1. Case
Your intern admitted a patient with pneumonia and symptoms of heroin withdrawal. She did a very cursory workup, and did not treat the patient’s withdrawal symptoms at all. When you question her, she says : “What’s the point? She is just going to leave AMA anyway. I don’t have time for this.”
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 importance of managing withdrawal symptoms in an acutely ill patient and offer to review the management of heroin withdrawal with her. Your intern rolls her eyes.

3. What is the diagnosis?

4. The Reluctant Learner Angela Jackson, MD Rachel Stark, MD, MPH
Vice Chair for Education,
Director, Primary Care Training Program
and
Rachel Stark, MD, MPH
Asst. Director, Primary Care Training Program

5. Goals of the session:
Define Reluctant Learner
“Diagnose” the reluctant learner
Discuss in small groups effective approaches to engage the reluctant learner

6. The Reluctant Learner Definition:
A learner who appears not to be eager, willing and ready to learn what you want to teach
Why is it that the reluctant learner elicits such a strong reaction from us? Investment in what we are doing, a strong sense of the “right thing to do” for the patient, a strong sense that what we are trying to teach matters, is important to patient care, etc

7. Examples of reluctant learners… (and why they are so memorable…)
Brainstorm examples of reluctant learners-
What do we call “reluctant learners?”
“jerks”
Losers
uninterested

8. Examples of reluctant learners…
The Know It All
The Minimizer
Passive-Aggressive
The Lazy Learner
Excuses, excuses…
Not my job!
Disinterested/Bored
The Head Bobber

9. Why the reluctance?
Brainstorm

10. Example of boring attending rounds as a student or resident
Reluctance is not a permanent personality “trait”, but a modifiable “state”
Example of boring attending rounds as a student or resident

11. Approach the reluctant learner as you would a “clinical case”

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

13. Diagnose the Learner:
Remember - ASK

14. 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

15. The Learning Process
CONTEXT
LEARNER
TEACHER
CONTENT

16. “Find the Lesion” for Educators:
Example:
Teacher
Learner
Content
Appears not to be interested
Too longwinded?
Not clear on relevance to clinical setting?
Post-call ?
Just reviewed this with the CR?
Distracted with-sick pt? Life?
Clinical relevance not clear?
Background knowledge missing?
Know it All
Intimidating?
Or tentative?
Does in fact, master this material?
Afraid to admit deficiency?
Too basic?
Importance not made clear?

17. 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

18. “The Therapeutic Trial”
Treatment Options:

19. Principles of Motivational Interviewing (MI):
Develop DISCREPANCY
Avoid ARGUMENTATION
Roll with RESISTANCE
Express EMPATHY
Support SELF-EFFICACY

20. Principles of Managing Interns:
Develop DISCREPANCY
Avoid ARGUMENTATION
Roll with RESISTANCE
Express EMPATHY
Support SELF-EFFICACY
Discrepancy- Few HOs are truly psychopaths
Argumentation – Confrontation will cause the learner to feel attacked and resist suggestions
Roll with resistance –rather than confrontation, “rolling” with the resistance means diffusing the resistance, getting the conversation to go in another direction, rather than shutting down
Empathy – “seeing the world thru the learner’s eyes” , demonstration of an understanding of the learner’s expereince– does not mean agreeing with the behavior/position, etc
Self-efficacy – “change is possible”- highlight past success, variety of options, they decide how to change

21. STEP 3 – Get a Consult:
Other colleagues
Program Director
Clerkship Director

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

23. “Stages of Change” for the Reluctant Learner
“This is not important for good patient care”
“I already know all I need to”
Pre-contemplation
“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”

24. 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

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