Dealing with the challenging learner/student/resident/faculty

1. Dealing with the challenging learner/student/resident/faculty March 30, 2010 Happy Passover!

2. Outline • Scenarios from Liles • Examples from the crowd • Feedback techniques • Getting to Yes • Made to Stick • 1 minute preceptor

3. Scenario 1 • Clinic attending calls me to complain about a resident X • X is habitually late for preclinic conference • X is unprepared for preclinic conference • “I need you to talk to X”

4. Feedback • Feedback is clinical teaching • Feedback is given a lot more often than it’s labeled as “feedback” • Learners consistently say they want more feedback • Feedback can occur on any facet of the encounter…communication skills, PE, assessment, differential, written work, presentation, literature review, etc.

5. Groundwork for Feedback • Set the climate and establish the goals • The more explicit expectations are initially the better! • Demand self-assessment • “What did you do well?” • “Where do you need to improve?”

6. How to Give Feedback • Label your feedback • Deal with performance not performer • In negative and positive feedback • Focus on remediable behaviors

7. Effective Feedback • Focused • Honest • Timely • Private sometimes • Specific • Behaviorally focused • Based on shared, understood objectives/expectations (Day 1!)

8. Scenario 1b • Receive email forwarded to me from division chief, chief received it from nurse manager who heard a story from a charge nurse about a negative interaction a night nurse had with resident Y • Resident Y was verbally abusive to the RN • Resident Y used foul language and shouted at the RN • “will you address this incident with resident Y?”

9. Scenario 2 – tardy attending • Receive several emails and hallway comments about an attending who is frequently late • Signs out in am by phone • Delays rounds (or absent) • Administrators frustrated with lack of paper work • What do you do?

10. Getting to Yes“what is the best way for people to deal with their differences?” • Separate the people from the problem • Relationship v substance • Focus on interests, not positions • Principles/demands, ask “why” and “for what purpose” • Invent options for mutual gain • Prioritize, other side’s interests, “help me understand” • Allow student to set the goals • Insist on using objective criteria • Shared, explicit, objective outcomes (measurable)

11. Scenario 3 – brash resident • Consultant attending (psychiatry) stops me and relays concerns about interaction with resident Z • Aggressive, demanding, accusatory • RNs stop me in MPCU • Put off – “disrespectful” • Resident Z is very bright, decisive, opinionated (and not southern) • What to do?

12. Scenario 4 • Student S is energetic, seems very bright • Work ups are cursory • Probing for more info on S’s patients leads to more confusion • Offer of student teaching rounds are met with enthusiasm • I get stood up • Excuses offered multiple times • I am asked for letter of recommendation

13. Scenario 5 • Student Q is quiet • Student Q meets every expectation I set • Knows details of patients when asked • Is prompt • Never joins the conversation, offer opinions • Rarely asks questions, but will respond to rounding questions from me • Is this a problem?

14. Scenario 6 • “Subterfuge by the RN” • 55 yo with abdominal pain felt to be constipation related • After 4 calls to me informing me of patient’s continued abdominal pain I go to the room • In room RN dismisses my idea of Golytely for the pain and asks for narcotics for patient (this is after multiple attempts at explanation of negative effects of narcotics on this situation and need for pooping)

15. Made to StickLessons From Marketing • Simple • Unexpected • Concrete • Credentialed • Emotional • Story

16. Simple • Core • Masters of Exclusion • Mission Intent • Ask “why” or “what” seven times • Use existing schema to add knowledge • The power of analogy • The curse of knowledge – we no longer know what is simple

17. Unexpected • Demonstrate Gaps in existing knowledge • You have to start with knowledge though • Curiosity • We stay up to watch the end of movies – even bad ones • Mystery attracts our attention • Shift from “what I want them to know” to “what questions I want them to ask”

18. Concrete • Build on knowledge and existing schema • Enduring points • Aesop, proverbs, concrete examples (cases, stories) • Put abstract ideas into context • Asian Math Teaching • Invite people to the table

19. Credible • Details • Sinatra test – “if I can make it there…” • Past success, precedent • Challenge

20. Emotional • Action is spurred by caring and feeling • Generate caring • Self interest • Idealized self – what would a person like me do? • Create a mission

21. Story • Mental simulations • Avoid going straight to the points and skipping the story

22. Made to Stick Summary:For Effective Communication an audience must… • Pay attention • Understand and remember • Agree and believe • Care • Be able to act on it!

23. Scenario 7 • Underperforming resident/intern/student • Unprepared for rounds • Unaware of recent data – vitals/labs • Defers plan-making to me

24. A Model for Efficient Teaching…The One Minute Preceptor • Get a commitment • Probe for supporting evidence • Reinforce what was done right • Correct mistakes • Teach general rules • Summarize

25. How and When to Apply • Usual • After the usual presentation • ? Most appropriate for less experienced learner • Hard to break this habit! • True One Minute Preceptor • These steps are the entire presentation • ? Most appropriate for more advanced learner • ? More in-sync with adult learning theory

26. Get a Commitment • What do you think is going on? • Forces the learner to assimilate information and make a decision. • This process can then be explored • Probe for Supporting Evidence • Why do you think so? • This is usually where the action is and illustrates the thought process • Leads to discussion and reflection

27. Reinforce what was done right • I agree with…, I think you are correct with…, That is right on target…, • This is the beginning of the feedback part – BE SPECIFIC • Correct mistakes/omissions • Probe and Question • “In your presentation, I would have liked to have known about……” • BE SPECIFIC

28. Teach general rules • Can be anything related to the patient. Just choose 1 topic. (enemy of good is perfect) • Take the learner one step further • Summarize • Educational and Time-Saving?!?

29. Summary • Frustration = expectation/reality • Listen and ask questions • Use objective measures • Find common ground