from failure to…

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

Success

I held 1,093 patents world-wide

“Genius is 1% inspiration, 99% perspiration.”

I am best known for this:

From Failure to…

Who am I ?

I loved sports growing up.I was cut as a sophomore from my

high school basketball team.

SuccessI ended up in the NBA

I won 6 NBA championships

I have appeared on front of the Wheaties box more than any other athlete

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

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

Residents In DifficultyMAJ Scott Grogan

Faculty Development Fellow2 May 2012

Is this resident’s performance below the line??

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

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

Your Experiences…

Why Talk About Residents In Difficulty?

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

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

Three Kinds of Difficulty1. Academic – learning difficulty

– Behavior / attitude– Cognitive– Psychomotor

2. Disciplinary– Usuall breaking rules or laws

3. Impairment / Disability– Avoid temptation to diagnose

Past PD Responses

• Academic 19–Behavior / attitude 12–Knowledge base 3–Others 4

• Discipline 4

• Impairment / disability 9

I Wish I Would Have…

• Identified problem earlier• Documented earlier• Started remediation earlier • Acted earlier

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

Be Careful Saying…

“Just ignore it”

“They’ll grow out of it”

“They’re having personal problems”

“It might be just this once”

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

Other Pitfalls

Big hearts

Trying to be a provider

Halo Effect

Being a fixer

Conspiracy of Silence

Dr. White Cloud

What would you do now?

A Model to Guide You

Above the line vs. below the line…

Resident prerogative vs.

Program prerogative

Nancy Stevens MD, Univ. of Wash.

Routine Resident Evaluation

PROBATION CYCLEProgram/Faculty Prerogatives

ResidentAgrees? NOYES Gather data

& evaluate for Perception / Valuedifferences

Provide assistance

Monitor performance, Recommendinterventions

Take administrativeaction

ConcernRemains? NO

YES

Problem Focus & Hypothesize

WORK-UP CYCLEResident Prerogatives

NOYES Concerns?

ProbationJustified? YESNO “The Line”

Work-up Cycle

For problems that remain the resident’s prerogative

to resolve




NOYES Concerns?

“The Line”

Routine Resident EvaluationRegular opportunities for:

–Assessing, guiding, and reassuring– Identify problems for further “work-up”–Acting early–Verbal feedback–Documenting





NOYES Concerns?

“The Line”

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





NOYES Concerns?

“The Line”

ResidentAgrees?YES

Provide assistance

ConcernRemains? NO

YES

ProbationJustified?

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?!





NOYES Concerns?

“The Line”

ResidentAgrees?YES

Provide assistance

ConcernRemains? NO

YES

ProbationJustified?



ConcernRemains? NO

YES

Task 3: Gather InformationAround 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





NOYES Concerns?

“The Line”

ResidentAgrees?YES

Provide assistance

ConcernRemains? NO

YES

ProbationJustified?



ConcernRemains? NO

YES

YESNO

Probation Cycle

For problems that become the program’s prerogative

to resolve





Provide assistance


ConcernRemains? NO

YES



NOYES Concerns?


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





Provide assistance



ConcernRemains? NO

YES



NOYES Concerns?


Task 5: Administrative Action• End remediation & begin routine eval

• Begin probation

• End probation

• Extend probation

• Terminate

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

The Tardy Resident

Case 1

The Inefficient Resident

Case 2

Case 3

The Depressed Resident

The Severely Ill Resident

Case 4

Reduced Knowledge Resident

Case 5

The Administratively

Challenged Resident

Case 6





Provide assistance



ConcernRemains? NO

YES



NOYES Concerns?


Documentation

• Document early• Document at the time of the event• Document throughout the work up cycle• Document during the probation cycle• Document, document, document

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

Your Comments

Thank You

from failure to…

Documents