The faculty hour problem with communication remediation

What the faculty-hour evidence actually measures

Guerrasio and Aagaard tracked 53 learners with clinical reasoning deficits in a structured remediation program at the University of Colorado. The mean was 29.6 specialist contact hours, including 20.4 hours of face-to-face work and 9.2 hours of email. The study did not measure communication remediation, and it excluded time from program directors, Clinical Competency Committees, coordinators, and legal teams.

That distinction matters. The number is good evidence that individual remediation can absorb substantial specialist time. It is not evidence for a 29-to-45-hour or 25-to-75-hour range across competencies and institutions, and it gets cited that way often enough that it is worth saying so.

Program directors are asking for a repeatable process

A 2017 CERA survey reached 267 family medicine program directors. Of the respondents, 93% reported at least one resident in remediation during the prior three years, and 50% selected an accessible remediation toolkit as the most important tool for improving the process. Another 22% identified missing documentation as a major challenge (Frazier et al., 2021).

The survey does not isolate communication cases, so it should not be read as a communication-remediation prevalence estimate. It does show that remediation is common in family medicine and that program directors want a more consistent way to identify a deficiency, assign work against it, and reassess progress.

Not all of those hours are the same kind of hour

Sort a remediation plan by what actually requires a physician in the room and it splits cleanly in two.

On one side sit the decisions: defining the concern, reviewing performance, coaching the learner, judging whether the evidence is enough for the CCC. Those need faculty judgment and there is no version of remediation that removes them.

On the other side sit the repetitions. A learner working on how they respond to a family's anger needs to do it more than twice, and each attempt has historically consumed a faculty hour, a standardized patient booking, or both. That is the avoidable part, and it is the part that scales badly: the learner who needs the most practice is the one whose program can least afford to schedule it.

ClinicalSim separates those jobs. Learners run physician-authored communication scenarios between coaching sessions, each scored against the standard approved for that case, with the learner's own words quoted under every score. The platform extends faculty coaching and standardized patient programs rather than replacing either one.

What a coach reads before the session

The argument for separating practice from coaching only works if what comes back is worth a coach's attention. Here is one of the encounters we publish in full, so that is checkable rather than asserted.

A pediatric hematology-oncology fellow meets Monique Williams, whose thirteen-year-old son has HbSS sickle cell disease and has been taking hydroxyurea inconsistently. She opens the conversation like this: "Before we start, let me just say it. Nobody in these places really listens to Black patients, and that medicine you keep pushing makes my son feel sick. So tell me why I should keep giving it to him."

Nine minutes and 39 conversational turns later, the encounter scores 18 out of 25 against the MITI global ratings and 17 out of 25 against NURSE. The fellow did the hardest thing in the case well, refusing to falsely reassure her about long-term safety and saying plainly that the data does not exist.

The lowest of the five NURSE elements is exploring, at 3 out of 5, and the reason is specific: the fellow's open questions went after content and logistics, what the mother knew about the drug, where she was reading, when to bring Jordan in, and never after the feeling underneath. The mistrust in that opening line was named and then left alone. The report suggests what a question aimed at the emotion would have sounded like: "Can you tell me more about the times you've felt unheard here, so I understand what to do differently?"

A coach who reads that before the session starts from a named behavior, the verbatim moment it was missed, and a concrete alternative. A coach who has only "the encounter went reasonably well" spends the first half of the session finding all three.

Documentation has to show change over time

The CERA survey found that missing documentation often delays or weakens remediation. A useful communication-remediation record shows the assigned skill, the standard used to assess it, what the learner actually said, and whether the same behavior changed on later attempts.

That is the practical case for structured practice, and it is not a cost-savings claim. We are not attaching a dollar figure to faculty hours, because the published 29.6-hour mean does not support one for communication. The case is narrower and easier to defend: faculty get better evidence before the next coaching session, and the CCC gets a record it can actually evaluate.