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Case

Case. Your intern admitted an elderly patient from a nursing home with change in mental status. She did a very cursory workup, and did not speak to the family at all. When you question her, she says, “I don’t have time for this. He’s just demented. All these resources going to waste.”.

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Case

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  1. Case Your intern admitted an elderly patient from a nursing home with change in mental status. She did a very cursory workup, and did not speak to the family at all. When you question her, she says, “I don’t have time for this. He’s just demented. All these resources going to waste.”

  2. You point out the features suggestive of delirium, and discuss the importance of prompt dx and management. Your intern rolls her eyes.

  3. What is your working diagnosis?

  4. The Reluctant Learner • Definition • A learner who appears not to be eager, willing, and ready to learn what you want to teach • Examples…

  5. How should you respond to your uneager intern? Approach the reluctant learner as you would a “tough clinical case”

  6. Use a S.O.A.P. Approach • Subjective: Use your experience and opinion to gain an individualized impression of the student’s difficulty. • Objective: Document specific examples of the problem • Assessment: Diagnose the problem • Plan: Develop and implement a plan to address the problem.

  7. Subjective: The Learning Process TEACHER LEARNER CONTENT

  8. Objective: Be a cool observer, take notes Assessment: Why the reluctance? • Take a History • Examine the Problem • Make the Diagnosis

  9. Remember to ASK

  10. ASK- Does the learner: • Have a problem with Attitude? • Lack of professionalism • Judgmental • “Bleeding heart” who can’t set limits • “Sociopathic” • Lack Skill? • Unable to put knowledge to practical use • Uncomfortable asking the questions • Disorganized • Stress, depression • Lack Knowledge? • Clinical relevance of material • Missing some “background information”/content

  11. Plan – Treat the Problem: “The Therapeutic Trial” • It usually takes more than one try • Keep the focus on the behavior • Keep your goal realistic

  12. “Stages of Change” for the Reluctant Learner “This is not important for good patient care” “I already know all I need to” Denial “There may be an easier way to deal with this kind of problem, but I am doing fine” Contemplation “There are some concrete skills that I can learn and use” “Mastering these skills will make me a better doctor” Determination

  13. “I understand the importance of this skill to good patient care I can do this” “RECOVERY” • Fatigue • Burn out • Personal issues • Substance use RELAPSE

  14. If you need help – Get a Consult! • Other Chief Residents • Program Director • Other faculty

  15. The Best Defense… • Apply educational theory to your practice: • Learner as active contributor • Take into account their knowledge/ experience • Opportunities for self-learning • Opportunities for self-assessment, reflection • Role modeling

  16. Take Home Points: • “Reluctance is in the eye of the beholder” • The same skills that work with challenging patients work with challenging (reluctant) learners • Use SOAP • Don’t forget to ASK • Get a consult

  17. Use the One-Minute Preceptor Method • Get a commitment • Probe for supporting evidence • Reinforce what is right • Give guidance about errors or omissions • Teach general principles • Conclusion

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