Thursday, May 7, 2009

CUT YOUR LOSSES or LATE BLOOMER???

New residency program directors have limited experiences and face multiple problems each day. One new PD has recently had a challenging time managing two residents, one a third year and one an intern. The third year had posed a professionalism problem from his first year along with some problems integrating into the system and organizational challenges. Things had not gotten too much better over the course his training and lots of time and energy had been invested in getting this resident through the program. Now a new intern was showing the same beginning pattern. He wondered if he should just cut his losses on this intern now rather than waiting three years. His "sample of 1", indicated that he was taking on a 3 year problem. But we all can think of examples of residents who begin with problems and end up being "STARS". So his question: What percent of new residents who show both professionalism problems and knowledge problems in their first year ever turn it around and become contributing members of the residency program? What is your experience?

10 comments:

Anonymous said...

Obviously these things have to be taken on a case by case basis and one cannot generalize about such a critical issue.

I personally have more problems with professionalism issues than knowledge issues (if they are truly knowledge issues). Some "knowledge issues" are really problems with thinking and medical pattern matching or medical common sense.

Poressionalism issues that are related to lack of honesty, integrity, concern for the patient or those stemming from behviours like those seen in borderline personality disorders are the ones where "Cutting ones loses early" might be the right approach. The problem is often lack of appropriate documentation re' failure to meet expectations, feedback, chance for remediation etc...

The concern is due to these factors we often let residents complete the program and go out into the world.

Anonymous said...

I would suggest taking a look at the NEJM article: Disciplinary action by medical boards and prior behavior in medical school. Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, Veloski JJ, Hodgson CS, N Engl J Med. 2005 Dec 22;353(25):2673. The article offers some insight into really severe problems with professionalism and that medical educators should look at this competency beginning in medical school. Were there any problems noted in medical school? I like to think that people are open to change and improvement, and yes, it can take a whole community to make these changes.

Anonymous said...

I think this is a component of a larger issue, which is whether a hurried snapshot interview process is adequate to predict success or failure, which are themselves ill-defined.

The flip side is also an issue: the crash-and-burn of people who look good on paper. Two 'superstar' MSTP scholars in my med school class bailed the moment they hit third year- after a long string of relatively minor behavioral problems. I was a barely-squeaked-in nobody who's now a tenure-track faculty; they were superstars who never went anywhere in medicine. In my residency we had a very highly ranked graduate of a top 5 med school, who repeatedly displayed catastrophic poor judgement and behavior and left the program.

The entire interview and evaluation process is abysmally hopeless in ranking candidates for med school (or for residency) in trms of what actually matters: honesty, integrity, compassion, and a humble willingness to learn.

Yes, there are issues surrounding salvaging a problem child wihtout endangering pateints or programs, but the bigger issue is that we admit or reject candidates for a complex and demanding task in an unforgiveably shallow manner.

Rafi said...

Medical School is somewhat different than residency on this issue. Some find out that medicine wasn't their thing during Med School and with some direction and counseling change their path. However in residency we have already doctors on our hand. One thing that I would like to suggest is to go back and see their behavior both in Knowledge (learning behavior) and professionalism (mostly character) during medical school. If there is any change since then in residency we have to be alerted. In anesthesiology one thing that has to be checked for is addictions. This is a sad however real corner of the educator in residency.

Anonymous said...

I have experience with 2 interns from 4-5 years ago (in the same group). Both lacked clinical skills in their first few months of clinic. I gave similar feedback to both. The one who had the more emotional reaction actually took the feedback to heart, and through more direct observation and feedback, turned it around. He finished as one of my best residents ever. His follow up with patients was superb, and he found subtle abnromalities that others had ignored (including 2 new, difficult to make cancer diagnoses). The other seemed to listen, wasn't defensive, and had a similar effort on my part in terms of observation. He lacked insight, and his clinic was shifted to another preceptor the following year. He finished as one of the weakest residents our program has had.

The ability to reflect on feedback (the internal compass) and the sense of responsibility for self-improvement seemed to be the key differences here.

Seems that being able to assess these upfront is a crying need

Fretta said...

I have experienced examples of both late bloomers and nightmare residents. In fact, in one case we considered finger printing to see if the resident we hired was really the person whose credentials looked so promising! I agree with the other responders that believe a one hour interview will never tell the whole story. We have not done this, but I have heard of other programs in engineering asking the prospective graduate students to collaborate on a task with current students. This process has provided interesting data on communication and organizational skills.

Isaacson said...

I agree it is hard to predict what will happen to an individual with professionalism issues. My anectodal experience suggests that early intervention with defined expectations that are clearly documented offer the best chance for successful remediation. Additionally I have found that if the learner acknowledges the problem, as opposed to trying to defend themself there is a better chance for remediation.

Anonymous said...

I struggle much more with trainees who have professionalism issues than those with knowledge deficits.

I try to intervene more quickly when I observe problem behaviors. However, if the trainee does not acknowledge feedback, lacks personal insight, and does not value self-regulation to remediate in these areas, then I suggest "cut your losses" if behavior does not improve within short timeframe (3-6 months). Three years is too long to deal with a "bad apple".

VI said...

Interesting discussion...in my experience there are many more knowledge/clinical decision making problems than professionalism. We have more than one resident right now who, after rigorous intervention all year still desperately struggles with even basic decision making. With time (and likely frustration), he has less and less insight, and as his supervisors, we are struggling with how to further help him. Often, clinical decision-making wasn't thoroughly evaluated in medical school, and is difficult to parse from their evaluations.

To me, major professionalism issues that fail to remediate have, in most cases, a more clear cut end point. In the case of students that do not grasp "the big picture" of patient care, determining when improvement seems unlikely to happen is murkier. If they aren't going to succeed, how long do you press forward? I'd say certainly a year, but then what? It seems unfair to perpetuate the illusion of advancement in someone who is still failing after prolonged internship and focused intervention. Balancing giving them a fair chance for improvement with allowing them to move on is tricky.

Elias Traboulsi said...

Diificult to generalize. Early intervention and following due process per GME guidelines is paramount. Keeping an open mind yet suspecting the worst like drug abuse or psychiatric illnesses. Sometimes difficult to separate professionalism issues from disruptive and inconsistent behavior secondary to drug abuse or alcoholism. I have dealt with several people with varying outcomes. We have to stick to the process and keep the resident's best interest in mind. Definitely the toughest component of being a program director.