1. 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”

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

5. Examples of reluctant learners…
Brainstorm examples of reluctant learners

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

7. 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…”

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

9. Why the reluctance?
Brainstorm

10. 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

11. Remember to ASK

12. 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

13. The Learning Process
TEACHER
LEARNER
CONTENT

14. 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

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

16. “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”

17. 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

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

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