1. Dealing with Difficult Students and Residents Mark Meyer MD Pam Shaw MD

2. Learning Objectives After attending this meeting the learner will be able to: Define behaviors that can interfere with performance of learners Recognize the signs and symptoms of these behaviors Outline strategies to identify, intervene and manage these behaviors

3. Behaviors that are common problems Stress-personal and professional Depression Disruptive behavior Substance Abuse

4. Stress Situational stressors –Sleep deprivation, heavy work load, shortage of support staff, difficult patients, administrative duties Personal stressors –Family, financial, isolation, limited free time, inadequate coping skills, psychosocial problems Professional stressors –Responsibility for patients, teaching, professionalism, learning material

5. Symptoms of stress Physical –Myalgias, fatigue, headaches, indigestion, pain Emotional –Anxiety, fear, irritability, impatience, depression Behavioral –Change in appetite, sleep problem, forgetfulness, angry outbursts, aggression, decrease in productivity, increase in use of alcohol, drugs or caffeine

6. Stress management Communicate clearly expectations Provide time for acclimation Make resources available-training Ongoing support-may mean outsider from the program(advising) Regular meetings to discuss issues

7. Stress management Support group for spouses Model attitudes towards finding help for stress Mentoring Self-reflection (360 evals) Faculty development

8. Depression Prevalence has been reported to be 29% among residents Signs and symptoms –Depressed mood/feeling sad or empty/tearful –Diminished interest or pleasure in activities –Change in appetite/weight loss or gain –Insomnia or hypersomnia

9. Depression signs and symptoms Psychomotor retardation or agitation Fatigue Feelings of worthlessness/excessive guilt Diminished ability to think or concentrate/indecisiveness Thoughts of death or suicidal ideation

10. Management of Depression Transform professional attitudes Change policies to encourage physicians to seek help Recognize symptoms in peers helps to recognize symptoms in patients Support trainees who need help Depression is highly treatable!

11. Disruptive Behavior Disruptive behavior may occur as a response to an important event Disproportional to the event Causes polarization and escalation

12. Common Behaviors Inappropriate anger or resentments Inappropriate words or actions Inappropriate response to patient needs or staff requests

13. Angry Outbursts Use intimidating, abusive, condescending or degrading language Display body language and tone of voice that is pejorative and insulting Verbalize threats of violence, reprisal or legal action

14. Degrading or demeaning words or behaviors Harass others sexually Use racial or ethnic slurs Engage in inappropriate humor

15. Disregard for effective communication Fail to answer pages or calls in a timely manner Demonstrate unprofessional demeanor Blame staff for adverse outcomes Act in a defiant or rude manner Refuse requests for help Inappropriate email

16. Management of disruptive Behavior Adequate policies and procedures-honor code Identify the behavior and focus on it Identify resources to use and have a plan for corrective action-the learner must acknowledge as well Reveal the bottom line if behavior continues DOCUMENT, DOCUMENT, AND DOCUMENT

17. Substance abuse Recurrent substance use resulting in a failure to fulfill major role obligations Recurrent substance use in situations in which it is physically hazardous Recurrent substance-related legal problems Continued substance use despite recurrent social or interpersonal problems

18. Personal/family behavior Isolation and withdrawal Erratic or violent behavior Sexual dysfunction Legal problems-DUI Separation or divorce Compulsions

19. Social Behavior Inappropriate behavior at social functions Citation for DUI Deterioration in personal hygiene, clothing and dress habits Accidents, falls, motor vehicle accidents

20. Professional Behavior Recurrent tardiness or absences Rounds very early or late Diminished performance Over prescribes medicines-requests samples Alters behavior Slurs speech Fails to answer pages

21. Intervention Trained experienced leader Should be team approach Determine goals Present documented information Rehearse if possible Plan for all outcomes

22. Legal concerns Start from a clinical perspective and state the concern regarding the residents safety and the patients care- then DOCUMENT APPROPRIATELY Avoid diagnosis; describe the behavior and let experts make the diagnosis Required to report to NPDB if privileges are restricted from > 30 days-no report for evaluation or treatment

23. Combat Substance Abuse Education about policies and avoidance of abuse Define a clear and confidential process for referral Refer early and stay out of the evaluation and diagnosis Confidentiality Know the policies and resources in the state and locally

24. Resources available www.lifecurriculum.info 9 hours of CME and the free CD of vignettes and materials

25. Rock Chalk Jayhawk!