1. Assessing and Managing Residents in Difficulty Nancy Stevens, MD, MPH Department of Family Medicine University of Washington May 2013

2. Residents in Difficulty, Not Difficult Residents Leaves open mind, more opportunities to intervene Sometimes it is a program in difficulty Usually it is both

3. Three Kinds of Difficulty Academic: faculty dx learning difficulty behavior / attitude cognitive psychomotor Disciplinary: due process usually breaking rules or laws Impairment / Disability avoid temptation to diagnose

4. Quick Quiz Academic Disciplinary Disability

5. Quick Quiz Complaints from other residents about this resident’s disorganization and inadequate check out information Academic Disciplinary Disability

6. Quick Quiz EHR flags resident reading family members chart Academic Disciplinary Disability

7. Quick Quiz Resident uses marijuana legally at party Friday night, fails hospital required drug screen several days later Academic Disciplinary Disability

8. Quick Quiz Entering resident asks for accommodation to facilitate treatment of bipolar disorder, has psychotic episode at work Academic Disciplinary Disability

9. Quick Quiz Resident asks for accommodation for ADHD after 4 months of failing rotations for which she is on probation Academic Disciplinary Disability

10. Quick Quiz Resident with very low scores on patient satisfaction Academic Disciplinary Disability

11. Quick Quiz Resident refuses to provide care for patient whose behavior she finds morally objectionable Academic Disciplinary Disability

12. Quick Quiz Military resident fails fitness standards Academic Disciplinary Disability

13. Quick Quiz Resident avoids pelvic exams when indicated Academic Disciplinary Disability

14. Educating HR Disciplinary and Disability difficulties are HR’s responsibility / the resident is an employee Academic difficulties are the program’s responsibility / the resident is a student

15. Faculty Roles Conversation / consensus about expectations before a calamity Resident education about the process in advance Structure reduces wasted time / angst /splitting

16. Improve PerformanceAvoid Problems Coach (Advisor or selected for difficulty) League Manager (Program Director or DIO) Cheerleader (Faculty or staff with professional distance) Referee (Standing group or specifically appointed) Intimate Knowledge of Difficulty Distant From Difficulty Faculty Roles

17. Challenges for FM Educators We prefer to be the coach or cheerleader Focused on growth potential Suspicious of faceless discipline Relationships tempt us to side with residents Vulnerable to splitting

18. Prerogatives: Drawing the Line When a problem arises, who controls whether it gets resolved, the resident or the program? What about when there is uncertainty?

19. Quick Quiz Resident prerogative Program prerogative Work-up

20. Quick Quiz Resident has 60 incomplete charts during a period of regular work schedule. Resident prerogative Program prerogative Work-up

21. Quick Quiz One faculty member finds a resident’s appearance unprofessional but there is no faculty consensus about this. Resident prerogative Program prerogative Work-up

22. Quick Quiz Clinic staff concerned a resident is consistently late to clinic Resident prerogative Program prerogative Work-up

23. Quick Quiz A resident quietly texts during presentations by others Resident prerogative Program prerogative Work-up

24. Quick Quiz R3 has O attendance for the first 3 months of didactics, says she is “so done with that” Resident prerogative Program prerogative Work-up

25. Quick Quiz A OB faculty passes you in the stairwell an raises his concern about a resident with poor procedural skills who responds to feedback with little insight about it. Resident prerogative Program prerogative Work-up

26. Routine Resident Evaluation Concerns? RESIDENT PREROGATIVE / WORKUP CYCLE Program intervention Justified? Concerns Remain? Gather information on differences in Perceptions? Values? Provide Assistance Hypothesize and Focus Problems AgreeNo Agree PROGRAM/FACULTY PREROGATIVE Monitor performance, Make recommendations Take administrative action yes no yes no 1 2 3 45

27. Thank you!