THE ART OF RESIDENT REMEDIATION Institutional

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THE ART OF RESIDENT REMEDIATION
Institutional Person-Centered
Approaches?Michael Bednarski, PhD
med-coach.com

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QUESTIONS

• Are remediation and probation the same?
• How many directly involved in remediation?
• What type of problems are you confronting?
• How many stem from personal problems?
• Attitude problems?
• How prepared are you to deal with these problems?
• Do you have a uniform policy?
• Do departments differ in approach?
• Whose Responsibility is it?
• DIO, Chair, PD, Faculty, Problem Resident?
• What do you need to know today?

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Remediation

• Websters The act or process of correcting a
  deficit.
• Deficit Model
• Vs
• Environmental - Developmental Model
• or
• Institutional Approach Person-Centered Approach

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THE INSTITUTIONAL APPROACHIs Remediation the
Institutions Responsibility? NO

• Too Time Consuming/Expensive
• Drain on Departmental Resources
• Theyre Adults Should Know Better!
  Deficit!
• Experience It Doesnt Work! Deficit!
• Cant Change Character, Attitude, Motivation.
  Deficit!
• Natural Selection Bad Apples Drop Out.
  Deficit!
• ??

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THE INSTITUTIONAL APPROACHIs Remediation the
Institutions Responsibility? YES

• An Educational Process - Institution
• Commitment to Resident Success/Development -
  Institution
• We are Faculty/Mentors in a Teaching Institution
  - Institution
• Cant assume all residents are the same
  Person-Centered
• Some may need more help/time than others
• They dont arrive with same knowledge/skills
• Dont all hit the ground running
• Its Humanistic Person-Centered
• Produces More Effective Doctors Person-Centered
• Impacts Future Caring Person-Centered
• ??

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INSTITUTIONAL APPROACH Effective Remediation From
Organized Structure

• Organized Structure
• Uniform Policy
• Established methodology, Documented approach,
  ACGME criteria, signed agreement
• Academic intervention, not part of record
• Institutional Buy-In
• Involve Faculty, PD, Academic Affairs/Med Ed
  Office, DIO
• Centralized management serving interest of all
  parties
• Ensure all Understand Protocol/Process
• Case Management/Team Approach
• Cross departmental multiple disciplines
• Effective Assessment
• Identify Specific/Actionable Problems
  Objective/standardized methods
• Identify/Enforce Specific Interventions
• Multiple frequent sources of feedback
  progress evaluation
• Safe Liaison Psychologist/Objective 3rd party

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INSTITUTIONAL APPROACHBenefits of an Organized
Structure

• It works!
• Sets a positive tone for dealing with resident
  problems
• Preventive model -gives residents permission to
  ask for help not bury problems
• Provides early intervention
• Saves time and money
• Reduces noise at top of organization -
  litigation.
• Creates checks and balances, and high degree of
  accountability
• Support adverse action/probation when indicated
• Provides clean diagnosis of problem resident and
  limits institutional liability

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INSTITUTIONAL APPROACH The Consequences of Doing
Nothing

• Bad reputation with staff and other departments,
  morale
• Sends wrong signal to other residents
• Reduces morale
• Abdicates responsibility to Residents, staff, and
  public
• ??

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INSTITUTIONAL APPROACHSummary

• Who Residents that deviate from standards
  (ACGME)
• Severe offense (adverse action) should not
• What Specific, definable, and actionable
  behaviors in need of change
• When At first sign or expression of difficulty
  trust instincts
• Part of Formative Evaluation/Feedback Process
• Where Within a recognized/organized structure
• Follows uniform policy and procedures
• Coordinated between Academic Office Departments
• Shared effort/evaluations

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PERSON-CENTERED APPROACH Understanding
ResidentsWhat Makes Them TickWhat Ticks
Them Off
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UNDERSTANDING RESIDENTSResidency as Activating
Environment

• Challenging Change in Environment
• Hospital as Complex System
• Student to Resident
• Social Support
• Challenges to preferred Learning Style,
  Communication Style
• Long-Standing, Stable Traits Reflexes
• Adapt to varied teaching styles
• Consistent reminding of limits of own learning
  style
• Activates personal Coping Style
• Challenges assumptions about self and medicine

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UNDERSTANDING RESIDENTSDifferential Factors
Impacting Performance

• THREE SUCCESS FACTORS
• Intellectual/Cognitive Abilities (IQ)
• Standardized tests, memory, fund of knowledge
• Functional/Technical Ability
• Skills
• Dexterity
• Use of Appliances/Technology
• Emotional Intelligence/Interpersonal (EQ)
• Self-Awareness, Situational Awareness
• Interpersonal Skills - Communication Style
  Awareness
• Coping Style Hi-Jacking
• Inter-correlates with all 6 ACGME Competencies

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 UNDERSTANDING RESIDENTSFour Stages of
Competency Development

•  Unconsciousness Incompetence Unaware of what
  they do not know
• Do not recognize limitations - Do not ask for
  feedback
• Important to intervene at this level shapes
  subsequent development
• Conscious Incompetence Aware of what they do
  not know
• Recognizes limitations - Seeks knowledge, feed
  back learning opportunities
• Important to support at this level
• Conscious Competence Awareness of what you do
  and do not know
• Appropriately apply knowledge - Work towards
  expanding skills
• Unconscious Competence Apply skills and
  knowledge automatically
• Abilities Second Nature - Knowledge is
  generative
• Teaching is learning

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R.D. LANG KNOTS (1970)There is something I
dont know that I am supposed to know.I dont
know what it is I dont know, and yet am supposed
to know.And I feel I look stupid if I seem both
not to know it and not know what it is I dont
know. Therefore I pretend I know it.This is
nerve-wracking since I dont know what I must
pretend to know.Therefore I pretend to know
everything.I feel you know what I am suppose to
know but you cant tell me what it is because you
dont know that I dont know what it is.You may
know what I dont know, but not that I dont know
it, and I cant tell you. So you will have to
tell me everything.But I cant let you know that
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UNDERSTANDING RESIDENTSPersonal factors that
impact performance

• Internal Barriers Conditioned Learning -
  Temperament
• Mild Pathologies Quirks
• Perfectionism, performance anxiety, transferences
• Personality Style Conflicts
• Cognitive Style, Learning Style, Communication
  Style, Coping Style
• Social Support
• Inadequate support?
• Support conflicts
• Work/life imbalance
• Cultural Factors Assertiveness/Deference
  Multicultural unawareness

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UNDERSTANDING RESIDENTSEnvironmental factors
impacting performance

• Poorly Elaborated/Disseminated Policy
• Inadequate performance guidelines
• Informed Consent Understanding environmental
  demands, requirements
• Structural Issues
• Work flow, scheduling, under-staffing
• Process Issues
• Poor authoritative communications, ineffective
  meetings, lack of feedback
• Interpersonal Stuff
• Normative personality differences (Clashes),
  learning, coping, communication style conflicts
  among residents, peers, and mentors
• Leadership
• Poorly elaborated/disseminated policy,
  Infighting, role-confusion, morale
• Resource Allocation
• Role overload Role diffusion (Key stress
  factors)

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REMEDIATING THE PROBLEM RESIDENTPerson-Center
ed Approach
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REMEDIATING THE PROBLEM RESIDENTWhen to
Intervene

• First Signs or Expressions of Difficulty
• The sooner the better - Trust your instincts
• Early action can be less adversarial
• Sets a positive tone that is diagnostic
• Look for patterns Assess performance reviews
• Seek External Validation from Peers, Residents,
  Faculty

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When To Intervene(How It Sometimes Happens Or
Doesnt)

• There were four staff members named Everybody,
  Somebody, Anybody, and Nobody. They worked
  together as a team in a busy hospital. There was
  a resident that needed attention and Everybody
  was sure that Somebody would do it. Anybody could
  have done it, but it turned out that Nobody did.
  This made Somebody angry, because it really
  should have been Everybody's job. But Everybody
  thought Anybody could do it, and Nobody realized
  that Everybody wouldn't do it. So it ended up
  that Everybody blamed Somebody when Nobody did
  what Anybody could have done.

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REMEDIATING THE PROBLEM RESIDENTWho Should be
Involved

• Program Director
• Oversees process, stays informed, signs/enforces
  remediation agreement, meets with resident
• Chiefs
• Mentoring Feedback to resident. Report to PD,
  empathizers
• Faculty
• Key informants, daily contact report progress,
  mentor review progress at core faculty meetings
• Faculty Advisor
• Crucial third party objective and supportive to
  resident. Reports to PD
• Professional Counseling
• Crucial third party objective and supportive to
  resident. Reports to PD

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REMEDIATING THE PROBLEM RESIDENT Confronting
the Resident with Remediation

• Seek residents opinion on the issue first.
  Assess openness Vs defensiveness
• Say I understand .this happened.how do you see
  it?
• Emphasize Academic Intervention or
  Professional Development
• An investment in resident
• Not probation but can lead to
• Not part of permanent record
• Use a balanced, strength-based approach
• Depersonalize - Link to standards of performance
  agreement competencies

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REMEDIATING THE PROBLEM RESIDENTEstablishing
the Mentoring Process

• Communicate Clear Objectives with Actionable
  Goals
• Explore resident diversity
• Cognitive, Communication, Learning, Coping
  Styles
• Seek Possible Environmental Factors
• Work and personal Environments
• Perspective-taking
• View as problem solving- process (not
  Inquisition)
• Recognize personal biases
• Others think, communicate, make decisions like
  me.

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Essential Resources For Effective Remediation

• Agreements
• Prior agreements Linked to ACGME criteria
• Coherent remediation plan signed resident
  agreement
• Established goals with deadlines
• Independent Faculty Advisor
• Serves as support, feedback, representative
• Myers-Briggs Type Indicator (MBTI)
• Measures cognitive, communication, learning style
  Psychological Habits
• Widely used, valid and reliable
• Psychologist
• Acts as safe liaison
• Trained in professional development issues

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Psychological HabitsPsychological TypeNot
Knowing Type Unconscious Incompetence
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CASE DESCRIPTIONS

• The case of poor medical knowledge
• Why??
• The blunt resident
• Why?
• The uninvolved resident
• Why?
• Audience??

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TYPE QUESTIONS

• Introverted Type
• Sensing Type
• Thinking Type
• Judging Type

• Extraverted Type
• iNtuitive Type
• Feeling Type
• Perceptive Type

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UNDERSTANDING RESIDENT TYPES

• Introverted Residents
• Need time to reflect
• More self-contained
• Need thoughts and feelings drawn out
• Usually waits for others to make the first move.

• Extraverted Residents
• Seek interaction
• Seek energy/enthusiasm.
• Openly express their thoughts and feelings,
• Easily distracted by other activities (KISS)

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UNDERSTANDING RESIDENT TYPES

• Sensing Residents
• Like precise instructions
• Need info step-by-step
• Like facts, not theories
• Want details, next steps

• iNtuitive Residents
• Seek future implications
• Want the Big Picture
• Naturally skeptical
• Will tune-out details

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UNDERSTANDING RESIDENT TYPES

• Thinking Residents
• Need to know why things are done
• Dislike small talk
• Views things logically
• Debates

• Feeling Residents
• Wants to know impact on others
• Needs warmth/support
• View things emotionally
• Defers

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UNDERSTANDING RESIDENT TYPES

• Judging Residents
• Strong need for clarity of goals and objectives
• Like things settled and finished
• Need structure and predictability
• Need CLOSURE

• Perceiving Residents
• Strong need for understanding process
• Act spontaneously change minds
• Need flexibility
• Avoid CLOSURE

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CASE DISCUSSIONS

• The case of poor medical knowledge
• The blunt resident
• The uninvolved resident

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CASE EXAMPLES

• ??

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RESOURCES

• Remediation Policy Model
• Communications Packet
• Copy of PowerPoint
• Ancillary Materials

• med-coach.com
• mbednarski_at_aol.com
• 800-856-7219