What do I do when my resident ... ?

Dr Sudha KoppulaDepartment of Family Medicine

November 16, 2010

Objectives

By the end of this discussion, you will be able to:- Consider a spectrum of situations re:

residents in clinical settings- Develop approaches to these situations- Develop confidence in your ability to manage

these situations

Clinical Teaching

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

“Doctor” = “Teacher”

Scenarios

• 9 in total• Based on my residents or a colleague’s• Related to:– Clincal performance– Behaviour as a learner– “Good” residents– Professionalism

• 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 perform a

thorough and focussed knee exam- You ask her what her initial thoughts are re: dx- She isn’t sure what to think - she guesses OA but

appears unsure- You ask her for other options (ddx)- She appears nervous and says she doesn’t know

Abby, PGY-1

What 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 very few patients in a

continuity clinic initially• Communicate – her opinion and thoughts matter– expectation of ownership– practice problem-solving

• What fits? • What doesn’t fit? • What if ... ?

Brian, PGY-1

• Halfway through PGY-1 year• You realize every once in a while that there

are certain things he should know to do ...– ask red flags in patient with back pain– DRE in patient with rectal bleed– pap with ASCUS x 1 does not need colpo referral

• This makes you understandably nervous ...

Brian, PGY-1

What do I do when my resident’s knowledge is substandard?

- Does he read around cases?- Is something else going on in his life

preventing him from reading?- Does he know where to look up info?

Brian, PGY-1

• Bring/show him a good resource• Ask his familiarity with various evidence-based

resources• Ask 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 rotation is going• He says he is worried he may not pass. His

preceptor says he doesn’t manage complicated patients well so they give him “easier” ones to manage. He does well with those.

• Thinks this is true - he gets muddled re: what to do if a patient has too many illnesses at once

• You have noticed this to be a problem too

Carlos, PGY-1

What do I do when my resident has trouble managing complex patients?

- Knowledge issue?- Organization issue?- Feel overwhelmed?

Carlos, PGY-1

• Clarify if there is a concern with knowledge• Consider organizational strategies – Problem lists

• What if ... ?• Target his practice to increasingly complex patients• Ensure clear communication of his thought processes• Encourage him that he takes care of uncomplicated

patients well• May choose to talk to rotation preceptor to ensure he

has opportunity, graduated responsibility, help

Magda, PGY-2• In your office for AM clinic; usually clinical

assessments are done well• Finding she generally documents patient

encounters poorly:– Writes SOAP format but ‘plan’ is in ‘objective’ etc– Lacking detail– Does not seem to flow (new topics mentioned in plan

section)• You have noticed this is getting a lot worse and

are spending more and more time reviewing her notes

Magda, PGY-2

What 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-2

• Ensure she understands why good chart notes are essential

• Show her a note she has done well• Show her one of your notes as an example• Go through notes with her before she leaves

clinic• Ask 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 over the course

of her time with you• She says “ok” whenever you give feedback and does

not discuss much with you• You find the 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-2

What 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-2

• After feedback is given, ask for her next step to improve

• Document feedback (fieldnotes)• Encourage discussion about feedback– Verbalize you are interested in her perspective– Her 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 circumstance

• He arrives at clinic, does his work, is pleasant and leaves

• Feedback is always positive• You feel like you aren’t teaching him anything ...

Mark, PGY-2

What 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-2

• Communicate that you are very happy with his work and 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

Sushila, PGY-2

What 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?- Look them up together – consider the sources

Denis, PGY-2• On distributed community rotations• Repeatedly arrives late to your clinic– No chance to review patients beforehand– Missed a patient who changed her schedule to follow-

up with him specifically• On one occasion he completely missed a clinic

with you and did not call to let you know• Your colleague also tells you that he was booked

to do exam practice with him and he didn’t show• You realize this is a slippery slope!

Denis, PGY-2

What 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-2

• Communicate that professional behaviour, including punctuality, is constantly assessed

• Ask what the challenges have been• Suggest solutions• Document feedback• Consequences:– Call patient to apologize – Apologize to colleague

Vincentia, PGY-2• Presents to AM clinic happy that it is a warm,

sunny day outside• Eager to start clinic• Patients being rude to her 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 through which her colourful underwear can be seen!

Vincentia, PGY-2

What 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-2

• Prevent her from going to see the next patient• Communicate that you may know the source

of the problem (perhaps with another person in the room with you)

• Offer a lab coat to wear for the day• Discuss if she is upset• Diffuse the situation

Your scenarios?

You have ...

• Considered the possible scenarios involving residents in clinical settings

• Learned approaches to these situations• Interacted with your peers

QUESTIONS

Thank you

Sudha Koppulasudha.koppula@ualberta.ca

780.492.1972

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