Residents In Difficulty

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