The resident in difficulty Evelyn Constantin

Alan Chaput

We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.

Je n’ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d’appareils médicaux ou un cabinet de communication.

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Delete this box before presenting: Please keep only the applicable statement, shown above is Option 1 with Option 2 to follow on next slide. Note: Speakers who have no involvement with industry should inform the audience that they cannot identify any conflict of interest.

Supprimez cette boîte avant de faire votre présentation : Veuillez conserver uniquement l’énoncé pertinent; ci-dessus se trouve l’option 1, l’option 2 paraissant à la diapo suivante. Note: Les conférenciers qui n’ont aucun lien avec l’industrie doivent aviser leur auditoire qu’ils n’ont aucun conflit d’intérêts à déclarer.

Objectives

•  Provide a broad definition of the resident in difficulty

•  Discuss approaches to the systematic collection of information on resident performance

•  Describe various resources available to assist in supporting your resident in difficulty

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Timing

•  5 min Introduction of speakers •  15 min Introduction of participants •  10 min Overview of topic and case presentation •  15 min Group work •  20 min Reconvene – discuss issues, questions •  5 min Break •  15 min Presentation •  25 min Group work •  15 min Wrap up

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Introductions

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How do YOU identify a learner in difficulty

Case 1: Dr. Nathan Jones Nathan is a PGY-2 in family medicine training in a remote site. He is experiencing academic difficulties. Although his knowledge and judgment have been consistently rated as strong, his attitude has been progressively more problematic. Nathan is often late, does not show up for calls or clinics, and always seems to “have an excuse” for his tardiness. When given feedback, Nathan has very limited insight. As his Program Director, you are trying to better understand the underlying reasons for his current difficulties in order to help him improve.

Educational Diagnosis •  Strong medical expert competencies •  Difficulties with time management and remembering appointments •  Sense of entitlement •  Lack of recognition of non-medical expert CanMEDS roles as “important” •  Belief that behaviours are not modifiable •  Very limited ability to empathize and see other people’s perspectives •  Limited insight into impacts of his behaviours on others, including patients

and colleagues

Sample Learning Plan    

CanMEDS  Role        

Educa0onal  Diagnosis    (What  are  the  problems?)  

     

Educa0onal  Strategies  (What  will  you  do?)  

   

Evalua0on  Strategies      (How  will  you  

measure  success?)    

   

Collaborator  Not  collabora/ng  well  as  part  of  a  medical  team;  Issues  with  reliability  (Missing  clinics/calls,  without  finding  a  replacement)  

Professionalism  coach/mentor;  Simula/on/communica/on  sta/ons;  Professionalism    simula/on  sessions;    Self-­‐reflec/ve  exercises  

Feedback/close  monitoring  ITERS  OSCE  scores  Feedback  from  near-­‐peers  

   

Professional  Poor  aRtude  (progressively  worsening);  Problems  with  punctuality  and  reliability  to  meet  clinical  responsibili/es)              

Professionalism  workshops;    Professionalism  coach;    Review  of  professional  conduct  policy;  Iden/fying  and  resolving  barriers  to  punctuality  Self-­‐reflec/ve  exercises      

Frequent  monitoring/feedback  Mini  CEX  (Professionalism)  OSCEs  Feedback  from  near-­‐peers  

Learning strategy - sources

•  Other program directors within your university – consider a mentor •  Other program directors in your discipline across the country •  Other experts within your university

•  PGME/postgraduate dean •  CMPA •  Provincial regulatory organization •  Provincial medical organization •  CMA

•  Royal College – canmeds.royalcollege.ca or the book •  Other…

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Case 2: Dr. Janet Bloom Janet is a PGY-2 in general surgery who is experiencing academic difficulties. She has had numerous weaknesses identified in her rotations in her PGY-1 year, but the Program Promotions Committee decided to promote her to a PGY-2 level. At the PGY-2 level, Janet’s weaknesses have become more apparent and she has now met criteria for an extension of training in order to give her time to improve (“probation”). Her Program Director is trying to better understand the underlying reasons for her current difficulties in order to help her improve.

Creating a learning plan

1.  Identify the learning issue •  Subdivide by CanMEDS role

2.  Define the learning objective •  Think SMART

3.  Specify the learning strategy •  What? How often? Who?

4.  Define the expected outcome •  Be specific •  Use objective/standardized measures whenever possible

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SMART objectives

•  S – specific

•  M – measurable

•  A – assignable

•  R – realistic

•  T – time-related

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Sample Learning Plan    

CanMEDS  Role        

Educa0onal  Diagnosis    (What  are  the  problems?)  

     

Educa0onal  Strategies  (What  will  you  do?)  

   

Evalua0on  Strategies      (How  will  you  measure  

success?)    

   

Medical  Expert      

Poor  knowledge  base;    Limited  surgical  skills  (difficult  to  assess  since  has  had  limited  exposure  to  the  OR)          

   

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Group work (15 minutes)

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Discussion of issues encountered

Educational Diagnosis •  Lack of foundational surgical skills at PGY-1 level

"  Limited knowledge and experience of general surgery upon entering program •  Challenges with manager/leadership roles

"  Escalation of expectations at PGY-2 with uncertain clinical foundations •  Professionalism issues

"  Emotional reaction to stress by “lashing out” at others "  Fear of looking “weak” and so overcompensates by being demeaning to others

•  Social isolation "  contributing to limited outlets to share stresses with others

•  Good insight/motivated "  Wants to work hard and has insight into her situation

Educational Strategies •  Case-based discussions with probing questions •  Directed readings (clear objectives, guidance about content and

source) with accountability and follow-up •  Deepening understanding of concepts (eg. concept map,

algorithms) with accountability and follow-up •  Exercises in clinical reasoning (eg. verbalizing thinking process,

contrast/compare conditions) •  Observation with feedback

•  Structured observation (mini-CEX, OSCE)

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Educational Strategies •  Role plays with feedback •  Simulation with feedback / debriefing •  Observation of experienced clinicians •  Reflective tools (narratives, logs, portfolios) •  Standardized exams •  Mentors •  Role coaches (eg. medical expert, communicator, and collaborator) •  Adapted rotation schedule •  Lighter clinical duties •  Modifications to supervision •  Time management tools / courses •  Learning services •  Professional consultations

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Assessment strategies

•  ITER (In-Training Evaluation Report) •  OSCE •  Mini-CEX •  Direct observation with feedback •  Simulation with feedback •  Role plays with feedback •  Multi-source feedback from multiple observers (eg. nursing, clerical, patients,

students, etc.) •  Performance on standardized exams •  Chart / document reviews (eg. consultation letter, reports, etc.) •  Self-reflection

Developing an outcome document

•  Draft the template BEFORE remediation begins

•  Role of the resident

•  Role of the supervisor

•  Role of the program director

•  Learning strategy – completed or not?

•  Learning issue – outcome as expected or not?

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Summary - How to identify and remediate the resident in difficulty

•  Ensure you have/have access to a comprehensive library of assessment tools

•  Regular review of all assessments and evaluations •  Meet with trainee to discuss performance, review feedback already

received

•  Set goals to improve performance, directed feedback, documentation •  Determine the appropriate corrective action plan

"   ‘r’ versus ‘R’ remediation

"   Remediation versus probation

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Other considerations

•  Remember that you are their manager

•  Wellness

•  Take crucial conversations!

•  Knowledge of policies

•  Knowledge of procedures

•  Role of a mentor for you within or outside your university

•  Have your PG dean/PGME office on speed dial

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• Download the ICRE App,

• Visit the evaluation area in the Main Lobby, near Registration, or

• Go to: http://www.royalcollege.ca/icre-evaluations to complete the session evaluation.

Help us improve. Your input matters.

• Téléchargez l’application de la CIFR

• Visitez la zone d’évaluation dans le hall principal, près du comptoir d’inscription, ou

• Visitez le http://www.collegeroyal.ca/evaluations-cifr afin de remplir une évaluation de la séance.

Aidez-nous à nous améliorer. Votre opinion compte!

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