National survey of internal medicine residency program directors regarding problem residents

Context: Internal medicine residency training is demanding and residents can experience a wide variety of professional and personal difficulties. A problem resident is defined by the American Board of Internal Medicine as 'a trainee who demonstrates a significant enough problem that requires intervention by someone of authority.' Data are sparse regarding identification and management of such residents. Objective: To gain more understanding of the prevalence, identification, management, and prevention of problem residents within US internal medicine residency programs. Design, Setting, and Participants: Mailed survey of all 404 internal medicine residency program directors in the United States in October 1999, of whom 298 (74%) responded. Main Outcome Measures: Prevalence of problem residents; type of problems encountered; factors associated with identification and management of problem residents. Results: The mean point prevalence of problem residents during academic year 1998-1999 was 6.9% (SD, 5.7%; range, 0%-39%), and 94% of programs had problem residents. The most frequently reported difficulties of problem residents were insufficient medical knowledge (48%), poor clinical judgment (44%), and inefficient use of time (44%). Stressors and depression were the most frequently identified underlying problems (42% and 24%, respectively). The most frequent processes by which problem residents were discovered included direct observation (82%) and critical incidents (59%). Chief residents and attending physicians most frequently identified problem residents (84% and 76%, respectively); problem residents rarely identified themselves (2%). Many program directors believed that residents who are from an under-represented minority, are international medical graduates, or are older than 35 years are at increased risk of being identified as a problem resident (P<lt>.05). Program directors believed that frequent feedback sessions (65%) and an assigned mentor for structured supervision (53%) were the most helpful interventions. Conclusion: Nearly all internal medicine residency programs in this sample had problem residents, whose presenting characteristics and underlying issues were diverse and complex.