1. Anna Chang, MDAndrea Marmor, MD, MSEd Associate Professor, Geriatric MedicineAssociate Professor, Pediatrics University of California, San Francisco

2.  Introductions  Defining the problem:  Who is a “difficult” learner?  How can we help them?  Description of the SOAP approach  Work on cases in small groups  Large group review and wrap-up

3.  What departments are we from?  Who do we teach?  Key words: What types of difficult learners do we encounter?  E.g., late, rude, deferential, slacking off

4. 1. Adherence to ethical practice principles 2. Effective interactions with patients and those important to patients 3. Effective interactions with people working in health care system 4. Reliability 5. Commitment to autonomous maintenance/improvement in oneself, others and systems Wilkinson 2009

5.  Unprofessional students/residents more likely to subsequently be disciplined by Board  Papadakis: 2005, 2008  Other reasons?

6. Hickson, 2007

7. Pre-ClerkshipClerkship/Residency Formal Orientation week TLCS OSCE Critical reflections Patient interviews FPC curriculum Intersession Supervisor evaluations Case reviews/M and M USMLE step 2 CS Structured clinical obs Specialty boards Faculty mentors Peer/faculty evaluations Attendance and participation policy Remediation Informal White coat ceremony Small Group dynamics Graduation (oath, etc) Team dynamics Bedside teaching Role modeling (peers, teachers) Personal reflection

8. Pre-ClerkshipClerkship/Residency Formal Orientation week TLCS OSCE Critical reflections Patient interviews FPC curriculum Intersession Supervisor evaluations Case reviews/M and M USMLE step 2 CS Structured clinical obs Specialty boards Faculty mentors Peer/faculty evaluations Attendance and participation policy Remediation Informal White coat ceremony Small Group dynamics Graduation (oath, etc) Team dynamics Bedside teaching Role modeling (peers, teachers) Personal reflection Hidden Unintended role modeling Normative culture

10. 1. Recognize broad categories of professionalism problems in learners 2. Become familiar through practice with several approaches to recognizing and helping difficult learners 3. Know what resources are available to help with dealing with professionalism problems in learners.

11. 1. Recognize broad categories of professionalism problems in learners 2. Become familiar through practice with several approaches to recognizing and helping difficult learners 3. Know what resources are available to help with dealing with professionalism problems in learners.

12. 1. Recognize broad categories of professionalism problems in learners 2. Become familiar through practice with several approaches to recognizing and helping difficult learners 3. Know what resources are available to help with dealing with professionalism problems in learners.

13.  Application of a clinical framework to an educational problem  Learner-centered, instead of patient-centered  Takes us from our impressions (subjective) to a plan for action and reassessment

14.  The judgment/sense that there is a problem  “Current Complaint”  Should drive initial hypotheses (“differential diagnoses”) but not assessment  Consider:  Personal reactions  Alternate explanations for behavior

15.  Collection of information to support/refute hypotheses (“differential diagnosis”)  Consider:  Multiple sources of information  Scope of problem ▪ 5 domains of professionalism ▪ Settings affected ▪ Isolated vs. pattern

16.  Classroom  Faculty evaluations  Peer evaluations  Paper or SP Exams  Clinical Training  Faculty/resident/student evaluations  Critical incidents  Observation of clinical encounters  Practice-Based  Patient satisfaction  Self-administered rating scales  360 degree evaluations

17.  Reflectiveness  Advocacy  Lifelong learning  Dealing with uncertainty  Balancing availability to others with care of self  Seeking and responding to results of an audit Wilkinson 2009

18.  Your “working diagnosis”, after collection of objective data  Consider the differential:  Are there other possibilities?  How will you distinguish between them?

19. 1 Address learner directly Focus on behavior, not personality Assess their self-awareness 2 Remediate Individualized intervention Target to specific goals 3 Reassess When? How?

20.  Clinical and classroom vignettes  Represent different challenging learners  Your task: 30 minutes  Use the discussion guide to apply the SOAP method to these learners  May modify the specifics to suit your setting  Large group discussion:  Be prepared to present on your hypothesis- generation, assessment and initial plan

21.  Each group will present your SOAP approach to your case  Focus on hypotheses (S), information- gathering (O) and initial assessment (A)  Larger group: brainstorm on Plan

22.  Senior resident on inpatient service  Reputation for academic strength  Recently has acted disinterested/burnt-out  Interns/students intimidated  Background:  First in family to attend college, leader in medical school

23.  3 rd year med student with PhD  Late to clinic session, poor job on H and P and presentation  However, good knowledge of pathophysiology  Does not respond to feedback on these issues  Thinks he performed well, feels others are uncomfortable with his intelligence

24.  4 th year student on nephrology elective  Expresses enthusiasm about learning, and gets her work done  Looking at/typing in smart phone on rounds, in patient rooms and during teaching  Others have noticed, but aren’t sure how to handle it  Unclear if she is using phone for learning or personal

25.  Senior resident on ward, cheerful and enthusiastic  Allegra talks over others, humor is a little off  Gifted in psychosocial assessments, but misses some important clinical details  Background: community advocate, academic difficulty, “learning disability”

26. Hickson, 2007

27.  Remediation successful in cognitive domains  Easier to measure  Review by Hauer, et al 2001  What about professionalism?  We’re just starting to learn about this….  We need to be leaders in this area

28.  Use real incidents as examples  Critical reflection  Clear expectations  Use frameworks (Wilkinson, SOAP, etc)  Individualized improvement plan  Instruction with practice, feedback and reflection  Explicit faculty mentorship  Reassessment and certification of competence  Use existing infrastructure

30. Attributed to Gandhi

31.  Small group covers clinical and personal issues  Steve rarely contributes verbally  Will scribe for group, performs well on written assignments  3 other group members are very talkative  Today he started to speak but very quietly, then withdrew

32.  First year student, lecture series that includes patient interviews  Tara sits in the front, plays games/checks news on laptop  Regularly comments during lecture  Occasionally disrespectful to lecturers  Always warm and engaging with families

33.  SOM core curriculum small group setting  RT comes late, pulls out computer  Usually disengaged, occasionally dominates  Facial expressions show boredom/disrespect for you and other students