The Resident in The Resident in DifficultyDifficulty

University of BC University of BC Faculty of Medicine Faculty of Medicine

Department of Family PracticeDepartment of Family PracticePost Graduate Program Post Graduate Program

Written by Dr. Ken Harder December Written by Dr. Ken Harder December 20062006

Goals of this moduleGoals of this module

1.1. Identify the resident in difficulty.Identify the resident in difficulty.

2.2. Define the difficulties residents Define the difficulties residents may have.may have.

3.3. Provide a framework for planning Provide a framework for planning help.help.

4.4. Understand the failure, Understand the failure, remediation and probation remediation and probation process.process.

Task #1: Identify the Task #1: Identify the Resident in Difficulty Resident in Difficulty What do we What do we

mean by “The mean by “The resident in resident in difficulty”difficulty”

Divide into Divide into groups of 2 to 4 groups of 2 to 4 and, in five and, in five minutes come to minutes come to a consensus.a consensus.

Our working definition of Our working definition of “The resident in difficulty” “The resident in difficulty”

““A learner with academic performance A learner with academic performance that is significantly below that that is significantly below that expected because of an affective, expected because of an affective, cognitive, structural, or interpersonal cognitive, structural, or interpersonal difficulty.”difficulty.”

(Quirk, 1994)(Quirk, 1994)

If a resident If a resident makes you feel…makes you feel…

AnnoyedAnnoyedStressedStressed

ConfusedConfusedAvoidantAvoidant

ProtectiveProtective

There may be a problem.There may be a problem.

Categories of DifficultyCategories of Difficulty

AffectiveAffective InterpersonalInterpersonal StructuralStructural CognitiveCognitive

AffectiveAffective Personal situationsPersonal situations Psychological states: Psychological states:

low esteem, feelings of low esteem, feelings of being overwhelmed, being overwhelmed, guilt, fear of failure, guilt, fear of failure, depression, anxiety, etc.depression, anxiety, etc.

Feeling bad and Feeling bad and performing badlyperforming badly

Avoidance of learning, Avoidance of learning, failure to perform, failure to perform, withdrawalwithdrawal..

What situations have What situations have you encountered?you encountered?

Interpersonal #1Interpersonal #1

Learners have Learners have difficulty interacting difficulty interacting with otherswith others

Personal Personal characteristics:characteristics: Shy or non-assertiveShy or non-assertive Poor social skillsPoor social skills ManipulativeManipulative aggressiveaggressive

Interpersonal #2Interpersonal #2

Professional Professional behaviorsbehaviors

TeamworkTeamwork Prejudices – Prejudices –

racial, ethnic, racial, ethnic, gendergender

HonestyHonesty Ethical integrityEthical integrity

StructuralStructural Learners who are Learners who are

unable to structure unable to structure their experiences in their experiences in their environmenttheir environment.. Poor time Poor time

managementmanagement Lack of Lack of

organizational skillsorganizational skills Poor study disciplinePoor study discipline Excessive demandsExcessive demands

CognitiveCognitive Poor fund of knowledgePoor fund of knowledge Spatial perceptual Spatial perceptual

problemsproblems Oral communicationOral communication

ESL (English as a second ESL (English as a second language)language)

Poor Interviewing skillsPoor Interviewing skills Poor integration of Poor integration of

materialmaterial Learning disabilitiesLearning disabilities Written communicationWritten communication

Reading problemsReading problems Writing problemsWriting problems

BenchmarksBenchmarks

Please review the Resident Please review the Resident Benchmarks and the Bordage Stages Benchmarks and the Bordage Stages of Knowledge development at: of Knowledge development at: http://familymed.ubc.ca/residency/fahttp://familymed.ubc.ca/residency/facultydevelopment/BordageModel.htcultydevelopment/BordageModel.htmm. .

To understand what skills and To understand what skills and knowledge your resident is expected knowledge your resident is expected to haveto have

An ApproachAn Approach

STPSTP

SSpecify the problempecify the problem

TTarget / goalsarget / goals

PPlan and procedureslan and procedures

SSTPTPTask #2 Specify what the Task #2 Specify what the

problem isproblem is Take five minutes in your small Take five minutes in your small

groups to discuss:groups to discuss: Who should be involvedWho should be involved When should the problem should be When should the problem should be

dealt withdealt with Why it is important for you to deal Why it is important for you to deal

with this problemwith this problem How should a problem be How should a problem be

approachedapproached

SSTPTPSpecify the problemSpecify the problem

Gather and document information – Gather and document information – how does the learner fall short?how does the learner fall short?

Perception vs. realityPerception vs. reality Consider the learner, preceptor and Consider the learner, preceptor and

the learning environment.the learning environment. Always be aware of confidentialityAlways be aware of confidentiality Use a Team approachUse a Team approach Document, document, document.Document, document, document.

SSTTPPTarget / GoalsTarget / Goals

Discussion, Discussion, feedback, goal feedback, goal settingsetting

Resident Resident driven, program driven, program directeddirected

Document Document everythingeverything

These are a variety of These are a variety of interventions that might be interventions that might be

appropriate.appropriate. Discuss as a group possible Discuss as a group possible

interventions for dealing with a interventions for dealing with a resident having difficulty.resident having difficulty. Use examples from your own practiceUse examples from your own practice Do you have some teaching “pearls” Do you have some teaching “pearls”

that have worked for you in a difficult that have worked for you in a difficult situation? situation?

STSTPPPossible interventionsPossible interventions

Further Further assessmentassessment

More time on More time on rotationrotation

Schedule changeSchedule change Increased Increased

observation and observation and feedbackfeedback

Peer supportPeer support CounselingCounseling Leave of Leave of

absenceabsence Medical Medical

treatmenttreatment RemediationRemediation ProbationProbation

STSTPPPlans and ProceduresPlans and Procedures

Develop a planDevelop a plan Plan follow upPlan follow up learning learning

contract?contract?

Time to practice STP – Time to practice STP – Role PlayRole Play

Divide into groups of three. There are Divide into groups of three. There are three scenarios presented (or provide your three scenarios presented (or provide your own from personal experience). One own from personal experience). One preceptor, resident and observer. The preceptor, resident and observer. The preceptor should try to specify the problem, preceptor should try to specify the problem, set a goal and a plan in ten minutes. The set a goal and a plan in ten minutes. The resident should stay in role. Take 5 - 10 resident should stay in role. Take 5 - 10 minutes. The observers present a summary minutes. The observers present a summary and their observations to the group.and their observations to the group.

Scenarios may be printed from the last 6 Scenarios may be printed from the last 6 slidesslides

When a problem is not When a problem is not resolved.resolved.

(A process most of you will never or will (A process most of you will never or will rarely be involved in )rarely be involved in )

Rotation failureRotation failureRemediation Remediation ProbationProbationRemoval from the programRemoval from the program

Failing a residentFailing a resident

A mid-rotation evaluation should be A mid-rotation evaluation should be given, in person, and in writing given, in person, and in writing stating deficits, plans, and desired stating deficits, plans, and desired outcomesoutcomes

Documentation should be both Documentation should be both general and specific.general and specific.

A failed rotation results in A failed rotation results in remediation.remediation.

RemediationRemediation

A formal process of extra specified A formal process of extra specified training to enhance and further training to enhance and further evaluate a resident’s skills, evaluate a resident’s skills, knowledge and attitudes, that have knowledge and attitudes, that have been assessed to have significant been assessed to have significant deficits or concerns.deficits or concerns.

Outcome could be return to regular Outcome could be return to regular rotations, further remediation, or rotations, further remediation, or probation.probation.

ProbationProbation

Defined period of time.Defined period of time. Structured to address identified area Structured to address identified area

of weakness.of weakness. Outcome is either reinstatement or Outcome is either reinstatement or

dismissal.dismissal.

Remediation and Remediation and probation probation principlesprinciples

FairnessFairnessAccuracy Accuracy DocumentationDocumentation

FairnessFairness

Resident knows the rules.Resident knows the rules. Supervisor and resident are aware of Supervisor and resident are aware of

the objectives.the objectives. Adequate exposure for evaluation.Adequate exposure for evaluation. Previous evaluations kept Previous evaluations kept

confidential.confidential. Mid-rotation feedback is given.Mid-rotation feedback is given. Evaluations can be appealed.Evaluations can be appealed. The resident must have a mentor.The resident must have a mentor.

AccuracyAccuracy

Uniform standards apply which Uniform standards apply which are determined at the are determined at the supervisory level.supervisory level.

Evaluations are based on Evaluations are based on learning objectives.learning objectives.

Specific examples are given in Specific examples are given in evaluationsevaluations..

DocumentationDocumentation

Of problems – sequentialOf problems – sequential Of evaluations – sequentialOf evaluations – sequential Of interventions – sequentialOf interventions – sequential Of quantitative and qualitative Of quantitative and qualitative

evaluationsevaluations

If you encounter a resident If you encounter a resident in difficulty rememberin difficulty remember

Specify the ProblemSpecify the Problem

Targets and goalsTargets and goals

Plans and ProceduresPlans and Procedures

Case 1Case 1PreceptorPreceptor

You are working with a Second You are working with a Second year resident who is always year resident who is always smiling and hanging on your smiling and hanging on your every word. He tells you that your every word. He tells you that your knowledge of medicine and knowledge of medicine and clinical acumen is excellent (at clinical acumen is excellent (at least twice a day!) You feel a need least twice a day!) You feel a need to “brush him aside,” but he to “brush him aside,” but he seems to be all over you.seems to be all over you.

Case 1Case 1LearnerLearner

You are a second-year You are a second-year resident and a very insecure resident and a very insecure person who needs to be liked. person who needs to be liked. You have difficulty dealing You have difficulty dealing with authority figures. You with authority figures. You compensate by being compensate by being ingratiating.ingratiating.

Case 2Case 2PreceptorPreceptor

You are working with a first-year You are working with a first-year resident who attends regularly, resident who attends regularly, appears to do her work well, but appears to do her work well, but asks a lot of detailed questions asks a lot of detailed questions about each case. When asked to about each case. When asked to pursue a particular topic, she pursue a particular topic, she never reports back or indicates never reports back or indicates that she has completed the task. that she has completed the task. In addition, she does not seem to In addition, she does not seem to read on her own initiative.read on her own initiative.

Case 2Case 2LearnerLearner

You are first-year resident who You are first-year resident who never learned to be an never learned to be an independent learner. You are used independent learner. You are used to a very didactic teaching style to a very didactic teaching style from medical school and don’t from medical school and don’t know how to do independent know how to do independent reading or research and are reading or research and are completely at a loss as to how to completely at a loss as to how to proceed. You rely on your proceed. You rely on your preceptor for all of the answers.preceptor for all of the answers.

Case 3Case 3PreceptorPreceptor

A senior resident has missed at A senior resident has missed at least two clinics per week during least two clinics per week during the past month. This resident has the past month. This resident has called in several times claiming called in several times claiming not to feel well. At work the not to feel well. At work the resident appears to be irritable resident appears to be irritable and distractible.and distractible.

Case 3Case 3LearnerLearner

You are a resident with a You are a resident with a substance abuse problem. substance abuse problem. You have excessive work You have excessive work absence, irritability, and poor absence, irritability, and poor work performance.work performance.

Thank YouThank You This module was written as an aid to the This module was written as an aid to the

Preceptors in the Postgraduate Family Preceptors in the Postgraduate Family Practice Program at the University of Practice Program at the University of BC.BC. Study credit is available to groups of Study credit is available to groups of

preceptors who complete the modulepreceptors who complete the module Please give us your feedback on the module Please give us your feedback on the module

so that we may improve it for others.so that we may improve it for others. Email you comments to Dr. Fraser Norrie, Email you comments to Dr. Fraser Norrie,

Faculty Development, UBC Family PracticeFaculty Development, UBC Family Practice Fraser.Norrie@vch.caFraser.Norrie@vch.ca