Case Your intern admitted an elderly patient from a nursing home with change in mental status and 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 is just demented. All these resources going to waste.” Is this a motivated intern??? Rich talked about MOTIVATION as not being a trait, an all or nothing, he talked about a state of ambivalence with patients “Assessing readiness to change” --- “Assessing readiness to learn”

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

What is your working diagnosis?

Associate Director, Boston University Residency Program in Medicine The Reluctant Learner Angela Jackson, MD Associate Director, Boston University Residency Program in Medicine

Examples of reluctant learners… Brainstorm examples of reluctant learners

The Reluctant Learner Definition: A learner who appears not to be eager, willing and ready to learn what you want to teach

Approach the reluctant learner as you would a “tough clinical case” Care of DM, or PNA- no one says “no improvement? Must not be motivated to get better…” Easy to make judgments about people – unprofessional, uninterested… Why is that? Because we are teaching something that we feel is important – or cool- to know- AT LEAST TO US. Think back on the most atrocious attending rounds ever- now, do you really think thata that person woke up that day and said- “Today, I am goin got give the most boring and irrelevant talk ever given by a human being…”

STEP 1- Make the Diagnosis: “Take a History” Remain neutral and objective, and TAKE A FULL HISTORY

Why the reluctance? Brainstorm

The Learning Process TEACHER LEARNER CONTENT This is where you make the diagnosis. And where you move beyond the emotional response that “learner reluctance” engenders CONTENT

Remember to ASK

Have a problem with Attitude? ASK - Does the learner: Have a problem with Attitude? - judgmental - “bleeding heart” who can’t set limits Lack Skill? - unable to put knowledge to practical use - uncomfortable asking the questions Lack Knowledge? - clinical relevance of material - missing some “background information” Knowledge- Does the learner not understand the clinical relevance of what you are trying to teach? Does the learner need some “background information”, before able to grasp a new teaching point. For example, if they don’t know that DT’s carries a significant mortality rate, they may not be very excited about learning how to prevent it. Diagnosis: Problem with attitude: Professional and Personal Psychiatric issues, substance use Cognitive problems Confidence Motivation

The Learning Process TEACHER LEARNER CONTENT

STEP 2 – Treat the Problem: “The Therapeutic Trial” It usually takes more than one try Keep the focus on the behavior Keep your goal realistic Therapeutic trials: It usually takes more than one try Be consistent and be fair Keep the focus on the behavior, not the individual Distinguish isolated episodes from patterns Keep notes

STEP 3 – Get a Consult: Other Chief Residents Program Director Other faculty

“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 bean easier way to deal with this kind of problem, but I am doing fine” Contemplation Determination “There are some concrete skills that I can learn and use” “Mastering these skills will make me a better doctor”

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

Diagnosis and Treatment Options: PROBLEM:____________________________________ Possible Dxs Possible Rxs:

Take Home Points: “Reluctance is in the eye of the beholder” The same skills that work with challenging patients, work with challenging (reluctant) learners