In my early years as program director, my approach to difficult or unprofessional trainees was very black-and-white: There were very clear rules and very clear consequences if those rules are broken. As I have grown in this role over the past 20 years, my approach has evolved to account for the various shades of gray that occur when the same rules are applied to a spectrum of trainees. Now, I know that some those rules can be interpreted differently depending on the situation. The shades of gray cannot be overlooked, and each situation needs to be evaluated independently and on its own merit.
Spotting a Problem
How do I know when a trainee is in trouble? First, I compare how trainees are performing against their peers. If an individual trainee is lagging behind his or her peers, it will become obvious quickly, as other staff and colleagues start to complain about a trainee’s fund of knowledge or clinical skills.
Of course, part of being a program director is interacting with both physician colleagues, and nursing and support staff in the hospital. One of my priorities has been to break down hierarchical barriers so that any nurse or patient services representative – anyone who comes into contact with a trainee – feels free to share his or her concerns about any trainee. These relationships are invaluable, and important sources of feedback; without it, I could not be a successful training program director.
There are many subtle cues to pay attention to and many different ways that the stress of being a trainee can manifest. The problem is identified when a pattern starts to emerge; for instance, if a resident has severe depression, he or she might not attend social events with the rest of the group or he or she may not communicate with colleagues at work. Such a person may have started the year engaged but has become less so as the fellowship progresses. Or, a fellow with poor clinical reasoning skills may overcompensate and divert clinical presentations with humor or questions.
Many programs, such as ours at University of Pennsylvania, now have Clinical Competency Committees that assess whether individual fellows have met the standards in the various competency domains (such as medical knowledge, professionalism, etc.) identified by the training program as requisite for promotion or graduation. Additionally, this group can help identify disturbing patterns of behavior, thus validating what the program director has been witnessing.
Diagnosing the Problem
Once you determine that someone has a competency deficiency, you must consider the etiology of the problem, which usually falls into one of several buckets: knowledge, skills, or attitude. The skill bucket is broad and includes communication skills, organization, efficiency, multi-tasking, and clinical reasoning.
In my experience, “problematic” trainees usually struggle with more than one issue. Rarely is it just an insufficient fund of knowledge or a lack of organization, for example.
I carry this differential diagnosis of competency deficiency around in my head, and, when I meet with a trainee, I try to figure out what underlying factors have contributed to the problem. While the competency committee may have helped to identify a problem or validates the existence of one suspected by the program director, it is the program director’s responsibility to meet with the fellow to look at the potential barriers to success. A key aspect to this meeting is determining whether the problem is acute or chronic, and whether the issue is personal or professional.”
Building a relationship with the fellow is vital; I don’t always get the answers to these questions in one meeting, and I certainly don’t expect to sit down and have the trainee open up to me if I haven’t created a trusting environment. The fellow needs to believe you are honestly trying to help him or her.
The competency deficiency could be caused by an outside stressor: perhaps the trainee has moved to a new location; he or she may have just started a family and has small children at home; he or she could be having marital problems, or a family member has a severe illness. At this level in their training, fellows are working extremely long hours and are gaining more responsibilities; they are constantly under the microscope. They are worried about getting a job or a faculty position after fellowship. Like anyone else, they can burn out, and the stress can get overwhelming.
It may also be caused by a more “chronic” issue. For example: Are there learning barriers or mental health issues (such as severe anxiety, performance anxiety, ADHD, executive dysfunction syndrome, or depression)? Are there language barriers for a trainee who has English as a second language? Do you have a trainee who does not understand the body language or cultural cues in a clinical setting that occurs here, versus in his or her home country?
Working Toward a Solution
When someone falls below expectations in one (or several) of these competency domains, what can be done?
The most important strategy when working with a problematic trainee is to use a standardized approach for each person. Everybody must be treated fairly and reasonably.
As the training program director, once you know that someone is not meeting expectations and you have spoken with him or her to figure out the barriers to success, it is time to develop a discrete learning plan – in conjunction with the faculty and the competency committee – that addresses the individual trainee’s specific difficulties. Ask questions like:
- How are we going to help him or her improve his or her fund of knowledge?
- How are we going to help him or her improve his or her clinical problem-solving skills?
- Can we adjust scheduling (i.e., to better accommodate someone who has a baby at home who’s not sleeping at night)?
- Would one-on-one coaching for an English as a second language doctor be helpful?
The next step is sharing that plan with the trainee. If he or she does not improve as expected, then I typically give him or her a warning of poor performance with an official letter. This is still “pre-discipline” and acts as a “shot across the bow” to let the trainee know that he or she needs to correct course.
Then, if the plan doesn’t correct or improve performance, the disciplinary actions begin.
Of course, if patient care is compromised, that’s a very different issue that cannot be tolerated. For instance, if a fellow is not showing up to work or is entering incorrect orders, that deserves an immediate response such as removing that fellow from a clinical rotation until the underlying issues are addressed.
After years of experience, I can tell you that clinicians are all very good at compartmentalizing and compensating – putting issues in a nice little box, closing it up, and setting it aside. That’s not necessarily a good thing, but it does allow us to function at a high level despite significant personal stress without impacting patient care. When that “worst-case scenario” does happen, it needs to be taken seriously.
The Hardest Thing to Teach
There’s one set of competency issues that despite significant efforts at coaching or remediation is difficult to fix: poor professionalism. People are born with personal value systems and beliefs that are nurtured over time; by the time someone gets to a stage of training at which I am a supervisor, that person’s emotional intelligence is pretty much set in stone. I’m not going to be able to change anyone’s established personality.
In those cases, I take a much more black-and-white approach. Once I’m convinced it’s not a substance abuse or mental health issue, I basically say, “Either get your act together or you’re out of here.” People with professionalism issues tend to show themselves early on in the process and move to probation very quickly if they don’t improve their behavior. All the other competencies and skills are pretty coachable, but professionalism is really difficult.
Of course, the best way to head off these problems is to take the fellow selection process seriously. There’s no one right formula, but when you have the best fellows you can get and you do everything you can to ensure their success – including being flexible in your training approach – you greatly improve your odds.