RE M E D I A T I O N / P R O B A T I O N T E M P L A T E

Please submit to: Postgraduate Medical Education Office (PGME)

SchulichSchool of Medicine & Dentistry

MSB Room 103,Western University

for PGE ADVISORY BOARD(PGE:AB) review and approval

Today’s Date:
Resident’s Name:
Training Program:
Program Director’s Name:
Training Year:
Dates of Unsuccessful rotation:
Location and topic of Unsuccessful rotation:
Proposed Start Date of Remed/Prob Plan: (pending PGE:AB Approval)
Location of Proposed Rotation:
Remediation Supervisor’s name:
RemediationMentor’s name:

A. REQUEST OF RESIDENCY PROGRAM COMMITTEE TO POSTGRADUATE EDUCATION ADVISORY BOARD(PGE:AB)

□ Remediation period of ______blocks

□ Probation period of ______blocks

□ Other:

B. BACKGROUND

1. Training Profile

The overview of the training profile is outlined below:

  • DATES (e.g. July 2007-June 2008)
  • < Year One > OUTCOMES of training and evaluations
  • DATES (e.g. July 2008-June 2009)
  • < Year Two > OUTCOMES of training and evaluations
  • DATES (e.g. July 2009-June 2010)
  • < Year Three > OUTCOMES of training and evaluations

NOTES:

  • Append ITERS, FITER
  • Other relevant evaluations, documents

2. Development of the PLAN

□ Residency Training Committee (RTC) involved in development of plan

□ Resident involved in development of plan

□ Resident has been provided a copy of the plan

□ Resident has received a copy of the “Resident Evaluation and Appeals Policy”

  • Describe the involvement by the Residency Training Committee in development of the plan
  • Describe the involvement by the Resident in development of the plan
  • Comment on Resident’s opportunity to meet about the remediation plan with RTC
  • List and describe any extenuating circumstances pertinent to the PGE ADVISORY BOARD/Associate Dean

3. PGE ADVISORY BOARD Profile

Outline previous PGE:Advisory Board actions for this trainee:

□ Not Applicable

□ Resident was previously considered by the PGE ADVISORY BOARD (state dates and outcomes)

C.PLAN

1. Rationale

  • Identify the aspects of the Trainee’s performance or behaviour that require remedial attention, with reference to specific learning objectives
  • Specify individual deficiencies to be addressed. List these by CanMEDS competency, with specific details.

2. Outline of Remediation or Probation Plan

For each identified deficiency:

Describe the proposed education and the resourcesavailable to the Trainee

State the name of the individual responsible for organizing and administering each item

State the specific duration of theremediation plan

Define the expected outcomes of the remediation plan and how they will be evaluated

State the consequences of a successful or unsuccessful outcome of the remediation plan

Specifically, the remediation plan will focus on meeting the goals and objectives

related to:

□ Medical Expert / □ Communicator
□ Collaborator / □ Advocate
□ Scholar / □ Manager
□ Professional

For CFPC programs, the remediation plan will focus on meeting the Four Principles of

Family Medicine:

□ The Family Physician is a Skilled Clinician / □ The Family Physician is a Resource to a Defined Practice Population
□ Family Medicine is Community-Based / □ The Doctor-Patient Relationship is Central to the Role of the Family Physician

3. Conduct of the remediation plan

  • Specify the frequency of feedback:
  • Meetings with supervisor
  • Meetings with mentor
  • Formative feedback
  • Interim evaluations

4. Outcome of the remediation plan

  • Successful completion of the plan will result in:
  • Unsuccessful completion of the plan will result in:

SIGNATURES REQUIRED:

______

Program DirectorDate

Resident:

□ Agree______

Date

□ Has reviewed but requested modification of the plan(please attach comments or provide directly to the PGME )

______

ResidentDate

NOTE: The plan is not in effect, and cannot begin, until approved by PGE:ADVISORY BOARD.

Approval date by PGE:ADVISORY BOARD ______

Date

Remediation/ProbationPlanpage 1 of 4

Confidential Form revised: 18 September 2018