Dr Sudha KoppulaDepartment of Family Medicine

November 16, 2010

ObjectivesBy the end of this discussion, you will be able

to:

- Consider situations re: residents in clinical settings

- Develop approaches to these situations

- Develop confidence in your ability to manage these

Clinical Teaching

• Why do we choose to do it?• What are the positive aspects?• What is challenging?• How can we make this more rewarding?• What tools do we need?

Scenarios9 in totalBased on my residents or a colleague’sRelated to:

Clincal performanceBehaviour as a learner“Good” residentsProfessionalism

Your scenarios welcome also

Abby, PGY-1- Family Medicine residency for 5 weeks - 3rd continuity clinic- Sees a patient with a painful R knee - Took a good hx; you watched her do knee exam- You ask her what her initial thoughts are re: dx- She isn’t sure - guesses OA, appears unsure- You ask her for other options (ddx)- She appears nervous and says she doesn’t know

Abby, PGY-1What do I do when my resident reports findings

but doesn’t make them meaningful?- Nervous?- Feels rushed?- Used to report findings in medical school and

was never asked for her opinion?

Abby, PGY-1• Ensure “safe” learning environment• Take time for learner• Expect she may see few patients per clinic

initially• Communicate

– her opinion and thoughts matter– expectation of ownership– practice problem-solving• What fits? • What doesn’t fit? • What if ... ?

Brian, PGY-1Halfway through PGY-1 year

You realize every once in a while that there are certain things he should know to do but doesn’t ... ask red flags in patient with back pain DRE in patient with rectal bleedpap with ASCUS x 1 does not need colpo referral

This makes you understandably nervous ...

Brian, PGY-1What do I do when my resident’s

knowledge is substandard?- Does he read around cases?- What else going on in his life preventing him

reading?- Does he know where to look up info?

Brian, PGY-1Show him a good resourceAsk familiarity with various evidence-based

resourcesAsk him to verbalize his thought processes Be open to him speaking about his life

circumstances

Carlos, PGY-1• On Internal Medicine, back for continuity clinic

• You ask how the Internal Medicine is going

• Worried he may not pass• preceptor says doesn’t manage complicated patients

well • gives him “easier” ones; he does well with those

• Thinks this is true• he gets muddled if a patient has too many illnesses

• You have noticed this to be a problem in your clinic too

Carlos, PGY-1What do I do when my resident has trouble

managing complex patients?- Knowledge issue?

- Organization issue?

- Feel overwhelmed?

Carlos, PGY-1• Clarify if concern with knowledge• Consider organizational strategies

– Problem lists• What if ... ?• Target practice to increasingly complex patients• Ensure clear communication of thought processes• Encourage him - cares for uncomplicated patients

well• May talk to rotation preceptor, ensure he has

• opportunity• graduated responsibility• help

Magda, PGY-2• In your office for AM clinic• Usually clinical assessments are done well• Found she documents patient encounters poorly:

– Writes SOAP format but ‘plan’ is in ‘objective’ etc– Lacking detail– Does not flow (new topics mentioned in plan section)

• You notice: • getting a lot worse • spending more and more time reviewing her notes

Magda, PGY-2What do I do when my resident’s

documentation is poor?- Is she in a rush to leave clinic?- Comfortable using a keyboard/computer?- Understand the importance of chart notes?

Magda, PGY-2Discuss why good chart notes are essentialShow note(s) she has done wellShow one of your notes as exampleGo through notes with her before she leaves

clinicAsk what are the barriers to good

documentation

Jing-Li, PGY-2• Transferred from another residency program• Got credit for rotations completed

successfully• You give frequent formative feedback• Her response = “ok” and no discussion• Behaviours for which you have suggested

specific improvements have not changed• You are frustrated• Jing-Li seems oblivious that this is happening

Jing-Li, PGY-2What do I do when my resident doesn’t seem to

listen to my feedback?- Is she hearing me?- Am I repeating myself?- Does she feel like she can discuss the

feedback provided?

Jing-Li, PGY-2After feedback given, ask for her next step to

improveDocument feedback (fieldnotes)Encourage discussion about feedback

Verbalize you are interested in her perspectiveHer thoughts on how to improve

Mark, PGY-2• Just started PGY-2 year, enjoying it• Performed well last year• Regard him as a colleague

– Focussed, thorough assessments– Reasonable management– Considers patient’s individual circumstances

• He arrives, does his work, is pleasant and leaves• Feedback is always positive• You feel like you aren’t teaching him anything ...

Mark, PGY-2What do I do when my resident is performing

well and barely needs my help?- Is this a problem at all?- What else could I teach him?- Awkward to be asking him higher level

questions ...

Mark, PGY-2Discuss that you are happy with his work &

progress

Consider teaching practice management, quality assurance, billing (ask if interested)

Ask “what if” clinical questions

Sushila, PGY-2• Halfway through PGY-2 year• Been a very conscientious resident so far• Studying for CCFP exam• Seems to be asking you more and more questions

that you don’t know the answer to right away• You feel embarrassed that you don’t know the

answers • You feel her questioning is genuine and want to

help her find the answers• You don’t want to disappoint her as her teacher

Sushila, PGY-2What do I do when my resident asks me

questions that I don’t know how to answer?- Why is she asking? (may be on exam)- Do those questions matter?- Why do the answers matter to her?

Sushila, PGY-2

Ask the reason for some questions she asks

Ensure she is targeting the correct things to study

Look the answers up togetherDifferent resourcesShare them

Denis, PGY-2• On distributed community rotations

• Repeatedly arrives late to your clinic– No chance to review patients beforehand– Missed patient who changed schedule to f/u with

him

• Once he missed an entire clinic & did not call ahead

• Your colleague tells you he was booked for exam practice with him and he didn’t show

• You realize Denis is on a slippery slope!

Denis, PGY-2What do I do when my resident

doesn’t keep commitments?

- What are the barriers?- Preoccupied with studying- Personal life

- Disorganization?

- Does he have insight that this is a concern?

Denis, PGY-2Communicate professional behaviour, incl

punctuality, is constantly assessed because it is important

Ask what the challenges have been

Suggest solutions

Document feedback

Consequences:Call patient to apologize Apologize to colleague

Vincentia, PGY-2• Presents to clinic happy the weather is finally

warm• Eager to start clinic• Patients being rude and making “comments”• Can’t understand why• You talk about it with her between patients• As she gets out of her chair, you realize she is

wearing• a thin skirt • colourful underwear ...

Vincentia, PGY-2What do I do when my resident does not dress

in a professional manner?- Does she realize what she is wearing?- Is she upset by the comments?- How do I tell her ... ?!?!

Vincentia, PGY-2Prevent her from seeing next patient

Communicate you may know what the problem is (consider having another person with you)

Suggest a lab coat

Discuss if she is upset

Emphasize tomorrow is another day ...

Your turn!

Remember …

“Doctor” = “Teacher”

Reward is making a difference

You have ... Considered scenarios re: residents in clinical settings

Learned approaches to these situations

Interacted with your peers

Let’s Discuss

Thank you

Sudha Koppula

sudha.koppula@ualberta.ca

780.492.1972

www.familymed.med.ualberta.ca/Home/Education/FacultyDevelopment/Events.cfm