The Resident in Difficulty

1. The Resident in Difficulty University of BC Faculty of Medicine Department of Family Practice Post Graduate Program Written by Dr. Ken Harder December 2006 This module is designed to be an interactive activity utilizing the experience and expertise of the group to look at the resident in difficulty. It can be presented in 45 minutes as a power point lecture or as a facilitated small group session. If role plays and have some interaction around remediation and probation are included you may need 90 minutes. Questions are posed in red throughout the presentation. These are intended to promote discussion to gain insights of all participants. This module is designed to be an interactive activity utilizing the experience and expertise of the group to look at the resident in difficulty. It can be presented in 45 minutes as a power point lecture or as a facilitated small group session. If role plays and have some interaction around remediation and probation are included you may need 90 minutes. Questions are posed in red throughout the presentation. These are intended to promote discussion to gain insights of all participants.

2. Goals of this module Identify the resident in difficulty. Define the difficulties residents may have. Provide a framework for planning help. Understand the failure, remediation and probation process. Most medical students and residents will have weaknesses and trouble in some areas but only a very small minority will truly be �in difficulty�. It is important for preceptors to recognize when a resident is in difficulty and understand what may be causing the trouble. Once recognized most of these situations can be addressed. The Site Director and Site Faculty are there to help you with these situations. If in doubt, call for help. Most medical students and residents will have weaknesses and trouble in some areas but only a very small minority will truly be �in difficulty�. It is important for preceptors to recognize when a resident is in difficulty and understand what may be causing the trouble. Once recognized most of these situations can be addressed. The Site Director and Site Faculty are there to help you with these situations. If in doubt, call for help.

3. Task #1: Identify the Resident in Difficulty What do we mean by �The resident in difficulty� Divide into groups of 2 to 4 and, in five minutes come to a consensus. We need understand the definition of the �resident in difficulty� if we are to have an effective approach. Please discuss your ideas in small groups for five minutes and then each group should spend one minute presenting their ideas. We need understand the definition of the �resident in difficulty� if we are to have an effective approach. Please discuss your ideas in small groups for five minutes and then each group should spend one minute presenting their ideas.

4. Our working definition of �The resident in difficulty� �A learner with academic performance that is significantly below that expected because of an affective, cognitive, structural, or interpersonal difficulty.� (Quirk, 1994) This is the definition that most authors agree upon.This is the definition that most authors agree upon.

5. If a resident makes you feel� Annoyed Stressed Confused Avoidant Protective There may be a problem. Be aware that the first clue that your resident is in difficulty may be the feelings that he or she engenders in you. Be aware that the first clue that your resident is in difficulty may be the feelings that he or she engenders in you.

6. Categories of Difficulty Affective Interpersonal Structural Cognitive It is helpful to catergorize the types of problems that residents encounter. Most authors accept the following categories as practical. Residents may have problems in more than one category.It is helpful to catergorize the types of problems that residents encounter. Most authors accept the following categories as practical. Residents may have problems in more than one category.

7. Affective Personal situations Psychological states: low esteem, feelings of being overwhelmed, guilt, fear of failure, depression, anxiety, etc. Feeling bad and performing badly Avoidance of learning, failure to perform, withdrawal. What situations have you encountered? Personal situations and psychological states: Difficult personal situations and subsequent anxiety or depression can sometimes be difficult to identify in normally high functioning individuals. Feeling Bad and Performing badly: Anxiety and a depressed mood lead to poor performance which then leads to further poor performance. A vicious cycle. Avoidance is commonly seen with affective problems. What examples have the group encountered.Personal situations and psychological states: Difficult personal situations and subsequent anxiety or depression can sometimes be difficult to identify in normally high functioning individuals. Feeling Bad and Performing badly: Anxiety and a depressed mood lead to poor performance which then leads to further poor performance. A vicious cycle. Avoidance is commonly seen with affective problems. What examples have the group encountered.

8. Interpersonal #1 Learners have difficulty interacting with others Personal characteristics: Shy or non-assertive Poor social skills Manipulative aggressive Interpersonal Personal characteristics are often well established traits and are hence often difficult to deal with. These characteristics could be hiding other issues. This list is not exhaustive. Interpersonal Personal characteristics are often well established traits and are hence often difficult to deal with. These characteristics could be hiding other issues. This list is not exhaustive.

9. Interpersonal #2 Professional behaviors Teamwork Prejudices � racial, ethnic, gender Honesty Ethical integrity A resident must be respectful of each of his or her colleagues and co-workers and have the ability to work cooperatively in a team environment. Teamwork requires an understanding of the role of each team member and a respect for each team member�s value. Issues of prejudice, personal honesty or ethical integrity must be addressed immediately. You should seek guidance from the Site or Program Director. A resident must be respectful of each of his or her colleagues and co-workers and have the ability to work cooperatively in a team environment. Teamwork requires an understanding of the role of each team member and a respect for each team member�s value. Issues of prejudice, personal honesty or ethical integrity must be addressed immediately. You should seek guidance from the Site or Program Director.

10. Structural Learners who are unable to structure their experiences in their environment. Poor time management Lack of organizational skills Poor study discipline Excessive demands One wonders how residents with poor time management and organizational skills made it through medical school. The rigors of a residency that involves more than books and exams may prove too much. Some residents may be stretched between work, study and family responsibilities. A resident who is chronically late or leaves at the crack of five pm regardless of the clinical situation could reflect poor time management or lack of interest. This same scenario, however, could be explained by an inflexible daycare and unmanageable childcare responsibilities. The resident who has always managed in the past may have taken on too much and need help to re-organize his or her life. One wonders how residents with poor time management and organizational skills made it through medical school. The rigors of a residency that involves more than books and exams may prove too much. Some residents may be stretched between work, study and family responsibilities. A resident who is chronically late or leaves at the crack of five pm regardless of the clinical situation could reflect poor time management or lack of interest. This same scenario, however, could be explained by an inflexible daycare and unmanageable childcare responsibilities. The resident who has always managed in the past may have taken on too much and need help to re-organize his or her life.

11. Cognitive Poor fund of knowledge Spatial perceptual problems Oral communication ESL (English as a second language) Poor Interviewing skills Poor integration of material Learning disabilities Written communication Reading problems Writing problems The problems experienced in this category are diverse. Consider the �educational diagnosis�. Does the resident simply lack knowledge or is the knowledge poorly organized or inaccessible? What should the resident�s skills be at each level of his or her training. Please review the Resident Benchmarks and the Bordage stages of knowledge development at: http://www.familymed.ubc.ca/residency/facultydevelopment/BordageModel.htm. Remember that learning disabilities do exist in adults. Some residents may need special testing to diagnose unique problems. Helping residents with these types of difficulties may require specialized help which the Site and Program directors could help you with.The problems experienced in this category are diverse. Consider the �educational diagnosis�. Does the resident simply lack knowledge or is the knowledge poorly organized or inaccessible? What should the resident�s skills be at each level of his or her training. Please review the Resident Benchmarks and the Bordage stages of knowledge development at: http://www.familymed.ubc.ca/residency/facultydevelopment/BordageModel.htm. Remember that learning disabilities do exist in adults. Some residents may need special testing to diagnose unique problems. Helping residents with these types of difficulties may require specialized help which the Site and Program directors could help you with.

12. Benchmarks Please review the Resident Benchmarks and the Bordage Stages of Knowledge development at: http://familymed.ubc.ca/residency/facultydevelopment/BordageModel.htm. To understand what skills and knowledge your resident is expected to have

13. An Approach We have defined �The Resident in difficulty� and categorized the kinds of difficulties they might have. We can approach this problem using skills we have as physicians. We have defined �The Resident in difficulty� and categorized the kinds of difficulties they might have. We can approach this problem using skills we have as physicians.

14. STP Specify the problem Target / goals Plan and procedures This model parallels what doctors do every day. When we see a patient we make a diagnosis, determine goals of treatment and make plans to achieve these goals. This approach works well for the resident in difficulty.This model parallels what doctors do every day. When we see a patient we make a diagnosis, determine goals of treatment and make plans to achieve these goals. This approach works well for the resident in difficulty.

15. STPTask #2 Specify what the problem is Take five minutes in your small groups to discuss: Who should be involved When should the problem should be dealt with Why it is important for you to deal with this problem How should a problem be approached Recognizing and specifying the problem is the most difficult task. Working in small groups, answer the who, when, why and how questions. (five minutes) Who Other teachers/preceptors Family doctor � for medical problems The Site director and sometimes the Program director Psychiatrist ? Learning problem specialist ? When Problems should be dealt with as soon as they are recognized. The usual response is to feel that �it�s probably OK and I�m over reacting� and problems persist for some time before being addressed OR never get addressed at all! Better to report a concern early when there is more time for remediation. Why For the sake of our medical system (i.e. so that we train competent doctors) For the sake of our residents. That they get the most out of their residency. For the sake of our patients For the sake of our preceptors, so that they can carry on. How Documentation is vital. Regularly documented evaluations and observations. Record specific incidents. Collect reports from all teachers working with the resident. Mid term evaluations are an important time to review with the resident. They need to be aware of the concern. Timely feedback. Does the resident accept and appear to incorporate feedback received? This discussion should establish that one should not try to deal with the resident in difficulty on their own. The resident and the preceptor need to agree that there is a problem before a plan can be made to correct it. The preceptor may manage minor problems him or herself but is encouraged to get help from the Site director, Site faculty or Program director if they feel at all unsure as to how to proceed. The next slide acts as a summary.Recognizing and specifying the problem is the most difficult task. Working in small groups, answer the who, when, why and how questions. (five minutes) Who Other teachers/preceptors Family doctor � for medical problems The Site director and sometimes the Program director Psychiatrist ? Learning problem specialist ? When Problems should be dealt with as soon as they are recognized. The usual response is to feel that �it�s probably OK and I�m over reacting� and problems persist for some time before being addressed OR never get addressed at all! Better to report a concern early when there is more time for remediation. Why For the sake of our medical system (i.e. so that we train competent doctors) For the sake of our residents. That they get the most out of their residency. For the sake of our patients For the sake of our preceptors, so that they can carry on. How Documentation is vital. Regularly documented evaluations and observations. Record specific incidents. Collect reports from all teachers working with the resident. Mid term evaluations are an important time to review with the resident. They need to be aware of the concern. Timely feedback. Does the resident accept and appear to incorporate feedback received? This discussion should establish that one should not try to deal with the resident in difficulty on their own. The resident and the preceptor need to agree that there is a problem before a plan can be made to correct it. The preceptor may manage minor problems him or herself but is encouraged to get help from the Site director, Site faculty or Program director if they feel at all unsure as to how to proceed. The next slide acts as a summary.

16. STPSpecify the problem Gather and document information � how does the learner fall short? Perception vs. reality Consider the learner, preceptor and the learning environment. Always be aware of confidentiality Use a Team approach Document, document, document. Perception vs. reality. Is there truly a problem or is it only a problem in the eyes of the preceptor? Does the resident believe or accept that there is a problem? Communication is key. Consider the learner, preceptor and the learning environment � some authors use the approach of considering these three things in any resident in difficulty scenario as a starting point as well as a template for solution. These are some summary statements to accompany the previous slide.Perception vs. reality. Is there truly a problem or is it only a problem in the eyes of the preceptor? Does the resident believe or accept that there is a problem? Communication is key. Consider the learner, preceptor and the learning environment � some authors use the approach of considering these three things in any resident in difficulty scenario as a starting point as well as a template for solution. These are some summary statements to accompany the previous slide.

17. STPTarget / Goals Discussion, feedback, goal setting Resident driven, program directed Document everything There is a tendency to have discussions about a problem but not to specify the target goals the resident is expected to achieve. A target goal must be set to make progress and the resident needs to know when he or she has corrected the problem. Discuss the problem with the resident. Give on going feedback as they work towards the goal. The solution should be resident driven with your and the Program�s guidance. Document the problem, your plan of action and your goals. The resident must understand what needs to be done to correct the problem. There is a tendency to have discussions about a problem but not to specify the target goals the resident is expected to achieve. A target goal must be set to make progress and the resident needs to know when he or she has corrected the problem. Discuss the problem with the resident. Give on going feedback as they work towards the goal. The solution should be resident driven with your and the Program�s guidance. Document the problem, your plan of action and your goals. The resident must understand what needs to be done to correct the problem.

18. These are a variety of interventions that might be appropriate. Discuss as a group possible interventions for dealing with a resident having difficulty. Use examples from your own practice Do you have some teaching �pearls� that have worked for you in a difficult situation? Discuss as a group possible interventions for dealing with a resident in difficulty. To get the group started you could suggest a particular problem and see how different members of your group might chose to intervene. Discuss as a group possible interventions for dealing with a resident in difficulty. To get the group started you could suggest a particular problem and see how different members of your group might chose to intervene.

19. STPPossible interventions Further assessment More time on rotation Schedule change Increased observation and feedback Peer support Counseling Leave of absence Medical treatment Remediation Probation This is a list of some possible methods to achieve agreed upon goals. This is a list of some possible methods to achieve agreed upon goals.

20. STPPlans and Procedures Develop a plan Plan follow up learning contract? Summary Slide. A plan follow up is very important. Agree on dates for subsequent meetings at the end of each meeting. Diarize! Learning contract � At the beginning of every rotation we encourage students and residents to set the goals they wish to achieve during that rotation. A similar process can be done with a �Learning contract� in a problem remediation process. Write out what is planned and when it will be achieved. Schedule a regular review to be sure the time line is being met.Summary Slide. A plan follow up is very important. Agree on dates for subsequent meetings at the end of each meeting. Diarize! Learning contract � At the beginning of every rotation we encourage students and residents to set the goals they wish to achieve during that rotation. A similar process can be done with a �Learning contract� in a problem remediation process. Write out what is planned and when it will be achieved. Schedule a regular review to be sure the time line is being met.

21. Time to practice STP � Role Play Divide into groups of three. There are three scenarios presented (or provide your own from personal experience). One preceptor, resident and observer. The preceptor should try to specify the problem, set a goal and a plan in ten minutes. The resident should stay in role. Take 5 - 10 minutes. The observers present a summary and their observations to the group. Scenarios may be printed from the last 6 slides Three scenarios are provided. You could provide your own Works in groups of 3 � preceptor, resident, observer Allow 5 to 10 minutes per role play Have the observer present a summary of the scenarios and their observation to the whole group.Three scenarios are provided. You could provide your own Works in groups of 3 � preceptor, resident, observer Allow 5 to 10 minutes per role play Have the observer present a summary of the scenarios and their observation to the whole group.

22. When a problem is not resolved.(A process most of you will never or will rarely be involved in ) Rotation failure Remediation Probation Removal from the program There is a process to deal with serious problems. These steps are taken in consultation with the Site director, the Program director and other involved preceptors and evaluators. There is a process to deal with serious problems. These steps are taken in consultation with the Site director, the Program director and other involved preceptors and evaluators.

23. Failing a resident A mid-rotation evaluation should be given, in person, and in writing stating deficits, plans, and desired outcomes Documentation should be both general and specific. A failed rotation results in remediation. Failure is not always a bad thing. It gives the resident an opportunity to improve critical skills in a process of remediation. �Borderline� assessments often allow a resident to carry on, unaware of important deficits. When these deficits are discovered later there may be inadequate time to correct them. Failure is not always a bad thing. It gives the resident an opportunity to improve critical skills in a process of remediation. �Borderline� assessments often allow a resident to carry on, unaware of important deficits. When these deficits are discovered later there may be inadequate time to correct them.

24. Remediation A formal process of extra specified training to enhance and further evaluate a resident�s skills, knowledge and attitudes, that have been assessed to have significant deficits or concerns. Outcome could be return to regular rotations, further remediation, or probation. Usually a resident has a �fresh start� with each rotation. Preceptors are not made aware of assessments from previous rotations so that they will not be prejudiced towards the resident in their assessments. This is not the case when remediation is undertaken. In this case the preceptors giving remediation are clearly aware of the problems which need to be addressed so that they can receive specific attention. Time and energy can be appropriately focused Usually a resident has a �fresh start� with each rotation. Preceptors are not made aware of assessments from previous rotations so that they will not be prejudiced towards the resident in their assessments. This is not the case when remediation is undertaken. In this case the preceptors giving remediation are clearly aware of the problems which need to be addressed so that they can receive specific attention. Time and energy can be appropriately focused

25. Probation Defined period of time. Structured to address identified area of weakness. Outcome is either reinstatement or dismissal.

26. Remediation and probation principles Fairness Accuracy Documentation This process, although designed to help the resident improve his or her skills and attain the required skill level, also carries serious consequences for the resident who does not successfully complete the remediation process. This serious process for the resident must be fair, accurate and well documented. This process, although designed to help the resident improve his or her skills and attain the required skill level, also carries serious consequences for the resident who does not successfully complete the remediation process. This serious process for the resident must be fair, accurate and well documented.

27. Fairness Resident knows the rules. Supervisor and resident are aware of the objectives. Adequate exposure for evaluation. Previous evaluations kept confidential. Mid-rotation feedback is given. Evaluations can be appealed. The resident must have a mentor.

28. Accuracy Uniform standards apply which are determined at the supervisory level. Evaluations are based on learning objectives. Specific examples are given in evaluations.

29. Documentation Of problems � sequential Of evaluations � sequential Of interventions � sequential Of quantitative and qualitative evaluations The resident deserves clear documentation of his or her problems. The Program must have good documentation of problems and how they have been addressed. If punitive action is ever necessary the Program must be able to clearly show that the resident was made aware of the problems and was given the appropriate opportunity to correct the problem. This all must be documented. The resident deserves clear documentation of his or her problems. The Program must have good documentation of problems and how they have been addressed. If punitive action is ever necessary the Program must be able to clearly show that the resident was made aware of the problems and was given the appropriate opportunity to correct the problem. This all must be documented.

30. If you encounter a resident in difficulty remember Specify the Problem Targets and goals Plans and Procedures

31. Case 1Preceptor You are working with a Second year resident who is always smiling and hanging on your every word. He tells you that your knowledge of medicine and clinical acumen is excellent (at least twice a day!) You feel a need to �brush him aside,� but he seems to be all over you.

32. Case 1Learner You are a second-year resident and a very insecure person who needs to be liked. You have difficulty dealing with authority figures. You compensate by being ingratiating.

33. Case 2Preceptor You are working with a first-year resident who attends regularly, appears to do her work well, but asks a lot of detailed questions about each case. When asked to pursue a particular topic, she never reports back or indicates that she has completed the task. In addition, she does not seem to read on her own initiative.

34. Case 2Learner You are first-year resident who never learned to be an independent learner. You are used to a very didactic teaching style from medical school and don�t know how to do independent reading or research and are completely at a loss as to how to proceed. You rely on your preceptor for all of the answers.

35. Case 3Preceptor A senior resident has missed at least two clinics per week during the past month. This resident has called in several times claiming not to feel well. At work the resident appears to be irritable and distractible.

36. Case 3Learner You are a resident with a substance abuse problem. You have excessive work absence, irritability, and poor work performance.

37. Thank You This module was written as an aid to the Preceptors in the Postgraduate Family Practice Program at the University of BC. Study credit is available to groups of preceptors who complete the module Please give us your feedback on the module so that we may improve it for others. Email you comments to Dr. Fraser Norrie, Faculty Development, UBC Family Practice Fraser.Norrie@vch.ca