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

2. Goals of this module 1. Identify the resident in difficulty. 2. Define the difficulties residents may have. 3. Provide a framework for planning help. 4. Understand the failure, remediation and probation process.

3. Task #1: Identify the Resident in Difficulty What do we mean by “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. Divide into groups of 2 to 4 and, in five minutes come to a consensus.

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)

5. If a resident makes you feel… AnnoyedStressedConfusedAvoidantProtective There may be a problem.

6. Categories of Difficulty Affective Affective Interpersonal Interpersonal Structural Structural Cognitive Cognitive

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?

8. Interpersonal #1 Learners have difficulty interacting with others Learners have difficulty interacting with others Personal characteristics: Personal characteristics: Shy or non-assertive Shy or non-assertive Poor social skills Poor social skills Manipulative Manipulative aggressive aggressive

9. Interpersonal #2 Professional behaviors Teamwork Prejudices – racial, ethnic, gender Honesty Ethical integrity

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

11. Cognitive Poor fund of knowledge Poor fund of knowledge Spatial perceptual problems Spatial perceptual problems Oral communication Oral communication ESL (English as a second language) ESL (English as a second language) Poor Interviewing skills Poor Interviewing skills Poor integration of material Poor integration of material Learning disabilities Learning disabilities Written communication Written communication Reading problems Reading problems Writing problems Writing problems

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

13. An Approach

14. STP S pecify the problem T arget / goals P lan and procedures

15. S TP Task #2 Specify what the problem is Take five minutes in your small groups to discuss: Take five minutes in your small groups to discuss: Who should be involved Who should be involved When should the problem should be dealt with When should the problem should be dealt with Why it is important for you to deal with this problem Why it is important for you to deal with this problem How should a problem be approached How should a problem be approached

16. S TP Specify the problem Gather and document information – how does the learner fall short? Gather and document information – how does the learner fall short? Perception vs. reality Perception vs. reality Consider the learner, preceptor and the learning environment. Consider the learner, preceptor and the learning environment. Always be aware of confidentiality Always be aware of confidentiality Use a Team approach Use a Team approach Document, document, document. Document, document, document.

17. S T P Target / Goals Discussion, feedback, goal setting Resident driven, program directed Document everything

18. These are a variety of interventions that might be appropriate. Discuss as a group possible interventions for dealing with a resident having difficulty. Discuss as a group possible interventions for dealing with a resident having difficulty. Use examples from your own practice Use examples from your own practice Do you have some teaching “pearls” that have worked for you in a difficult situation? Do you have some teaching “pearls” that have worked for you in a difficult situation?

19. ST P Possible interventions Further assessment Further assessment More time on rotation More time on rotation Schedule change Schedule change Increased observation and feedback Increased observation and feedback Peer support Counseling Leave of absence Medical treatment Remediation Probation

20. ST P Plans and Procedures Develop a plan Develop a plan Plan follow up Plan follow up learning contract? learning contract?

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. 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 Scenarios may be printed from the last 6 slides

22. When a problem is not resolved. (A process most of you will never or will rarely be involved in ) Rotation failure Rotation failure Remediation Remediation Probation Probation Removal from the program Removal from the program

23. Failing a resident A mid-rotation evaluation should be given, in person, and in writing stating deficits, plans, and desired outcomes 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. Documentation should be both general and specific. A failed rotation results in remediation. A failed rotation results in remediation.

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. 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. Outcome could be return to regular rotations, further remediation, or probation.

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

26. Remediation and probation principles Fairness Fairness Accuracy Accuracy Documentation Documentation

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

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

29. Documentation Of problems – sequential Of problems – sequential Of evaluations – sequential Of evaluations – sequential Of interventions – sequential Of interventions – sequential Of quantitative and qualitative evaluations Of quantitative and qualitative evaluations

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

31. Case 1 Preceptor 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 1 Learner 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 2 Preceptor 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 2 Learner 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 3 Preceptor 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 3 Learner 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. 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 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. 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 Email you comments to Dr. Fraser Norrie, Faculty Development, UBC Family Practice Fraser.Norrie@vch.ca Fraser.Norrie@vch.ca