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Click the topics below to raise your awareness of how and why you may be struggling.
Click the topics below to raise your awareness of how and why you may be struggling.
General identifiers of issues
General identifiers of issues
Written evaluations from faculty from RMS or other formal systems
Verbal comments or email to the program director from faculty, chief residents, other trainees, nurses/care teams, medical students, admin support staff, the program coordinator(s), the learner themselves
Reporting systems at the sites
Critical incident or patient safety reports
Common reasons that trainees struggle
Common reasons that trainees struggle
Structural or programmatic issues that require changes in the program or learning environment rather than trainee- specific issues
Medical knowledge deficits
Skill deficits
Environmental challenges
Transition issues (ex. Lack of understanding of the attending’s/facility’s standards; adjustment to new multi-disciplinary team members or new patient groups)
Deprivation (sleep, food)
Physical health issues
Situation related stress
Financial problems
Marital problems
Increased work hours
Decreased leisure time
Mental health issues
Depression
Performance anxiety
Personality disorders
Disability (neurocognitive, physical)
Drugs (alcohol, narcotics)
Maladaptive behavior patterns based on role modeling, experience, and reinforcement
Yelling at patients, other physicians, or nurses
Throwing of instruments
Tirades at nurses station
Questions to ask yourself when issues are identified
Questions to ask yourself when issues are identified
Are there larger educational or systemic problems in the residency program that may contribute to this problem?
If this is an issue specific to me, is the perceived performance issue primarily related to a knowledge deficit, an attitude or behavioral problem, a skill deficit, or a combination of these factors?
What is my perception of the issue vs. the faculty's perception?
Are there other contributing personal issues such as depression, anxiety, or personal or family illness that faculty are unaware of?
What is the potential impact of the problem regarding patient care?
What is the potential impact of the problem regarding my personal health and professional growth?
What is the potential impact of the problem regarding its impact upon other residents and faculty?
Recommended process for faculty in bringing issues forward
Recommended process for faculty in bringing issues forward
1. Faculty or staff, whenever possible, sit down with the trainee and share their observations, the impact on patient care, what behaviors they would like to see improved, and what they expect in the future.
2. When these difficulties are reported to the program director, they should also be documented on the formal evaluations.
a. The post-rotation evaluations should indicate a gap between desired and current performance.
b. Written comments should be consistent with the numeric rating scale.
c. Evaluations should be timely so that problems are not overlooked that could impact the development of the learner and patient care.
d. Evaluators should not circumvent direct feedback to the learner either in person or on the evaluation by having verbal conversations/using email with the program director.
Responsibilities of Program Directors, Program Coordinators, and faculty when a struggling learner is identified
Responsibilities of Program Directors, Program Coordinators, and faculty when a struggling learner is identified
1. Ask whether the difficulties being demonstrated by the learner could be a product of a systemic issue in the program/site itself (including discrimination, bias, or disrespect). If so, explore these possibilities before reaching conclusions.
2. Give the learner specific feedback and provide examples
3. Review the expectations and the expected level of proficiency for the learner at this point in their program
4. Notify appropriate leaders as needed (Program Director, GME, site directors, etc.)
5. Do not contribute to the rumor mill (only those who need to know should be notified)
6. Document the learner’s deficits with examples on post-rotation performance evaluations
7. Help the trainee identify the greatest deficit and address it first. Co-create a plan with them to improve. As much as possible, have the trainee identify the best path to improvement. If the root cause of the issue is a systemic problem in the program, work to address the issue.
8. Follow up at the agreed upon intervals to provide the trainee updates on their progress
Identifying problems - Warning signs that deficits are present
Identifying problems - Warning signs that deficits are present
Clinical Skills
Clinical Skills
Definition
An understanding of techniques and procedures and how they are applied to patient care
Ability to do procedural and surgical skills
Ability to perform key elements of exams and understanding their importance
Deficit Presentation
Physical exams lack key elements, are performed incorrectly, or inaccurate information is obtained
Not understanding what types of information should be obtained for each individual exam element
Poor procedural/surgical skills
Unable to answer technique questions about the exam or procedure
Clinical Reasoning and Judgment
Clinical Reasoning and Judgment
Definition
Ability to customize and individualize protocols and practice guidelines
Collecting the necessary information to rule in or rule out diagnoses and implement care plans
Deficit Presentation
Having extraneous information in H&Ps
Ordering too many tests
Having difficulty assigning pre and post-test probabilities
Having difficulty prioritizing the differential diagnosis and analyzing diagnoses
Having difficulty individualizing protocols/practice guidelines
Having an above difficulty, but not displaying adequate knowledge when asked knowledge-based, fact-based questions and/or performing well on pre-clinical exams
Responding inappropriately to urgent and emergent situations
Medical errors in the treatment plan, including medication and other orders
Communication
Communication
Definition
Ability to present clearly and confidently to patients and co-workers
Ability to ask and answer questions with ease
Utilizing appropriate non-verbal communication
Deficit Presentation
Poor oral presentations
Not as articulate as her/his peers
Struggling to answer questions, in contrast to exam scores
Struggling to convey information to patients
Difficulty formulating and asking questions
Struggling to convey variation in level of urgency and severity
Difficulty formulating and asking questions
Poor communication in patient charts
Needing to call patients or re-visit to obtain more information
Appearing to have more “non-compliant patients” than peers (due to the poor communication skills)
Observable confusion or increased questions from the interprofessional healthcare team
Interpersonal Skills
Interpersonal Skills
Definition
Ability to work well with others in multiple roles
Ability to negotiate with others, resolve conflicts
Understanding and respecting personal boundaries of patients, colleagues, and staff
Deficit Presentation
Difficulty functioning within a team
High incidence of interpersonal conflicts
Frequently attempting to transfer blame
Inflexibility with negotiations
Difficulty reading social cues
Awkward peer interactions
Actions and questions may seem inappropriate
Expecting too much or too little from peers, nurses, or ancillary support, inappropriate or lack of delegation
Receiving reports of unprofessional team interactions, such as blocking/turfing patients, yelling a colleagues, or condescending or inappropriate interactions with nursing and other staff
Medical Knowledge
Medical Knowledge
Definition
Knowledge about established and evolving biomedical, clinical, and cognate sciences
Ability to apply this knowledge to patient care
Deficit Presentation
Unable to answer knowledge-based, fact-based questions
Lacking evidence of reading
Poor written exam scores
Professionalism
Professionalism
Definition
Commitment to ethical principles
Maintaining professional responsibilities
Respectful of patient diversity
Deficit Presentation
Poor patient-doctor relationships
Demonstrating a lack of respect
Using technical jargon with patients
Inappropriate dress or comments
Late, absent or unreliable
Dishonesty
Laziness
Specific unethical actions brought to your attention
Inability to develop longitudinal continuity with her/his patients
Trying to pass off inappropriate amounts of work
Refusing to return calls/answer pages or deliver on promised work
Research or practice-based conflicts of interests
Condescension and sarcasm
Withholding vital information
Humor about vulnerable people or populations
Gossiping about other healthcare professionals or trainees
Failure to address witnessing of unprofessional behavior
Emotional volatility or disproportionately emotional responses to people and situations
Practice-Based Learning and Development
Practice-Based Learning and Development
Definition
Investigating and evaluating patient care practices, utilizing feedback to improve
Being a self-directed learner, understanding strengths and weaknesses, and seeking help when needed.
Deficit Presentation
Not showing evidence of self-directed learning
Not setting personal learning and patient care goals
Not showing evidence of reading
Not utilizing quality improvement methods
Not reviewing literature to answer patient care questions
Not seeking feedback
Being defensive when receiving feedback
Not understanding own limitations
Not seeking help when needed
Time Management & Organization
Time Management & Organization
Definition
Preparation for deadlines in clinical care (start of rounds, conferences, producing assignments, being ready to see patients in clinic at their scheduled time)
Presentations are logical and pertinent information is easily accessed, thought processes are organized
Charting is complete, in order, and on time with no important information missed
Deficit Presentation
Unprepared
Disorganized in appearance
Disorganized in presentations
Disorganized notes
Disorganized thought process
Shuffling through multiple documents on rounds
Multiple incomplete tasks
Starting earlier and/or leaving later than peers
Keeping patients waiting, frequently running behind
Spending patient care or otherwise dedicated time trying to get caught up on prior work
System-Based Practice
System-Based Practice
Definition
Awareness and responsiveness to the larger health care system; understanding the importance of transitions of care and financial impacts of different courses of care
Calling effectively on other resources to optimize health care
Participating in identifying system errors and implementing potential systems solutions
Deficit Presentation
Not valuing interprofessional input
Neglecting health care resources
Not considering cost and risk-benefit analyses
Disregarding stewardship of valuable resources
Not advocating for patients
Not seeking resources for patients
Neglecting transitions of care
Continuously criticizing other professions
Not participating in quality improvement to identify system errors and work on solutions
NOTE: How Mental Well-being contributes to performance issues
NOTE: How Mental Well-being contributes to performance issues
Your well-being may impact your performance significantly. You can be hampered by psychosocial stressors, psychiatric issues, substance abuse, or learning disabilities. Some of the behaviors that others may observe include:
Inconsistent performance
Current performance not matching test scores and past performance
Long-lasting sadness or irritability.
Extremely high and low moods.
Displays of excessive fear, worry, or anxiety.
Social withdrawal
Reports of dramatic changes in eating or sleeping habits
Clinical reasoning and organization deficits that aren’t explained by other factors
Because your well-being can drive behaviors, becoming aware of resources you can utilize is important in addressing any deficits others identify between the expectations and your performance. See the STRATEGIES and RESOURCES sections of this site for specific resources.
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