Strategies When Gaps Are Identified 

1. Identify your gaps in medical knowledge

a. Review your performance on prior standardized tests and written course exams

          i. If you have historically done fine, you may just need to put in more reading and study time or revive methods that worked in the past.

          ii. If you have struggled in past exams, you may need new strategies for learning medical knowledge. 

b. Determine if the problem is specific to a few areas or more general in nature. 

2. Review your reading/study plan and habits

a. Look at the amount of material you are covering and the time you are allotting to that activity.  Is it adequate to absorb the needed content?

b. Are you regularly reviewing the literature on current patients to be prepared to determine treatment plans?

3. Identify the goals for medical knowledge demonstration for a particular time frame and agree on a study/reading schedule with your faculty mentor or Program Director.

4. Investigate using active learning techniques like audio-recording learning and playing back at regular intervals, using visual maps and charts to organize content.

5. Review concepts with a faculty mentor – as much as possible recite what you have learned out loud.

6. Get clarity on how you will evaluated in your progress in medical knowledge from your program.

7. Any trainees can utilize Dr. Scott Slattery to consult on difficulties related to academic counseling and performance support, test preparation or test anxiety:  Office of Learner Development, Medical School:  (612) 626-7196 slattery@umn.edu

1. Do reading, online modules, or videos on clinical skills or procedures where you are experiencing gaps. 

2. Ask for opportunities to observe others performing the procedure whenever possible.

3. Get video-recorded practicing the deficient clinical skill.  Self-assess and then get observations from faculty.  Make sure you get the reasoning behind each step in the technique. 

4. Use standardized patients and simulators.  Repetition and practice is key.

5. Get real-time feedback from a peer or faculty mentor, based on the observations in the clinical environment. 

1.  Agree with your PD or faculty mentor on how much you are expected to accomplish in a given time frame:

a.  Ex. You should be able to write a follow-up note in 15 minutes or less.

b.  Ex. You should be able to see 9 patients this afternoon and have notes completed by 6 pm at the latest. 

2.  Determine a data organization system that fits the your needs

a.  To-do list with check boxes

             i.      Placed at the bottom of each progress note

             ii.      Place on the prior shift’s sign-out sheet

b.  Note template

c.   Daily outline

d.  Excel spreadsheet you can fill in each evening for the next day that covers both non-negotiables and prioritizes discretionary time.

3.  Have a mentor review your use of their data organization system to check that all essential tasks are included and unnecessary tasks are eliminated.  Discuss how they manage interruptions and other situations that throw off time schedules.

4.  Seek out models so you can observe good examples of activities like pre-rounding, chart reviewing, planning patient encounters with clear goals. 

5.  Keep a log of daily activities where your time is spent to analyze where more efficiency can be incorporated.

6.  Consider systematically building up to the desired times to complete tasks.

7.  Take advantage of the free and confidential 1:1 coaching to address specific issues.   Carolyn Hildebrandt, the Organizational Development Manager in the UMN Office of Graduate Medical Education, offers coaching services via Zoom. In these 50 minute appointments, you can explore your challenges, identify goals, discuss approaches, and plan action steps. You can self-refer for a confidential session. 

To schedule, choose a time slot: 

Book Coaching appointments here

To read more about Clinical Reasoning and Judgment click here.  The link leads to 3 frameworks for creating a differential diagnosis that a faculty member can utilize with a trainee who needs work in this area.  

1.  Get specific examples where the lack of interpersonal skills impacted your performance.  What behaviors got in the way?  Identify your program's expectations of future behavior in a given time frame. 

2.  Reflect on past interactions that did not go well.  How could you have approached the situation differently?  What were the needs of the other people in the interaction?  Sometimes doing a written reflection can be helpful in flushing out your thoughts and feelings on that interaction.

3.  Identify a buddy who would be willing to clue you in when you display the problematic behavior in the moment with a signal.  You can adapt your behavior immediately with that kind of feedback.

4.  Seek out a faculty mentor to provide real-time feedback based on observations in the clinical environment. 

5.  Learn how to mend relationships by:

a.  Acknowledge struggles and let others know what you are working on.

b.  Apologize when you hurt another’s feelings.

c.   In a tense conversation, ask for permission in the moment to try the response again.

6. Consider pursuing coaching to work on interpersonal skills.  Carolyn Hildebrandt, the Organizational Development Manager in the UMN Office of Graduate Medical Education, offers coaching services via Zoom. In these 50 minute appointments, you can explore your challenges, identify goals, discuss approaches, and plan action steps. You can self-refer for a confidential session.   To schedule, trainees can choose a time slot: Book Coaching Appointments here 

7.  Pursue some assessments of emotional intelligence, personality hard-wiring, conflict management behaviors, and personality style preferences to see where your tendencies are impacting performance.  Carolyn Hildebrandt is able to work with any trainee who wants to take one of these assessments.  No assessment results are included in your educational record, so the emphasis is on growth and development.  Book a coaching appointment to discuss with her (see above).  

8.  Consider the long and short term consequences of failure to improve interpersonal skills:  disciplinary action, difficulty in obtaining letters of recommendation for future education/employment, frequent job turnover, fewer patient referrals, lower income, less stability and job satisfaction.  Commit to taking the steps necessary to work on your behaviors.

1. Discuss specifically with faculty or your Program Director how the lack of good communication skills is preventing competent performance.  What behaviors do they notice?  Clarify expectations in a given timeframe for improvement that they have for you.

2. Get feedback on your oral presentations from faculty.  What do you do well?  What do they want to see more of?  Less of?

3. Implement the SBAR mnemonic (S- Situation, B – Background, A – Assessment, R – Recommendation) for brief communications with clinical staff to quickly and efficiently interact on a patient concern.  

4. Use video-taped recordings or simulation scenarios to improve self-awareness. 

5. Ask for real-time feedback throughout the workday.  Let faculty know specifically what would be helpful to observe.

6. Practice presentations with a mentor before rounds.

7. Do a simulated medical interview practice with standardized patients. 

8. Seek out an opportunity to participate in a meetings with Patient Relations at your site that focuses on patient complaints related to communication with physicians.

9. Consider coaching to work on communication skills or your confidence in presentations.  Carolyn Hildebrandt, the Organizational Development Manager in the UMN Office of Graduate Medical Education, offers coaching services via Zoom. In these 50 minute appointments, you can explore your challenges, identify goals, discuss approaches, and plan action steps. You can self-refer for a confidential session.   To schedule, trainees can choose a time slot:  Book Coaching Appointments here 

1. Get examples of what is perceived as unprofessional behavior.  Perform a root cause analysis to determine the cause of the behavior.  Discuss with your Program Director or mentor perceptions and impacts to others as a result.  Consider what alternatives you would propose in the future for similar situations.  Identify barriers to success.

2. Reflect via writing to reflect on your level of professionalism.  How does it affect patient care?  Teamwork?  Did you know the behavior(s) to be problematic, but hoped not to get caught/were willing to face the consequences?  Or, did you not know the behavior was unprofessional, but do now?

3. Get clarity from faculty/Program Director/Program Coordinator on the expectations around behavior in the future.  This may include adherence to requirements (punctuality, completion of administrative tasks, logs, evaluations).  Know what is not acceptable behavior.  

4. Read specific journal articles regarding professionalism; volunteer to facilitate mentored small group discussion and reflection with peers.

5. If appropriate, write a letter of apology to individuals affected by your behavior, reviewed with a mentor before sending. 

6. Consider asking for a mentor role model to shadow or meet with periodically. 

7. Seek to understand the perspectives of patients or staff who have been negatively impacted by your lack of professionalism.  You can meet with the patient representative at the hospital where they are rotating to better understand patient concerns.  If you struggle with a particular staff role (ex. RNs), you can set up a shadowing experience with someone in that role to learn about their pressures and perspectives. 

8. Present a didactic session regarding conflict strategies with common examples experienced in the clinical environment.

9. Consider pursuing coaching to work on professionalism.  Carolyn Hildebrandt, the Organizational Development Manager in the UMN Office of Graduate Medical Education, offers coaching services via Zoom. In these 50 minute appointments, you can explore your challenges, identify goals, discuss approaches, and plan action steps. You can self-refer for a confidential session.   To schedule, trainees can choose a time slot:  Book Coaching Appointments here 

10. If you have not taken the Situational Judgment Test thru GME, explore this as a no cost and effective diagnostic tool of where the problem lies.  The SJT also gives good development recommendations.  You can take this tool through Carolyn Hildebrandt.  No assessment results are included in your educational record, so the emphasis is on growth and development.   Make a coaching appointment to discuss (see link above).  

11. Consider the long and short term consequences of failure to change unprofessional behavior:  further disciplinary action, difficulty in obtaining letters of recommendation for future education/employment, frequent job turnover, fewer patient referrals, lower income, less stability and job satisfaction.

1.  Ask faculty how your lack of independent learning and/or willingness to accept feedback is perceived by others.

2.  Clarify expectations on what your program wants you to be doing and set a time frame for improvement. 

3.  Consider writing and reflecting in the areas where you struggle:

a.  Lack of awareness of strengths and weaknesses (write about your perceived strengths and weaknesses)

b.  Lack of interest in continued learning (write about the benefits of continued learning, what you perceive the current and lifelong expectations are)

c.  Receiving feedback (write about the importance of acknowledging ones’ own limitations and seeking feedback)

4.  Learn to ask for specific feedback rather a general “how am I doing?”   State your care plan concisely and then ask: “If you were managing this patient, how would you have done it differently?”  Listen to the feedback with a goal of understanding without defensiveness.  Then reflect on how to incorporate this new understanding to your practice. 

5.  Ask a mentor to model or role play appropriate responses, (both verbal and nonverbal) to receiving feedback and practice or work with a confidential coach.   Carolyn Hildebrandt, the Organizational Development Manager in the UMN Office of Graduate Medical Education, offers coaching services via Zoom. In these 50 minute appointments, you can explore your challenges, identify goals, discuss approaches, and plan action steps. You can self-refer for a session.   To schedule, trainees can choose a time slot: Book coaching appointments here 

6.  Consider the value of using assessments to help with identifying strengths and weaknesses: emotional intelligence, personality, conflict management, and situational judgment.  Work with Carolyn Hildebrandt to access these tools (see link for appointments above.  Each comes with ideas for development and this can be supported in coaching.  No assessment results are included in your educational record, so the emphasis is on growth and development.  

1.  To strengthen the understanding of the interaction of the individual practice with the larger system, develop a plan to improve teamwork with nurses/case managers/ancillary staff to improve skills.  Compile a list of the responsibilities of each member of the health care team.  You can also shadow one of these team members for a day to understand their roles and concerns. 

2.  Participate in a multi-disciplinary team simulation.

3.  Develop a complete patient care plan, from initial encounter to discharge, outlining the responsibilities of all members of the team. 

4.  Participate in an observed checked off transition-of-care experience, both as an observer to offer feedback and a learner to receive feedback.

5.  To enhance learning of the practice of cost-effective care:

a. Put together a written summary of the cost effectiveness of evaluation and treatment options for various common problems.

b.  Compare randomly selected cases with published clinical guidelines in common diagnoses.

c.  Review cost effectiveness of various plans of care for common diagnoses.  Look at how insurance coverage impacts access to resources.

d.  Make and share a list of affordable prescriptions for 10 common diagnoses.

e.  Spend time with hospital or clinic billing specialists to learn about charges associated with tests and procedures. 

f.  Discuss current cases with an attending prior to ordering diagnostic studies, provide an indication, and describe how each test result would change patient management. 

6.  To advocate for patients within the healthcare systems, consider the consequences for failure to advocate for patients in the system.

7.  Clarify expectations can be set for your responsibilities with patient transitions:

a.  Returning phone calls

b.  Completing charting and any paperwork

c.  Sending discharge summaries

d.  Setting up home health care services

8.  Call 5 discharged patients to discuss their experience and any barriers to following discharge instructions.

9.  Create and share a summary of potential resources after discharge for underinsured or uninsured patients. 

10. Do an administrative project targeting strategies for improving healthcare delivery and flow for your specialty at one of the clinical sites.

11.  For patient safety and quality improvement:

a.  Create a patient safety checklist to be used prior to performing a procedure.

b.  Prepare and deliver a lecture for rotating learners on how to maintain a safe environment, including the types of cognitive errors and their effects on patient care, how to report and monitor safety events.

c.  Identify 5 safety concerns and create a plan to implement changes.

d.  Attend a hospital/system patient safety committee or process improvement meeting.

e.  Participate in a root cause analysis.