From Failure to…

2. From Failure to… Who am I ? Teachers said I was “too stupid to learn anything.” I was fired from my first two jobs • Not productive enough I first failed 1000 times

3. Success I held 1,093 patents world-wide “Genius is 1% inspiration, 99% perspiration.” I am best known for this:

5. From Failure to… Who am I ? I loved sports growing up. I was cut as a sophomore from my high school basketball team.

6. Success I ended up in the NBA I won 6 NBA championships I have appeared on front of the Wheaties box more than any other athlete

7. From Failure to… Who am I ? I went to drama school with Bette Davis. I was dismissed for being too quiet and shy I began my performing career on Broadway, but then was quickly fired Next, I was dismissed from two different movie productions

8. Success As the star in my own TV show in 1948, I went on to win: – 13 Emmy Awards – 12 Golden Globes – A Lifetime Achievement Award – International Fame

10. Residents In Difficulty MAJ Scott Grogan Faculty Development Fellow 2 May 2012

11. Is this resident’s performance below the line??

12. Discussed your experiences Listed common resident problems Categorized those problems Reviewed a model for dealing with residents in difficulty Applied that modelto cases Objectives

13. Act swiftly… investigate and remediate Document, document, document Focus on program requirements Use a model to guide you Follow the program’s due process policy Take Home Points

14. Your Experiences… Why Talk About Residents In Difficulty?

15. The resident Teaching staff Fellow residents Program graduates GME chief and GMEC Big Navy/ Big Army Public & society Patients - we are different Stakeholders

16. Discuss a resident in difficulty that you have worked with What were the issues? How did you deal with the problem? What would you do differently? Be prepared to share With Your Neighbor

17. 1. Academic – learning difficulty Behavior / attitude Cognitive Psychomotor 2. Disciplinary Usuall breaking rules or laws 3. Impairment / Disability Avoid temptation to diagnose Three Kinds of Difficulty

18. Academic 19 Behavior / attitude 12 Knowledge base 3 Others 4 Discipline 4 Impairment / disability 9 Past PD Responses

19. Identified problem earlier Documented earlier Started remediation earlier Acted earlier I Wish I Would Have…

20. Warning Signs • Avoidance, no interest • Poor performance, task completion • Poor or inappropriate interactions • Tardiness, poor time management • Falling behind in charting • Excessive griping – moody • Complaints by others

21. Be Careful Saying… “Just ignore it” “They’ll grow out of it” “They’re having personal problems” “It might be just this once”

22. Barriers and Pitfalls • Fear of being the “bad guy” • No staff consensus on “The line” • Personality conflict w/ resident • Personal attacks • Fear avoidance of conversations • Time • Amount of documentation required

23. Other Pitfalls Big hearts Trying to be a provider Halo Effect Being a fixer Conspiracy of Silence

24. What would you do now? Dr. White Cloud

25. Above the line vs. below the line… Resident prerogative vs. Program prerogative Nancy Stevens MD, Univ. of Wash. A Model to Guide You

26. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

27. For problems that remain the resident’s prerogative to resolve Work-up Cycle

28. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives “The Line” PROBATION CYCLE Program/Faculty Prerogatives

29. Regular opportunities for: Assessing, guiding, and reassuring Identify problems for further “work-up” Acting early Verbal feedback Documenting Routine Resident Evaluation

30. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize “The Line” PROBATION CYCLE Program/Faculty Prerogatives

31. Discuss with resident (ONLY) Possible causes of situation? Respect resident’s perspective Sort issues according to whether resident agrees or disagrees Document conversation Task 1: Problem Focus& Hypothesize

32. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? YES Provide assistance Concern Remains? YES NO “The Line” Probation Justified? PROBATION CYCLE Program/Faculty Prerogatives

33. Focus only on area of agreed need Plan help jointly with the resident Be specific in comments Monitor plan for effectiveness Inform resident when done A good situation for a learning contract?! Task 2: Provide Assistance

34. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Resident Agrees? Gather data & evaluate for Perception / Value differences YES YES NO Provide assistance Concern Remains? Concern Remains? YES YES NO NO “The Line” Probation Justified? PROBATION CYCLE Program/Faculty Prerogatives

35. Differences in perception Assist resident to collect data on future events Differences in values Help resident articulate value positions Identify behaviors likely to result in conflict Communicate the likely consequences Task 3: Gather InformationAround Differences

36. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Resident Agrees? Gather data & evaluate for Perception / Value differences YES YES NO Provide assistance Concern Remains? Concern Remains? YES YES NO NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives

37. For problems that become the program’s prerogative to resolve Probation Cycle

38. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES Monitor performance, Recommend interventions PROBATION CYCLE Program/Faculty Prerogatives

39. Program level remediation Hospital level probation Requirements clearly identified Assistance / remediation plan explained Objective criteria to assess improvement Timeline for resolution Task 4: Probationary Monitoring

40. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

41. End remediation & begin routine eval Begin probation End probation Extend probation Terminate Task 5: Administrative Action

42. In groups discuss the cases… Above or below the line? What course of action would you take? How would you document this situation? Appoint a spokesperson Share your findings with the larger group Cases

43. The Tardy Resident Case 1

44. The Inefficient Resident Case 2

45. The Depressed Resident Case 3

46. The Severely Ill Resident Case 4

47. Reduced Knowledge Resident Case 5

48. The Administratively Challenged Resident Case 6

49. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action

50. Routine Resident Evaluation Concerns? NO YES WORK-UP CYCLE Resident Prerogatives Problem Focus & Hypothesize Resident Agrees? Gather data & evaluate for Perception / Value differences YES NO Provide assistance Concern Remains? YES NO “The Line” Probation Justified? NO YES PROBATION CYCLE Program/Faculty Prerogatives Monitor performance, Recommend interventions Take administrative action