GPSLON 2011.1Melbourne March 11

Managing Challenging Learners

Dr Nigel Gray

Medical Educator

Northern Territory General Practice Education

LEARNING OBJECTIVES

• To be able to identify various types of under performing learners and apply a management plan to each

• To better understand barriers to learning specifically experienced by IMG learners

• To be able to effectively utilise some tools assisting in the delivery of difficult feedback

WHY IS IT SO HARD?

• Lack of confidence in own skills• Confrontation avoidance• Unsure of own competence to judge• Compassionate persona• Fear of legal action• Fear of effect on career(s) • Concern intervention will exacerbate situation• No time

WHAT DOES IT TAKE?

• REFLECTION• COURAGE• HONESTY

• ACT IN THE BEST INTERESTS of ALL- You- Your learner- Your patients

EVIDENCE

• Multi-source feedback ( including staff, patients, peers )

• Direct observation ( including of procedural skills )• Video recordings• Learner reflection• Critical incidents, near misses• Professional judgement• Incognito standardised patients• Portfolios ( incl medical & prescribing records ) –

needs to include reflective component• Rating scales ( including at Selection )• Administrative capacity

PRESENTATIONS

• The disappearing act• Low work rate• Clinic rage• Rigidity• Bypass syndrome• Career uncertainty• Insight failure• Unethical behaviours• Physical & mental health issues

Contributory Factors – learner

• Knowledge and Competency ( including time management, documentation )

• Communication skills• Personality – self critical, low self esteem• Stress and emotional burnout• Personal life, accomodation, parenting,

finance• Cultural background, immigration status• Health status; substance use

Remember the B’s

• Blues• Booze• Birds / Blokes• Banks• Bilingual• Babies• Bonkers

Contributory Factors – supervisor & system

ALL OF THE PREVIOUS, PLUS• Interpersonal skills• Personality• Time pressure• Inadequate support , teaching and

feedback • Teaching skills

The Slow Learner

• Ruth is a shy third year medical student. She is repeating her placement on the medical ward due to borderline results on her clinical assessments in the last semester. You have been briefed by her previous supervisor who has told you to “keep a close eye”, as she takes forever to get things done and “really needs to be pushed”. In a recent clinical encounter you notice she has taken over an hour to take a history on Mrs Gurramurra, a patient with asthma and yesterday her case presentation was very long and tedious.

The Poorly Interacting Learner

• Jason is a junior doctor in a small town hospital. He has been under your supervision in the emergency department for over 2 weeks. Your impression of Jason is that he is knowledgeable and highly competent in his clinical practice. He also appears to be extremely confident in tackling anything new.

• Some of the staff think ‘Jase’ is a great bloke to have around as he is so capable of doing anything asked of him. He even likes to have a bit of a joke around in the tea room which lightens up the mood in an otherwise busy and stressful ED. Other staff have voiced some concerns about his bedside manner saying that he often fails to introduce himself to patients, has been observed speaking abruptly to them and treats some of the nursing staff in a condescending manner.

• On one occasion you overhear an interaction between Jason and a patient with a mental health problem. Jason’s manner is aggressive towards the patient and he appears to be annoyed at the behaviour the patient is exhibiting. You notice Jason walk away and joke with a nursing student about the mental state of the patient.

The Unmotivated Learner

• Daniel is repeating his clinical placement due to unsuccessful completion in the previous semester. He passed his exams and assignments but must now pass all clinical requirements. He arrives at his community based placement displaying a demeanour of boredom and disinterest. You ask Daniel for his clinical objectives and he gives you last year’s version with ‘bits’ missing and you note he has left his stethoscope at home. You ask him to assess a patient for discharge. He declines on the basis that he has already done this sort of thing before on his last clinical placement. He asks you for something more interesting to do.

The Incompetent Learner

• Chris is a GP Registrar in his second Primary Rural and Remote Term ( PRRT2 ). Chris’s philosophy has always been to ‘take the easiest road’. You are his clinical supervisor and on meeting him you notice this laid back attitude such as often arriving late for clinical tutorials or leaving early.

• You also notice that he has a very casual manner with patients. During feedback Chris comments that he has been told before that he is too casual, but believes that his style of interaction is important in establishing rapport. As the clinical teacher, alarm bells start ringing when you see the following on a patient ward chart :

• Chris’s findings – afebrile, sinus rhythm, BP 120/80• Real findings – temp 39, atrial fibrillation, BP 90/60

The Slow Learner

• Unfamiliarity with time expectations• Poor knowledge and / or skills• Fear of failure• Avoidance of new tasks• Language barriers

The Slow Learner

• Concrete examples of time management• Address knowledge / skills deficits; allow time

for revision / practice• Encouragement and exploration of fear of

failure• Provide safe ‘risk taking’ opportunities• Address language barriers with strategies

specific to those from NESBs

The Poorly Interacting Learner

• Brusque• Uncaring• Unkind• Condescending• Over familiar

The Poorly Interacting Learner

• Insight ?• Learner aware of your view as

supervisor ?• Clear standards of acceptable

behaviour ?• Need time set aside to address

concerns and implement a plan

The Unmotivated Learner

• Bored ?• Disenchanted ?• Preconceptions ?• Other issues ?

The Unmotivated Learner

• Relevant learning opportunities ?• Bridging theory-to-practice gap ?• Expectations, responsibilities & value of

these ?• Appropriate determination of learning

needs at outset ?• Career change ??

The Incompetent Learner

• Internal & external drivers ?• Tailored intervention• Focused, structured teaching• Critical incident debrief ( & defuse )• Counselling ?• Initial determination of learning needs

Recommendations for educators and supervisors of IMGs: Top 10

1. Explore IMGs’ understanding of cultural boundaries

2. Teach the use of open ended questions

3. Encourage the use of reflective listening skills

4. Develop the IMGs’ ability to explore psychosocial issues

5. Understand the impact that the teaching system from which the IMG has come, has

on the communication process

6. Differentiate IMGs’ cultural silence from lack of interest or under confidence

7. Deal with IMGs’ expectation of didactic teaching

8. Recognise the unspoken requirements of IMG

9. Guard against negative feedback being perceived as criticism

10. Understand the high level of English language proficiency required by IMGs• Pilotto LS, Duncan GF, Anderson-Wurf J. Issues for clinicians training international medical

graduates: a systematic review. MJA 2007; 187: 225-228.

All Learners

• Any remediation plan needs achievement indicators

• “Unpack your thinking”

Breaking Bad News

• Quiet private time • Confidential - SAFETY• Have a plan of management in mind• Act with heart• Maintain relationship

Breaking Bad News

• Start with positives• Ask for the learner’s views • Listening skills – reflect, paraphrase/check

back• Be Honest – define the problems• Involve them in the management plan• Arrange follow up and feedback

SIXTY SECOND OPENER

• Name the issue• Illustrate with examples• Clarify implications• Describe your emotions• Identify your contribution• Indicate your commitment• Invite a response

“The Fierce Conversation” – Karyn Schluter-White : 0413155001

FOUR STEP SPEED BUMP

• Describe the behaviour• Check perception• Describe your inference• Check this inference• Invite a response

“The Fierce Conversation” – Karyn Schluter-White : 0413155001

REFLECTIVE CYCLE

Description

Feelings

Evaluation

Analysis

Conclusion

Action Plan

PREVENTION

Plan for prevention in your practice:• Orientation to the practice• Clear lines of authority /responsibility• Agreement on teaching time/program• Regular feedback sessions• Practice caring eg welcoming social

occasion; team working well• Deal EARLY with the learner in difficulty

GPR Identified

Step 1 - informalStep 2 - formal

Registrar PerformanceContinuing Assessment and Monitoring

Assessment

• Collection of Evidence

NTGPE (summative and formative assessments)

GPT, GPR, clinic staff

• Define the area of focus

Personal health issues

Refer to the NT Medical board

Risk assessment

Voluntary treatment declined

Voluntary treatment

• Fitness to practice determined by treating doctor

• Voluntary feedback on progress to case manager

Conflict management

Internal practice or supervisor conflicts

External intervention processGPET

Internal intervention process

Learning Plan revised

Clinical performancedeficiencies in clinical competence and

knowledge

Professional and ethical behavioral

concerns

GPR Processing Satisfactory

Resolution

Review and Appeal Process

No resolution

Ongoing monitoring by TA and program coordinator

NTGPE’s PAMI Flowchart, 2008

References

• ‘Managing trainee performance management checklist’ – www.oxforddeanerycdu.org.uk

• ‘Doctors’ health and wellbeing’ – www.bma.org.uk

• ‘The student and junior doctor in distress’ – www.mja.com.au