residents in difficulty
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Residents In Difficulty. LTC Douglas Maurer, DO, MPH, FAAFP Faculty Development Fellowship Program Director. Is this resident’s performance below the line??. Discuss a resident in difficulty that you have worked with What were the issues? How did you deal with the problem? - PowerPoint PPT PresentationTRANSCRIPT
Residents In Difficulty
LTC Douglas Maurer, DO, MPH, FAAFPFaculty Development Fellowship
Program Director
Is this resident’s performance below the line??
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
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 your due process policy
Three Kinds of Difficulty1. Academic – learning difficulty
– Knowledge– Skills– Attitudes
2. Disciplinary– Usually breaking rules or laws
3. Impairment/Disability– Avoid temptation to diagnose
Past PD Responses
• Academic 53–Behavior/attitude 20–Knowledge base 28–Others 5
• Discipline 13
• Impairment/disability 11
Examples• Timely documentation/completion of
annoying but necessary admin tasks• Gen Y provides challenges in their
attitude towards service above self• Unprofessional• Severe time management difficulties• “Ownership" of patient, rather than
rushing to leave at the end of the day
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 with 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
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
WORK-UP CYCLEResident Prerogatives
NOYES Concerns?
“The Line”
Routine Resident Evaluation
Regular opportunities for:–Assessing, guiding, and reassuring– Identify problems for further “work-up”–Acting early–Verbal feedback–Documenting
Problem Focus & Hypothesize
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
WORK-UP CYCLEResident Prerogatives
NOYES Concerns?
“The Line”
Task 1: Problem Focus& Hypothesize
• Discuss with resident ONLY• Ask, Tell, Ask, Act• Possible causes of situation?• Respect resident’s perspective• Document conversation
Problem Focus & Hypothesize
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
WORK-UP CYCLEResident Prerogatives
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?!
Problem Focus & Hypothesize
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
WORK-UP CYCLEResident Prerogatives
NOYES Concerns?
“The Line”
ResidentAgrees?YES
Provide assistance
ConcernRemains? NO
YES
ProbationJustified?
ResidentAgrees? NOYES Gather data
& evaluate for Perception / Valuedifferences
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
Problem Focus & Hypothesize
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
WORK-UP CYCLEResident Prerogatives
NOYES Concerns?
“The Line”
ResidentAgrees?YES
Provide assistance
ConcernRemains? NO
YES
ProbationJustified?
ResidentAgrees? NOYES Gather data
& evaluate for Perception / Valuedifferences
ConcernRemains? NO
YES
YESNO
Probation Cycle
For problems that become the program’s prerogative
to resolve
Routine Resident Evaluation
PROBATION CYCLEProgram/Faculty Prerogatives
ResidentAgrees? NOYES Gather data
& evaluate for Perception / Valuedifferences
Provide assistance
Monitor performance, Recommendinterventions
ConcernRemains? NO
YES
Problem Focus & Hypothesize
WORK-UP CYCLEResident Prerogatives
NOYES Concerns?
ProbationJustified? YESNO “The Line”
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
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”
Task 5: Administrative Action• End remediation & begin routine evaluation
• Begin probation
• End probation
• Extend probation
• Terminate
Cases
• In groups discuss the cases…• Performance above or below the line?• What course of action would you take?• How would you document this?
• Appoint a spokesperson• Share your plan 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
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”
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”
Take Home Points
• Act swiftly…investigate and remediate
• Document, document, document
• Focus on program requirements
• Use a model to guide you
• Follow your due process policies
Documentation
• Document early• Document at the time of the event• Document during the work up cycle• Document during the probation cycle• Document, document, document
Thank You