Dealing with the challenging
learner/student/resident/faculty
March 30, 2010
Happy Passover!
Outline
• Scenarios from Liles
• Examples from the crowd
• Feedback techniques
• Getting to Yes
• Made to Stick
• 1 minute preceptor
3/24/2016
2
Scenario 1
• Clinic attending calls me to complain about
a resident X
• X is habitually late for preclinic conference
• X is unprepared for preclinic conference
• “I need you to talk to X”
3/24/2016
3
Feedback
• Feedback is clinical teaching
• Feedback is given a lot more often than
it’s labeled as “feedback”
• Learners consistently say they want more
feedback
• Feedback can occur on any facet of the
encounter…communication skills, PE,
assessment, differential, written work,
presentation, literature review, etc.
Groundwork for Feedback
• Set the climate and establish the goals
– The more explicit expectations are initially
the better!
• Demand self-assessment
• “What did you do well?”
• “Where do you need to improve?”
How to Give Feedback
• Label your feedback
• Deal with performance not performer
– In negative and positive feedback
– Focus on remediable behaviors
Effective Feedback
•
•
•
•
•
•
Focused
Honest
Timely
Private sometimes
Specific
Behaviorally focused
• Based on shared, understood
objectives/expectations (Day 1!)
Scenario 1b
• Receive email forwarded to me from
division chief, chief received it from nurse
manager who heard a story from a charge
nurse about a negative interaction a night
nurse had with resident Y
• Resident Y was verbally abusive to the RN
• Resident Y used foul language and shouted
at the RN
• “will you address this incident with
resident Y?”
3/24/2016
8
Scenario 2 – tardy attending
• Receive several emails and hallway
comments about an attending who is
frequently late
• Signs out in am by phone
• Delays rounds (or absent)
• Administrators frustrated with lack of
paper work
• What do you do?
3/24/2016
9
Getting to Yes
“what is the best way for people to deal with their
differences?”
• Separate the people from the problem
– Relationship v substance
• Focus on interests, not positions
– Principles/demands, ask “why” and “for what
purpose”
• Invent options for mutual gain
– Prioritize, other side’s interests, “help me
understand”
– Allow student to set the goals
• Insist on using objective criteria
– Shared, explicit, objective outcomes
3/24/2016
(measurable)
10
Scenario 3 – brash resident
• Consultant attending (psychiatry) stops me
and relays concerns about interaction with
resident Z
– Aggressive, demanding, accusatory
• RNs stop me in MPCU
– Put off – “disrespectful”
• Resident Z is very bright, decisive,
opinionated (and not southern)
• What to do?
3/24/2016
11
Scenario 4
• Student S is energetic, seems very bright
• Work ups are cursory
– Probing for more info on S’s patients leads to
more confusion
• Offer of student teaching rounds are met
with enthusiasm
– I get stood up
– Excuses offered multiple times
• I am asked for letter of recommendation
3/24/2016
12
Scenario 5
• Student Q is quiet
• Student Q meets every expectation I set
– Knows details of patients when asked
– Is prompt
• Never joins the conversation, offer
opinions
• Rarely asks questions, but will respond to
rounding questions from me
• Is this a problem?
3/24/2016
13
Scenario 6
• “Subterfuge by the RN”
• 55 yo with abdominal pain felt to be
constipation related
• After 4 calls to me informing me of
patient’s continued abdominal pain I go to
the room
• In room RN dismisses my idea of Golytely
for the pain and asks for narcotics for
patient (this is after multiple attempts at
explanation of negative effects of
narcotics on this situation and need for
3/24/2016
pooping)
14
Made to Stick
Lessons From Marketing
•
•
•
•
•
•
Simple
Unexpected
Concrete
Credentialed
Emotional
Story
Simple
• Core
– Masters of Exclusion
– Mission Intent
• Ask “why” or “what” seven times
• Use existing schema to add knowledge
– The power of analogy
– The curse of knowledge – we no longer know
what is simple
Unexpected
• Demonstrate Gaps in existing knowledge
– You have to start with knowledge though
• Curiosity
– We stay up to watch the end of movies – even
bad ones
– Mystery attracts our attention
• Shift from “what I want them to know” to
“what questions I want them to ask”
Concrete
• Build on knowledge and existing schema
• Enduring points
– Aesop, proverbs, concrete examples (cases,
stories)
• Put abstract ideas into context
– Asian Math Teaching
• Invite people to the table
Credible
• Details
• Sinatra test – “if I can make it there…”
– Past success, precedent
• Challenge
Emotional
• Action is spurred by caring and feeling
• Generate caring
– Self interest
– Idealized self – what would a person like me do?
– Create a mission
Story
• Mental simulations
• Avoid going straight to the points and
skipping the story
Made to Stick Summary:
For Effective Communication an
audience must…
1.
2.
3.
4.
5.
Pay attention
Understand and remember
Agree and believe
Care
Be able to act on it!
Scenario 7
• Underperforming resident/intern/student
• Unprepared for rounds
• Unaware of recent data – vitals/labs
• Defers plan-making to me
3/24/2016
23
A Model for Efficient Teaching…
The One Minute Preceptor
•
•
•
•
•
•
Get a commitment
Probe for supporting evidence
Reinforce what was done right
Correct mistakes
Teach general rules
Summarize
How and When to Apply
• Usual
– After the usual presentation
• ? Most appropriate for less experienced learner
• Hard to break this habit!
• True One Minute Preceptor
– These steps are the entire presentation
• ? Most appropriate for more advanced learner
• ? More in-sync with adult learning theory
•
Get a Commitment
What do you think is going on?

•
•
•
Forces the learner to assimilate information and
make a decision.
This process can then be explored
Probe for Supporting Evidence
Why do you think so?

•
•
This is usually where the action is and illustrates
the thought process
Leads to discussion and reflection
•
Reinforce what was done right


•
I agree with…, I think you are correct
with…, That is right on target…,
This is the beginning of the feedback part
– BE SPECIFIC
Correct mistakes/omissions



Probe and Question
“In your presentation, I would have liked to
have known about……”
BE SPECIFIC
•
Teach general rules


Can be anything related to the patient.
Just choose 1 topic. (enemy of good is
perfect)
Take the learner one step further
•
Summarize
•
Educational and Time-Saving?!?
Summary
• Frustration = expectation/reality
• Listen and ask questions
• Use objective measures
• Find common ground
3/24/2016
29