2. From Failure to… Who am I ? Teachers said I was “too stupid to learn anything.” I was fired from my first two jobs – Not productive enough I first failed 1000 times

3. Success I held 1,093 patents world-wide “Genius is 1% inspiration, 99% perspiration.” I am best known for this:

5. From Failure to… Who am I ? I loved sports growing up. I was cut as a sophomore from my high school basketball team.

6. Success I ended up in the NBA I won 6 NBA championships I have appeared on front of the Wheaties box more than any other athlete

7. From Failure to… Who am I ? I went to drama school with Bette Davis. I was dismissed for being too quiet and shy I began my performing career on Broadway, but then was quickly fired Next, I was dismissed from two different movie productions

8. Success As the star in my own TV show in 1948, I went on to win: – 13 Emmy Awards – 12 Golden Globes – A Lifetime Achievement Award – International Fame

10. Residents In Difficulty MAJ Scott Grogan Faculty Development Fellow 2 May 2012

11. Is this resident’s performance below the line??

12. Objectives Discussed your experiences Listed common resident problems Categorized those problems Reviewed a model for dealing with residents in difficulty Applied that model to cases

13. Take Home Points Act swiftly… investigate and remediate Document, document, document Focus on program requirements Use a model to guide you Follow the program’s due process policy

14. Your Experiences… Why Talk About Residents In Difficulty?

15. Stakeholders The resident Teaching staff Fellow residents Program graduates GME chief and GMEC Big Navy/ Big Army Public & society Patients - we are different

16. With Your Neighbor Discuss a resident in difficulty that you have worked with What were the issues? How did you deal with the problem? What would you do differently? Be prepared to share

17. Three Kinds of Difficulty 1. Academic – learning difficulty –Behavior / attitude –Cognitive –Psychomotor 2. Disciplinary –Usuall breaking rules or laws 3. Impairment / Disability –Avoid temptation to diagnose

18. Past PD Responses Academic 19 –Behavior / attitude 12 –Knowledge base 3 –Others 4 Discipline 4 Impairment / disability 9

19. I Wish I Would Have… Identified problem earlier Documented earlier Started remediation earlier Acted earlier

20. Warning Signs Avoidance, no interest Poor performance, task completion Poor or inappropriate interactions Tardiness, poor time management Falling behind in charting Excessive griping – moody Complaints by others

21. Be Careful Saying… “Just ignore it” “They’ll grow out of it” “They’re having personal problems” “It might be just this once”

22. Barriers and Pitfalls Fear of being the “bad guy” No staff consensus on “The line” Personality conflict w/ resident Personal attacks Fear avoidance of conversations Time Amount of documentation required

23. Other Pitfalls Big hearts Trying to be a provider Halo Effect Being a fixer Conspiracy of Silence

24. Dr. White Cloud What would you do now?

25. A Model to Guide You Above the line vs. below the line… Resident prerogative vs. Program prerogative Nancy Stevens MD, Univ. of Wash.

26. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Provideassistance Monitor performance, Recommendinterventions Takeadministrativeaction Concern Remains? NO YES Problem Focus & Hypothesize WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? Probation Justified? YES NO “The Line”

27. Work-up Cycle For problems that remain the resident’s prerogative to resolve

28. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? “The Line”

29. Routine Resident Evaluation Regular opportunities for: –Assessing, guiding, and reassuring –Identify problems for further “work-up” –Acting early –Verbal feedback –Documenting

30. Problem Focus & Hypothesize Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? “The Line”

31. Task 1: Problem Focus & Hypothesize Discuss with resident (ONLY) Possible causes of situation? Respect resident’s perspective Sort issues according to whether resident agrees or disagrees Document conversation

32. Problem Focus & Hypothesize Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? “The Line” Resident Agrees? YES Provideassistance Concern Remains? NO YES Probation Justified?

33. Task 2: Provide Assistance Focus only on area of agreed need Plan help jointly with the resident Be specific in comments Monitor plan for effectiveness Inform resident when done A good situation for a learning contract?!

34. Problem Focus & Hypothesize Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? “The Line” Resident Agrees? YES Provideassistance Concern Remains? NO YES Probation Justified? Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Concern Remains? NO YES

35. Task 3: Gather Information Around Differences Differences in perception –Assist resident to collect data on future events Differences in values –Help resident articulate value positions –Identify behaviors likely to result in conflict –Communicate the likely consequences

36. Problem Focus & Hypothesize Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? “The Line” Resident Agrees? YES Provideassistance Concern Remains? NO YES Probation Justified? Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Concern Remains? NO YES NO

37. Probation Cycle For problems that become the program’s prerogative to resolve

38. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Provideassistance Monitor performance, Recommendinterventions Concern Remains? NO YES Problem Focus & Hypothesize WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? Probation Justified? YES NO “The Line”

39. Task 4: Probationary Monitoring Program level remediation Hospital level probation Requirements clearly identified Assistance / remediation plan explained Objective criteria to assess improvement Timeline for resolution

40. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Provideassistance Monitor performance, Recommendinterventions Takeadministrativeaction Concern Remains? NO YES Problem Focus & Hypothesize WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? Probation Justified? YES NO “The Line”

41. Task 5: Administrative Action End remediation & begin routine eval Begin probation End probation Extend probation Terminate

42. Cases In groups discuss the cases… Above or below the line? What course of action would you take? How would you document this situation? Appoint a spokesperson Share your findings with the larger group

43. The Tardy Resident Case 1

44. The Inefficient Resident Case 2

45. Case 3 The Depressed Resident

46. The Severely I ll Resident Case 4

47. Reduced Knowledge Resident Case 5

48. The Administratively Challenged Resident Case 6

49. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Provideassistance Monitor performance, Recommendinterventions Takeadministrativeaction Concern Remains? NO YES Problem Focus & Hypothesize WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? Probation Justified? YES NO “The Line”

50. Routine Resident Evaluation PROBATION CYCLE Program/FacultyPrerogatives Resident Agrees? NO YES Gather data & evaluate for & evaluate for Perception / Value differences Provideassistance Monitor performance, Recommendinterventions Takeadministrativeaction Concern Remains? NO YES Problem Focus & Hypothesize WORK-UP CYCLE ResidentPrerogatives NO YES Concerns? Probation Justified? YES NO “The Line”

52. Documentation Document early Document at the time of the event Document throughout the work up cycle Document during the probation cycle Document, document, document

53. Take Home Approach Act swiftly… investigate and remediate Document, document, document Focus on program requirements Use a model to guide you Follow your due process policies

54. Your Comments

55. Thank You