, when feedback is framed in such a way that aligns with their values. Pawson’s seminal work on realist synthesis draws on a number of broader substantive sociological theories that help understand the role of identity in behaviour change. One of these is Merton and Merton’s reference group theory,102 developed in the 1950s largely in relation to the behaviour of US soldiers who were situated either on the inside or on the margins of the established community of soldiers. 102 This theory posits that individuals will change attitudes and behaviours to assimilate with the reference group. More recently, Elder-Vass103,104 has developed the idea of norms circles which, like reference groups, invoke change through people assimilating to the norms of the group. Linking this to behaviour change theory, studies have shown that self-identification with the perceived norms of a reference group can significantly predict behavioural intention. 105 This is particularly relevant in the field of medical education, given the importance attached to the communities of practice model of learning. 106–109

The causal mechanism can be termed ‘normative enticement’, as it describes a situation in which an individual is enticed to the norms of a particular group. This mechanism could crudely but accurately be described as ‘I identify as being part of a particular group and therefore will accept the need to change my behaviour to retain membership of that group, to reaffirm to myself that I am a legitimate group member’. The normative enticement mechanism may run alongside the dissonance mechanism, feeding into it and facilitating its function at various stages throughout the remediation programme. This mechanism also bridges motivation and insight outcomes. The enticement to follow the norms of the profession may lead to acceptance that change is necessary (i.e. insight), but also intrinsic motivation to embark on that change. Motivation is discussed in the next section.

Context–mechanism–outcome configuration 13 suggests that being identified as needing remediation may, in the absence of efforts to frame feedback in a way that seeks to protect the remediating doctor’s professional identity, trigger a mechanism of identity dissonance. This type of dissonance, rather than invoking acceptance, may lead to a reconstruction or rejection of that identity to relieve this dissonance. Again, this is likely to have demotivating influence. This alluded to in Box 6, extract 4.

Involving the remediating doctor in remediation planning: perceived control

Involving a remediating doctor in planning a remediation programme may have a motivating influence. Facilitating a remediating doctor to maintain a degree of professional autonomy may have positive motivational consequences because it protects professional identity and engenders a sense of agency. Being involved in the remediation planning necessitates that the remediating doctor has an active, rather than a passive, role and they may perceive that they have more control over the outcome. In the literature, this is often framed in terms of developing ‘buy-in’ to the programme, suggesting that involving the doctor in the design of the programme may also give them more of an emotional investment. 44,48,50,55,57,91,97,111,112

Having input into remediation planning may also help protect professional identity. Autonomy is a key component of professional identity, especially in those doctors who have passed through training and become a consultant doctor (i.e. an attending physician). 12 As noted in Facilitating remediation: developing insight, professional identity is part of how doctors learn, and doctors may be intrinsically motivated by the desire to serve patients. 55 As highlighted above, invoking the remediating doctor’s own sense of professionalism and professional values may help create professional dissonance, leading to insight. This is because individuals can be intrinsically motivated to adopt certain behaviours or practices when these behaviours are associated with their own professional values, previously discussed in terms of the mechanism of normative enticement (see Table 6). 57 In other words, remediating doctors can be motivated because they want to be, or remain, part of the ‘in group’.

The amount of professional autonomy available in a remediation programme may be limited (remediation, by definition, means that the doctor has no choice but to remediate if they want to continue in their existing role or continue in their training pathway). However, reducing the inevitable loss of professional autonomy may be an important part of a successful remediation programme.

The important point here is that remediation necessitates a loss of autonomy, but if doctors have some input into the design of the programme then their professional identity will be less disrupted and the doctor will feel a greater degree of control over the process. Subsequently, they will have more intrinsic motivation.

Realist analysis for involving the doctor in remediation planning: perceived control

In CMOc 14 (Table 7), the extent to which a remediating doctor has input into the remediation programme functions as context. The input into the remediation programme increases the perception of control. Perceived control has been identified as a behaviour change mechanism in previous realist reviews. 113 This is consistent with behavioural change theories that have been used to understand and develop remediation programmes, and were identified through supplementary searching, which emphasise the importance of perceived control in motivation. 114 This provides a credible causal explanation for the substantial emphasis placed on creating remediating doctor involvement in remediation planning in a number of remediation programmes worldwide. This is illustrated in several of the extracts in Box 7.

Conversely, in CMOc 15, the loss of professional identity triggers normative rejection, which leads to a lack of motivation. This normative rejection is the converse of the CMOc of normative enticement in CMOc 12. The remediating doctor may be less likely to reject their professional identity if they maintain a degree of autonomy in the remediation programme.

Correcting causal attribution

If a remediating doctor does not believe that they have the ability to improve their performance or their behaviour then they will not be motivated. This is likely to happen when the remediating doctor incorrectly attributes the problem to something they cannot control. Durning et al. 116 use the example of a remediating doctor who attributes his poor performance to a lack of ability, which is demotivating because ability is perceived as an innate and immutable characteristic. However, after investigating the causes of the problem and finding that it is related to study techniques – something over which the remediating doctor has control – motivation is increased. 116

Similarly, for behaviour, literature points to the importance of doctors identifying particular emotional triggers. If a remediating doctor is able to recognise particular triggers for poor behaviour, they may become more aware of why they are behaving in this way and how they might seek to change their behaviour. In some papers the process of self-identification is part of an initial conversation, in which the remediating doctor is encouraged to explore their own perceptions of a particular problem. 90,117

This supports the strategies for post-referral assessment4,7,45,50,52,56,65,71,76,78,79,89–91,116–118 that examine not just the identified performance or behavioural problem, but also the possible causes of that problem. Accurate causal attribution will also enable the development of individualised and targeted remediation plans, a feature of a large number of remediation programmes. 7,11,47,73,100,118–123

This points to a further overlap between insight and motivation. Identifying the causes of a performance or behavioural issue is important in developing insight (i.e. the remediating doctor knows what is triggering a particular set of behaviours or performance and therefore has greater insight). This kind of insight leads directly to motivation, as it may enable doctors to overcome problems with causal attribution and therefore improve self-efficacy.

Realist analysis for correcting causal attribution

In CMOc 16 (Table 8), the causal mechanism is again a perception of control. In this case, the perception of control comes from correctly identifying the issue itself and through this process understanding that the problem is manageable. Again, this is supported by the wider literature on motivation and learning that highlights the motivational consequences of someone knowing what they are capable of and what they can control. 124

When a remediating doctor can be coached through specific strategies to improve learning then they may also improve their self-efficacy, which in turn leads to more engagement. This process is explained in CMOc 17. Self-efficacy in the setting of remediation is about having the confidence that you can successfully remediate and achieve the goals that have been put in place. There are clear overlaps here with the perceived control mechanism, because having confidence to put knowledge into action implies a belief in control over the application of this knowledge. This is informed in Box 8, extract 3. Extract 4 informs the overall points about the relationship between self-efficacy and motivation.

The role of self-efficacy in enhancing motivation is noted in the wider literature on behaviour change that was uncovered through supplementary searching on the topic of self-efficacy and behaviour change (see Box 8, extract 6). 114,125 CMOc 18 explains how strategies that are related to identifying emotional triggers for behaviour work. Self-awareness here describes the process of identifying those triggers and becoming aware of when and how they operate to change behaviour.

Goal-setting

There are other features of interventions that may induce self-efficacy. One of these may be goal-setting. A number of interventions note the importance of having clear and achievable goals set out in the remediation programme. 52,55,71,87,91,118,126,127 There are various ways that this goal-setting is framed, but the basic premise is that goals should be both clear and achievable. Telling a doctor to ‘improve background radiology knowledge’ is not as helpful as ‘improve knowledge of chest radiography, anatomy and pathology’. 71 The clarity is not just about the goals themselves, but ensuring that the doctor understands how these goals are being assessed. 118

Although developing self-efficacy (i.e. the sense that the goals can be achieved) may be an important component of a remediation programme, it does not necessarily mean that very high self-efficacy will always facilitate effective remediation. Indeed, there may at times be an inverse relationship between levels of self-efficacy and successful remediation if the doctor’s self-efficacy is not based on insight. Studies on doctor performance, and professional performance more generally, have shown that poor performers tend to have the extra burden of being less likely than higher performers to judge their own performance level accurately. 128–132 If a remediating doctor has very high self-efficacy beliefs going into a remediation programme then this may suggest a lack of insight and may impede remediation. 93 The corollary to this is that low self-efficacy may be a sign of insight, as the remediating doctor is aware of their deficiencies, although this may also induce low intrinsic motivation. 7 Therefore, it seems that there is a fine line in remediation programmes. Feedback has to be direct enough to ensure that an individual is faced with credible evidence of the need to change (we called this juxtaposition; see Framing feedback 1: juxtaposition). However, careful goal-setting and support may be important in inducing the self-efficacy required to believe that goals are achievable. This relates to what was discussed in Facilitating remediation: developing insight, about framing feedback in manageable way.

Realist analysis of goal-setting

In CMOc 19 (Table 9), the extent to which the goal is perceived to be achievable functions as context and can be changed with specific, measurable, achievable, relevant, time-bound (SMART) goal-setting strategies and goals that are tailored to the individual being remediated. Again, the focus on self-efficacy as a mechanism fits with behaviour change models that underpinned some of the literature on remediation that were found through citation searching. This was also a point of discussion in the stakeholder group. Box 9 sets out the data that we have drawn on to develop this CMOc.

Destigmatising remediation

If professional identity is important for intrinsic motivation, then all efforts to mitigate the negative impact of remediation on a remediating doctor’s professional identity are potentially important. In this respect, a number of papers note that the stigma attached to remediation acts a barrier to engagement. 8,41,133 If a doctor feels stigmatised, then they will feel isolated from their colleagues and this can have negative implications for identity development. The importance of professional identity in remediation therefore brings into the focus some of the broader contextual issues around how remediation is conceptualised within the medical profession and the extent to which it stigmatises remediation. 12

A study in Canada considered the perception of remediating doctors from various stakeholders within the medical community. It found that those involved in remediation programmes often held ambivalent perceptions, describing remediating doctors as being both ‘one of us’ and ‘not like us’. 134 This is important as it suggests that negative perceptions exist and also that it may be possible to nurture more positive perceptions of remediation. This finding emphasises the relevance of in- and out-group dynamics that may impact professional identity for remediating doctors. Similarly, in the UK, it has been noted that policy developments have simultaneously sought to normalise remediation, while also creating a contradictory and unhelpful climate of fear around doctor performance. 8

One approach to mitigate this barrier is to seek to remove the stigma attached to remediation. This is noted as important in a number of papers. 8,40,84,91,117,135 However, the literature does not elaborate on what this looks like in practice beyond renaming the process itself,91 ensuring that the process is not framed as punishment84 and seeking to conduct remediation in such a way so that the remediating doctor is not easily identified as such by peers. 41

A further approach to lessen the sense of isolation and the stigma attached to remediation is to bring remediating doctors together. Group remediation is advocated in a number of papers. 4,51,73,74,85,89,95,120,121,136–138 The process of working in a group may help doctors feel less alone and the process of seeing colleagues progress through and complete a remediation programme may be motivating. 85 However, as noted in stakeholder group discussions, group work may in many situations be impractical. Other ways of networking with doctors undergoing remediation may be more pragmatic.

Realist analysis for destigmatising remediation

Context–mechanism–outcome configuration 20 provides a causal explanation for the emphasis placed on seeking to remove the stigma of remediation, which is discussed in a number of papers (Table 10 and Box 10, extracts 4–6). 41,84,135 Again, this is a plausible explanation because it is congruent with broader notions of the importance of professional identity and negative impacts of isolation on motivation. This was derived, in part, from the discussions with the stakeholders, including those undergoing remediation, which noted how doctors would often not disclose their remediation to friends or family, let alone other doctors, and the ensuing sense of loneliness experienced.

Context–mechanism–outcome configurations 21 and 22 offer a causal explanation of what happens when the framing of remediation creates isolation. In CMOc 21, the sense of alienation – broadly speaking, the process of detachment of things that belong together – can be understood as a causal mechanism, leading to isolation. Extract 7 (see Box 10) advocates the use of group remediation to lessen isolation. In CMOc 22, the corresponding sense of isolation invokes the mechanism of normative rejection, as discussed above. In this case, it is the sense of isolation that leads the remediating doctor to dissociate with the community of practice in which they work. These are not well substantiated in the literature and would benefit from further testing.

Although intrinsic motivation may be the ultimate goal of remediation, extrinsic motivation is widely used and deemed effective. One paper reports a survey of residency programme directors (n = 253) in the USA. The threat of termination or not progressing were reported in the survey as the most effective strategies of ensuring engagement with remediation programmes. 139 A number of papers noted the importance of having clear consequences for not improving performance or behaviour. 58,71,76,78,122,140 In the stakeholder group discussions, it was also suggested that understanding the consequences of engaging (or not) with a remediation programme may also be considered an aspect of insight (i.e. insight into the consequences of future actions).

The way in which extrinsic motivation works and interacts with other mechanisms within a remediation programme is not clearly expressed in the remediation literature. In a sense, it is presented as common sense logic (i.e. if a remediating doctor understands that non-engagement will be bad for their career, then they are more likely to engage). However, as our earlier findings and CMOcs have demonstrated, it is difficult to explain how extrinsic motivation alone could induce sustained changes to performance or behaviour. Even if a remediating doctor is sufficiently motivated by the potential consequences of not engaging, the engagement could be superficial or transitory if they are not intrinsically motivated to engage.

Clear consequences

However, outlining clear consequences in remediation may play a role in maintaining engagement throughout a remediation programme141 and, once engaged in a remediation process, this may provide extra motivation to keep a remediating doctor on board. The consequences can escalate if there is continued lack of improvement at specified intervals. 53 Inducing extrinsic motivation through clearly articulating the consequences of actions is not advocated as a standalone strategy, rather it works to support strategies aimed at stimulating a remediating doctor’s intrinsic motivation. Hanna et al. 95 report that mandatory engagement with a remediation programme encouraged attendance, but not necessarily engagement. 95 If a remediating doctor is not intrinsically motivated to change, then they may also re-evaluate their goal. In stakeholder group discussions it was suggested that older doctors, who are nearing retirement, may choose to accept restrictions on the scope of their practice.

The potential for external motivation may be contingent on the perceptions of self-efficacy and perceived control. If a remediating doctor understands that there will be consequences if they do not improve, but does not believe that the improvement is possible, they may change their goals or their commitment. A doctor may adapt their goals for other reasons, such as being near retirement, and, from a patient safety perspective, this may not be a bad thing. Doctors still in training may use the opportunity to reflect on their career and choose a different career path. A number of papers highlighted the importance of systems for ‘coaching out’ of a particular programme of study. 40,50,66,69,91,142

Realist analysis for clear consequences

Context–mechanism–outcome configuration 23 (Table 11) posits that a process of evaluating costs and benefits will be a causal factor in determining the level of motivation. However, the outcomes of this evaluation will be contingent on a number of factors. The processes overlap, so whether a remediating doctor engages in remediation or decides to change their goal may depend on processes present in some of the other CMOcs presented earlier (Box 11). For example, whether or not they experience affirmation and feel psychologically safe, perceive that they have some control over the outcome, and feel part of the medical profession with which they identify and wish to retain in-group status.

Practising new behaviours/skills

Remediation may be most effective at changing behaviour or performance when remediating doctors get the opportunity to practise and master new behaviours or skills. Two papers70,143 in the returned literature explicitly discuss learning in a remediation programme in terms of an experiential learning cycle. Experiential learning theories posit that learning occurs most effectively when the learner gets the opportunity to move from abstract reasoning to concrete experience, and then reflect on that experience to develop learning. 70,143 Processes of guided reflection (discussed below) are likely to be integral to that process if the remediating doctor is practising new skills in the workplace.

Interestingly, some studies also noted the importance of practising behaviours in a professionalism remediation programme. 51,65 One paper51 notes that, during a course on boundary violations, it is not a lack of understanding of ethics issues that besets the referred doctors, but a lack of understanding of how these apply to clinical situations. Therefore, practising behaviours in a simulated environment is an important component of behavioural change. 51 Coaching may also be used to facilitate practising new behaviours. This links to reflection (see Table 2, CMOcs 10, 11, 25 and 26), in that the coach can discuss progress with a remediating doctor, help them rehearse correct behaviours59 and set proper boundaries. 76

Realist analysis for practising new behaviours and skills

Context–mechanism–outcome configuration 24 (Table 12) describes the repetition of performance or behaviours as contexts, as noted in Box 12, extracts 1 and 2. This seems fairly obvious, but practising new skills and behaviours is not always easy in remediation programmes. When simulation is not available, guided reflection on workplace interactions may be even more important. CMOc 25 links the repetition of skills/behaviours to guided reflection (see Box 12, extract 3). The process of guided reflection facilitates the remediating doctor to integrate the new knowledge and experience into their learning. Integration of new knowledge and experience is a mechanism that underpins learning theories such as the Kolb learning cycle, and so it is no surprise that it functions here. What is important is that, in remediation, the circumstances under which the intervention occurs can make this a more complicated process, especially if the problem is a behavioural one.

Guided reflection

As noted above, the literature suggests that the way in which feedback is delivered in a remediation programme is important in determining whether or not that feedback is accepted. In particular, we noted that feedback that is both specific and from multiple sources is more likely to induce dissonance rather than denial. Building on this, feedback works to enhance performance when a practitioner reflects on what that feedback means,56,65,87,115,126,144 and this process works best when it is a guided process (i.e. reflection will not automatically follow feedback, but with guidance from a coach or mentor, reflective practice can aid behaviour change). This is noted for both clinical skills and knowledge issues,63,87,126 as well as professionalism. 56,87 It seems that a key role of coaches or mentors is to guide the remediating doctor in reflection.

Guided reflection may be easier to facilitate with face-to-face meetings with a coach, mentor or supervisor. Our stakeholders suggested that in remediation coaching situations this guidance can start with an open question, inviting the remediating doctor to reflect in general on their experience throughout the remediation programme. If the meeting is face to face, then body language may be important in determining whether reflection is genuine or if they are just going through the motions. These meetings are also an opportunity to invite the remediating doctor to consider what they think the consequences, either positive or negative, are likely to be as a result of their efforts and progress so far.

Meetings with someone external to the organisation may be more effective than meetings with someone from within the organisation. This is because guided reflection will seem less threatening. For example, if someone is asked ‘what do you think the consequences might be if you do not engage in this programme?’ this may seem like an implied threat if it comes from someone senior within the organisation. If it comes from someone outside the organisation, or someone that is deemed impartial, it is much more likely to be perceived as a genuine question for reflection. This links back to the earlier points of receiving feedback in an environment that is perceived as being safe by the doctors involved (see Table 2, CMOcs 1 and 3).

In addition to face-to-face meetings, written reflective logs of experience and learning will help a remediating doctor to learn from their experiences. 49,51 The purpose of these logs is that they are meaningful to the remediating doctor and, therefore, should not form part of the assessment process. However, it may encourage engagement if a supervisor checks to ensure that reflections have been completed. 71 The idea that assessment of written reflections could diminish their effectiveness was also raised by stakeholders. Stakeholders were broadly agreed that such written reflections should not be summatively assessed, but noted that they might form part of a process of formative assessment that would enable remediating doctors to progress through the remediation process.

In general, the process of reflection may be most effective when divorced from the assessment of progress entirely. Like feedback presented initially, feedback on progress should also be as specific and objective as possible (see Table 2, CMOc 7). In our stakeholder group, it was suggested that multisource feedback, including feedback from patients, may be the most effective in engendering change, although clearly the optimum type of feedback would be dependent on the issues being remediated.

Realist analysis for guided reflection

Context–mechanism–outcome configuration 26 (Table 13) is derived from the importance attached to guided reflection through regular meetings, clearly evidenced in Box 13, extracts 1–6. This process of guidance functions as new context in a remediation programme. A common theme in these extracts is the notion that the process of regular guided reflection is used to ensure that remediating doctors are engaging with feedback and making sense of it, hence ‘making sense’ is a causal mechanism that helps change practice. The intervention strategies of face-to-face meetings and open questioning came from stakeholder group discussions. CMOc 27 illustrates how the mechanism of dissonance operates throughout a remediation programme, with the process of guided reflection facilitating the function of the dissonance mechanism at various points in the remediation journey.

Context–mechanism–outcome configuration 28 posits that the position of the individual providing the feedback is a context that determines how threatening the feedback is perceived to be. This links back to psychological safety, in that engagement and insight are more likely to follow when a remediating doctors feels safer. The idea that perceptions of safety will be enhanced if the person guiding the reflection is external to the employing organisation was derived from stakeholder group discussions.

Context–mechanism–outcome configuration 29 is based on the evidence (see extracts 6–8 in Box 13) that producing written reflections serves as contexts that trigger engagement. For example, extract 7 (see Box 13) describes this process as challenging ‘passivity’. This engagement allows the remediating doctor to integrate new knowledge and experiences, which is a mechanism that provides new insights and therefore more authentic learning and changes to performance or behaviour.

Programme theory

The complete programme theory of how remediation of doctors produces its effects is presented in Figure 3.

FIGURE 3.

Programme theory of remediation. Reproduced with permission from Price et al. 1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced with permission from Price et al. 1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

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.

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.

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(MAINSUBJECT.EXACT(“Remedial teaching” OR “Remedial education”) OR TI(remedia* or “reskilling” or “re-skilling” or “retraining” or “re-training”) OR AB(remedia* or “reskilling” or “re-skilling” or “retraining” or “re-training”)) AND (MAINSUBJECT.EXACT.EXPLODE(“Doctors”) OR TI(physician* or doctor* or clinician* or practitioner* or allergist* or anaesthesiologist* or cardiologist* or dermatologist* or endocrinologist* or gastroenterologist* or GP or GPs or geriatrician* or hospitalist* or neonatologist* or nephrologist* or neurologist* or neurosurgeon* or oncologist* or ophthalmologist* or otolaryngologist* or pathologist* or paediatrician* or pediatrician* or physiatrist* or psychiatrist* or pulmonologist* or radiologist* or rheumatologist* or surgeon* or urologist*) OR AB(physician* or doctor* or clinician* or practitioner* or allergist* or anaesthesiologist* or cardiologist* or dermatologist* or endocrinologist* or gastroenterologist* or GP or GPs or geriatrician* or hospitalist* or neonatologist* or nephrologist* or neurologist* or neurosurgeon* or oncologist* or ophthalmologist* or otolaryngologist* or pathologist* or paediatrician* or pediatrician* or physiatrist* or psychiatrist* or pulmonologist* or radiologist* or rheumatologist* or surgeon* or urologist*) OR TI((residen* or trainee*) and (medic* or clinic* or hospital* or surger* or surgical or radiolog* or patient* or “primary care” or “general practice”)) OR AB((residen* or trainee*) and (medic* or clinic* or hospital* or surger* or surgical or radiolog* or patient* or “primary care” or “general practice”)) OR TI(“continuing medical education”) OR AB(“continuing medical education”)).

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(remedia* OR reskilling OR re-skilling OR retraining OR re-training) AND (physician* or doctor* or clinician* or practitioner* or allergist* or anaesthesiologist* or cardiologist* or dermatologist* or endocrinologist* or gastroenterologist* or GP or GPs or geriatrician* or hospitalist* or neonatologist* or nephrologist* or neurologist* or neurosurgeon* or oncologist* or ophthalmologist* or otolaryngologist* or pathologist* or paediatrician* or pediatrician* or physiatrist* or psychiatrist* or pulmonologist* or radiologist* or rheumatologist* or surgeon* or urologist* or continuing medical education or ((residen* or trainee*) and (medic* or clinic* or hospital* or surger* or surgical or radiolog* or patient* or primary care or general practice)))