annual meeting learning objectives preceptor development · med educ. 2004;38:1044‐52. acad med....

Preventing, identifying and remediating challenging trainees in experiential education

Lindsay Davis, Pharm.D., BCPSMidwestern University – Glendale

[email protected]

2014 Annual Fall MeetingPreceptor Development

Learning Objectives1. Define the concept of “challenging trainee” in light of

Steinert’s framework for analyzing “problem learners”2. Describe the concept of primary, secondary and tertiary

prevention of challenging situations/trainees in experiential education

3. Apply literature‐based and practical strategies for identifying challenging trainees with clinical skills and communication deficits

4. Generate early prevention strategies to assist with preceptor of a trainee with clinical skill and communication deficits

5. Develop a remediation plan to resolve issues with clinical skill and communication deficits

Terms Utilized in Literature for “Learner with Difficulties”

Challenging Trainee

Trainee in Crisis

Difficult Trainee

Disruptive Trainee

Problem Trainee

Troublesome Trainee

Challenging Trainee Defined

The term “challenging trainee” will be used in this session to indicate a student or resident who is

performing below the expectations of the preceptor due to a significant concern regarding their

knowledge, attitude, and/or skill set.

• The 2008 survey of internal medicine physician residency program directors

• 268 programs completed survey– 197 programs (73.5%) reported having “residents in difficulty” in their program at some point in time

– For 2007 – 2008 academic year, 3.5% of trainees were “problem residents” (532 / 15,031 positions)

– The majority of residents in difficulty had deficiencies in multiple competencies

– Performance deficiencies were rarely (5.6%) self‐identified by residents

Am J Med 2012;125(4):421‐5.

Survey of Medical Residency Directors Challenging Trainees in Experiential Education

• Preceptor Perspective:– Trainee knowledge, performance, behavior, and/or progression does not meet expectations

Images courtesy of Master isolated images and Danilo Rizzuti at FreeDigitalPhotos.net

• Trainee Perspective:• Unclear, unrealistic or changing expectations• Conflicting feedback from each rotation preceptor• Lack of guidance on how to improve

Handling Challenging TraineesPrimary, Secondary, & Tertiary Prevention

Prevention Solution Concession

Primary Prevention (Prevention)In Medicine

• Measures aimed at the population as a whole to prevent disease / illness

In Experiential Education

• Global measures applied to all trainees to preventeducational challenges

Fam Med 2000:32(4):232‐4.Med Teach 2013;e1‐11.

“An ounce of prevention is worth a pound of cure” – Benjamin Franklin

Primary Prevention (Prevention)1) Learn Obtain advanced training in pedagogy, assessment & feedback Be aware of training program policies & expectations

2) Prepare Establish “minimum competency” for your rotation IPPE vs. APPE, PGY1 vs. PGY2

Create a syllabus with clear goals and expectations Review trainee’s educational plan and/or rotation evaluations

3) Orient Trainee to rotation and experiential site Discuss trainee’s roles/responsibilities, facility culture & workflow

Preceptor to trainee Establish your reasons for precepting and role as mentor Assess trainee strengths and weaknesses early Individualize rotation goals set mutual goals based on trainees

needs/interests & your assessment of the learner’s needsFam Med 2000:32(4):232‐4.Med Teach 2013;e1‐11.

Secondary Prevention (Solution)In Medicine

• Measures applied to those with risk factors for disease, with a focus on early identification and treatment of disease / illness


• Teaching strategies utilized with trainees exhibiting poor rotation performance to identify problems early and effectively manage issues as they arise

• Remediation plans must be individualized to problem and unique learner / situation


Secondary Prevention (Solution)

• Early problem identification– Provide performance reviews early and often

• Be clear, direct, constructive• Re‐orient learner to your expectations when/if necessary

– Routinely and consistently document trainee progress, or lack thereof

– Assess and diagnose deficiency(ies)•Use Steinert’s problem identification steps and framework for analysis of challenging trainees

• Communicate with experiential administrators early

AJPE 2010:74(2):Article 25.BMJ 2008;336:150‐3.

Secondary Prevention (Solution)• Quickly & effectively manage issues as they arise

– Design a comprehensive remedial program that includes defined goals, objectives, strategies, and evaluation methods

– Remediation needs to be individualized to address the specific problem (e.g., knowledge, attitude, skill) while remainingrelevant to the learner AND the unique situation

– Remedial programs may include:• Revised strategies for learning/teaching• Provision of additional learning opportunities• Additional didactic coursework or simulation training• Reduced clinical workload• Arranging for additional support (e.g., peer, mentor, tutor)

AJPE 2010:74(2):Article 25.BMJ 2008;336:150‐3.

Comprehensive Remediation Plan Components

1. Clearly state the core competency being addressed2. Provide a detailed description of the deficiency, event, and/or

behavior that led to remediation3. Provide a time frame for the remediation4. State objective measurements that will be used to assess compliance

and constitute successful remediation5. State approximate schedule for follow‐up intervals6. Develop an individualized learning strategy and plan with trainee input7. State consequences of failure to successfully remediate the core

competency8. Review and obtain signatures from all key stakeholders (i.e., trainee,

teacher/preceptor, system representative)

Acad Emergency Medicine 2010;17:S95‐S103.

Tertiary Prevention (Concession)In Medicine

• Measures utilized when primary prevention has failed and secondary prevention has done all it can to improve the patient’s disease / illness


• Measures utilized when primary prevention has failed and secondary prevention has done all it can to solve / rectify poor performance


Tertiary Prevention• Preceptor Role

– Often beyond the scope of what the preceptor can do to remediate the trainee given training/expertise, time, and available resources

– Preceptor decisions: • Early dismissal from rotation• Rotation failure

– Tips:• Document, document, document!• Communicate early with EE program’s administration

AJPE 2010:74(2):Article 25.BMJ 2008;336:150‐3.

Survey of Medical Residency Directors• In 2007–2008, 532/15,031 residents with performance

deficiencies– Majority of deficiencies (83.3%) identified during inpatient rotations– Multiple interventions required for remediation with varying success– ~50% of residents successfully remediated using various strategies

• Secondary prevention:– Informal discussion (52.3%)– Formal remediation (38.2%)

• Tertiary prevention:– Academic probation (12.6%)– Requirement to repeat a rotation (15.4%)– Requirement to repeat an entire year of training (3.9%)– Dismissal (4.7%)– Residents who resigned from programs (7.9%)

Am J Med 2012;125(4):421‐5.

Problem Identification Steps

• What is the problem?

• Whose problem is it?

• Is it a problem that must be resolved?

BMJ 2008;336(19):150‐3.Images courtesy of Master isolated images and Danilo Rizzuti at FreeDigitialPhotos.net

Framework for Analysis of Challenging Trainees in Experiential Education

Trainee Competency DomainsKnowledge Attitudes Skills

Gaps in knowledge of clinical sciences

Difficulties with:

‐Motivation‐ Insight‐ Self‐assessment‐ Professional‐patient relations

Difficulties with:

‐ Interpreting info‐ Interpersonal skills‐ Technical skills‐ Clinical judgment‐ Organization

Med Teach 2013;e1‐11.

Framework for Analysis of Challenging Trainees in Experiential Education

Key Stakeholders in EETeacher Learner System

‐ Perceptions‐ Expectations‐ Personal experiences‐ Stress‐ Demanding workload‐ Colleagues’ perceptions

‐ Relevant life history‐ Personal problems (e.g., acute life stress, psychiatric illness, substance abuse)

‐ Expectations and assumptions

‐ Reactions to identified problems

‐ Unclear standards‐ Overwhelmingworkload

‐ Inconsistent teaching or supervision

‐ Lack of ongoing feedback or appraisal

Med Teach 2013;e1‐11.CAPE Educational Outcomes 2013. Am J Pharm Educ 2013;77(8):S8.

CAPE Outcomes 2013

• Domain 4: Personal and Professional Development– 4.1 Self awareness (Self‐aware)Examine and reflect on personal knowledge, skills, abilities, beliefs, biases, motivation, and emotions that could enhance or limit personal or professional growth.

‐ 4.4 Professionalism (Professional)Exhibit behaviors and values that are consistent with the trust given to the profession by patients, other healthcare providers, and society.

Vignette 1• Meet Heidi, a PGY1 resident on an internal medicine rotation in her 4th month of residency

• Heidi has completed the following residency rotations:– July: Orientation / Institutional staffing– August: Internal medicine– September: Infectious disease– October: Advanced internal medicine ** current rotation **

• Heidi is expected to attend medical rounds independently after reviewing her patients with her preceptor

Video Vignette 1

Image courtesy of Salvatore Vuono at FreeDigitalPhotos.net

Problem Identification(Refer to Handout)

• What is the problem and whose problem is it?

• If there are multiple identified problems, what is the primary trainee problem?

• Are the identified problems concerns that must be resolved?

TraineeCompetency Domains

Key Stakeholders in Experiential Education

Knowledge Teacher / PreceptorAttitudes LearnerSkills System

Challenging Trainee: HeidiIDENTIFYING & DEFINING THE PROBLEM


Problem Identification*Strengths*

‐ Foundations in physiology and pharmacology

Evidence to Support Identified Problem

‐ Baseline knowledge “good to excellent” per previous preceptor



Problem Identification*Challenges*

‐ Insight / self‐assessment‐ Establishing professional credibility

Evidence to Support Identified Problem‐ Being “unaware” of medical

team’s perception‐ Did not take initiative to do

research prior to rounds despite preceptor prompting




‐ Interpreting data in context

‐ Clinical judgment

Evidence to Support Identified Problem‐ Critical thinking skills

lacking‐ Gaps in Heidi’s

assessment/plan for patients she follows

Challenging Trainee: Heidi

Key Stakeholders in EETeacher / Preceptor Learner System

* Potential Areas for Improvement *

‐ Learner reactions to identified problems

‐ Despite acknowledgement of concerns previously identified, efforts to improve critical thinking skills not yet apparent

IDENTIFYING & DEFINING THE PROBLEM

Challenging Trainee: Heidi


‐ Unrealistic expectations for level of learner?


‐ Preceptor unclear on how to proceed … lack of preceptor training and/or confidence?

* Strengths *‐ Open communication of Heidi’s progress between preceptors


‐ Provide preceptor education

IDENTIFYING & DEFINING THE PROBLEM

Challenging Trainee: Heidi• Primary prevention measures:

– Those instituted have not resulted in 100% success• Previous assessment & open communication amongst residency preceptors and resident to date

• Secondary prevention measures:– Identify problems early– Effectively manage issues as they arise– Provide consistent, constructive and candid feedback– Create a comprehensive remediation plan

• Tertiary prevention measures:– Not needed at this time

Constructs of an Individualized Remediation Plan for Heidi

2013 CAPE OutcomesObjectives for Heidi’s evaluation

4.1 Self‐awareness• 4.1.1. Use metacognition to regulate one's own thinking & learning• 4.1.2. Maintain motivation, attention, and interest (e.g. habits of mind*) during learning and work‐related activities

• 4.1.5. Demonstrate persistence & flexibility in all situations; engaging in help seeking behavior when appropriate

• 4.1.6. Strive for accuracy & precision by displaying a willingness to recognize, correct, & learn from errors

4.4 Professionalism• 4.4.5 Recognize that one’s professionalism is being constantly evaluated by others

JAMA. 1999;282:833‐9.*Am J Pharm Educ 2012;76(6):Article S3.*

ASHP: Self‐Awareness and Assessment

• ASHP 2007 Standards– Outcome R3: Exercise leadership and practice management skills.

• Goal R3.1: Exhibit essential personal skills of a practice leader.– OBJ R.3.1.1 (Characterization) Practice self‐managed continuing professional development with the goal of improving the quality of one’s own performance through self‐assessment and personal change.

• ASHP Draft Standards (for comment through 1/2014)– Competency Area: Professionalism, Leadership, and Practice

Management • Goal 1: Demonstrate personal leadership skills.

– Objective 1.1: (Characterization) Demonstrates personal integrity

– Objective 1.2 (Applying) Apply a process of ongoing self assessment and performance improvement

http://www.ashp.org/menu/Accreditation/ResidencyAccreditation

Competency Matrix

http://www.cognitivedesignsolutions.com/

Self‐Assessment

Fostering Self‐Assessment

Reflection / Self‐Assessment

Assessment / Feedback

Structured Learning Activity

Psychol Rev. 1993;100(3):363‐406.Med Educ. 2004;38:1044‐52.Acad Med. 2009;84:1822‐32.Am J Pharm Educ 2006;70(3):Article 64.

Deliberate PracticePreceptor’s Roles

• Planning: provide structured, well‐defined activities adapted to the level of the individual learner

• Assessment: provide timely & informative feedback on performance in structured activities

• Creating opportunity: repetition is imperative to develop, hone & refine skills

Student’s Roles• Reflection: Self‐assessment allows

individuals to become distinctly aware of one’s knowledge, abilities & personal biases– Preceptors can assist in

development by consistently role‐modeling this behavior

• Continuous Professional Development (CPD): motivation & endurance are key to maintaining an upward trajectory of CPD– Setting interim, attainable

goals can be empowering

Med Educ. 2004;38:1044‐52.

Self‐Assessment to Promote Awareness

• Reflective writing– Have Heidi familiarize herself with:

• ACPE / CAPE outcomes (“achieved” thru Pharm.D. curriculum)• ASHP PGY1 Goals & Outcomes (current training program)• ASHP PPMI (advancement of pharmacy profession)

– Ask Heidi to write a letter to herself titled “On the last day of my residency I am…”

• This letter should be a reflection of what Heidi envisions her advanced, honed and refined knowledge & skill set to “look like”

• This can help Heidi set goals that align with her past and current training as well as her future practice goals

Building Professional Relationships• The components of successful “relationships” are variable, complex, and require insight

• Heidi’s lack of awareness regarding how she is perceived is an observable behavior to her preceptors

• Heidi may be more likely to “self‐assess” her situation if she could watch herself from the 3rd person– Effective remediation strategies may include: 360o review, role‐playing, simulation, video‐taping performance

• Technique vs. incompetence• Preceptor roles of role‐modeling and coaching will be valuable to help Heidi improve this competency

Acad Med 2009;84:1822‐32.

Enhancing Critical Thinking By Utilizing Socratic Questioning

Questions define tasks, express problems and delineate issues

Question Type Question PurposePurpose Define a taskInformation Assess source & quality of informationInterpretation Examine how information is organized & evaluated

Assumption Assess what is being taken for granted

Implication Follow the path of thinking

Point‐of‐view Examine individual & global perspectiveRelevance Discriminate what is & is not worth consideringAccuracy Test for truth & correctnessPrecision Give details & be specificConsistency Assess for contradictionsLogic Assess big‐picture thinking

Paul R, Elder L. The thinker’s guide to the art of Socratic questioning. Foundation for Critical Thinking. 2006.

Question Type

Question Purpose

Example EE Question

Assumption Assess what is being taken for granted

Your patient is on warfarin for prevention of stroke for a chronic condition (AF) and is currently experiencing an active GI bleed. You have suggested the re‐initiation of warfarin therapy.

Given the scenario of an active bleed, how do you feel the chronic prevention of stroke and systemic thromboembolism due to AF should be managed in the short term?

Application of Socratic Questioning

Question Type

Question Purpose

Example EE Question

Point‐of‐view

Examine individual & global perspective

How do you feel that your therapeutic recommendations were received by the medical team?Did you receive any nonverbal cues regarding the acceptance of your recommendations?

Application of Socratic QuestioningQuestion Type

Question Purpose

Example EE Question

Consistency Assess for contra‐dictions

In your review of systems you indicated the following about your patient:(1) hypovolemic secondary to GI bleed(2) showing s/sx of dehydration per physical exam(3) requiring administration of IV fluidsDespite this you are recommending restarting furosemide due to concern of heart failure exacerbation.Do you feel that if your recommendation to restart furosemide is instituted that any unintended consequences could occur?

Application of Socratic Questioning

Comprehensive Remediation PlanRemediation Components Comprehensive Remediation Plan for HeidiCompetency deficits 1) Attitude 2) Skills 3) LearnerDescription of deficiency Preceptors have identified competency deficits

over several rotations that have resulted in poor performance in formulating appropriate care plans and interacting with the medical team.

Time frame 4 week advanced internal medicine rotationObjective measurements ‐Preceptor and Heidi will review her residency

plan, Heidi will write a reflection paper on her personal goals & together they will re‐establish rotation goals

‐Heidi will complete two written comprehensive care plans each week for preceptor to assess for appropriateness & preceptor will provide constructive feedback within 72 hours

‐The medical team will provide a 360o review now and at the completion of the rotation

Follow‐up intervals Rotation mid point and completion

Comprehensive Remediation Plan

Remediation Components Comprehensive Remediation Plan for HeidiIndividualized plan ‐Heidi will begin work‐up of patients for morning

rounds at the end of each day to identify areas for self‐study at night

‐Heidi will pre‐round with preceptor 1 hour before medical rounds to allow for focused Socratic discussion

‐Heidi will complete comprehensive written care plans for patients with multiple co‐morbidities (to assist with interpreting data in context)

‐Preceptor will shadow Heidi on rounds Mon/Wed and facilitate reflection sessions immediately after to enhance insight

Consequences of failure Failure of residency rotation and/or programReview/obtain signatures from key stakeholders

Transparency is a key factor to plan success

Vignette 2

• Meet Ashley, a young, PGY‐1 pharmacy resident

• Ashley has completed the following residency rotations:– July: Orientation / Institutional staffing– August: Cardiology consult service

• Ashley is starting her medicine rotation and has the current expectations– Ability to conduct and complete all required pharmacy consult services including patient education

– Develop independence in patient evaluation and effectively implement plans

Video Vignette 2

Image courtesy of phanlop88 at FreeDigitalPhotos.net

Problem Identification(Refer to Handout)

• What is the problem and whose problem is it?

• If there are multiple identified problems, what is the primary trainee problem?

• Are the identified problems concerns that must be resolved?

TraineeCompetency Domains

Key Stakeholders in Experiential Education

Knowledge Teacher / PreceptorAttitudes LearnerSkills System

Challenging Trainee: AshleyIDENTIFYING & DEFINING THE PROBLEM


Problem Identification*Strengths*

‐ Ashley seems to have a good knowledge base

Evidence to Support Identified Problem

‐ Answered knowledge based questions without problem




‐ Undervalues nursing staff’s competence

‐ Lacked empathy for the patient

Evidence to Support Identified Problem‐ Self conduct in times of

uncertainty (panic)‐ Professional and patient relations




‐ Communication with patient and HCP

‐ Technical skills

Evidence to Support Identified Problem‐ Interprofessional

communication skills‐ Lacks EMR

interpretation

Challenging Trainee: AshleyKey Stakeholders in EE

Teacher / Preceptor Learner System*Strengths*

‐ Personable, positive attitude towards patient

*Areas for Improvement*‐ Overconfidence‐ Lacks discernment of limitations

‐ Conflict/problem management skills

Challenging Trainee: Ashley


‐ Preceptor may expect that resident is fully trained in consults

‐ May have not yet observed resident at bedside

*Strengths* ‐ Formal training offered

during orientation

*Areas for Improvement*‐ May have not had independently practiced previously

‐ May not have been observed or competence demonstrated

Challenging Trainee: Ashley

• Primary prevention measures: – Primary prevention not adequate at this time

• Secondary prevention measures:– Address communication challenge ASAP– Address EMR skill deficit– Create a comprehensive remediation plan

• Tertiary prevention measures:– Not needed at this time

Constructs of an Individualized Remediation Plan for Ashley

Secondary Prevention: 1st ‐ Assess Problem: Communication

• Document event! (i.e., Resitrak®snapshot, incident report)

• Determine if a true problem exists by the following: – Facilitate a guided self‐reflection with trainee– Review previous preceptor evaluations in regards to communication– Spend time with trainee at the bedside and use DIRECT observation to

witness interactions with patients and HCPs

• Consider contributing factors– Lack of bedside exposure during previous training– Overwhelmed by new responsibility (counseling independently)– Outside contributing factors (stress, lack of life experience as a patient)

Med Educ 2012; 46:216‐27.

Interpersonal Communication SkillsEmphasis on sharing vs. providing information

Am J Pharm Ed 2013; 77(2) Article 36.

General Interpersonal Communication Skills

Patient Interprofessional

Cultural competence

Emotional intelligence Self

confidence

ASHP PGY‐1 Residency Standards Regarding Communication

2007 Approved Standards• Outcome E7: – E7.1: Use approaches in all communications that display sensitivity

– E7.2: Communicate effectively– E7.2.3: Use listening skills effectively in performing job functions

2014 Draft Competency Areas• Competency area: Patient

Care Services– Objective 1.1 (use effective

communication skills under professional relationships)

– Objective 1.4 (ensure timely communication of information in transitioning patients)

http://www.ashp.org/menu/Accreditation/ResidencyAccreditation

Communication Problems: Specifics of Remediation and Reassessment

– Role playing– Evaluation of case studies– Engage in reflective learning

• What? So What? Now What?*

– Preceptor should provide clear, specific, constructive feedback• Stop, Start, Continue Model #

• ARCH Feedback Model for Clinical Teachers ^– Ask learner to self‐assess, Reinforce correct thinking & actions, Correct errors, Help

leaner develop improvement plan

– Formal interprofessional communication training

* http://throwingbacktokens.wordpress.com/2011/11/21/presenting‐the‐experiential‐learning‐cycle/# http://www.millsgroup.ca/Tips/MCG_Stop_Start_Continue.pdf^ http://florida.theorangegrove.org/og/items/f08dbd67‐ca07‐5cfe‐0a58‐8a50784ee6c6/1/

Secondary Prevention: 2nd –Address Problem: Communication

• Remediation tactics– Informal conversation with trainee for single incident*– Encourage trainee to:

contact nurse and admit error to maintain relationship return to patient bedside (with preceptor) to complete counseling

– Provide modeling then coaching with direct observation for several bedside interactions

– Provide clear and constructive feedback– Promote self‐reflection

*Acad Med 2007; 82(11): 1040‐48.J Grad Med Ed 2010; 242‐245.

Facilitating

Coaching

Modeling

Direct instruction

Perspective Help Ashley gain perspective

on the value of importance of excellent communication skills in the delivery of healthcare

“Decades of research have confirmed that poor skills in patient communication are associated with lower levels of patient

satisfaction, higher rates of complaints, an increased risk of

malpractice claims, and poorer health outcomes.”

Comprehensive Remediation PlanRemediation Components Comprehensive Remediation Plan for HeidiCompetency deficits 1) Attitude 2) Skills 3) LearnerDescription of deficiency Interpersonal patient/professional skill deficits:

Resident provided inaccurate/inappropriate information to a patient during bedside education session implying safety concerns with care and was confrontational with nursing staff.

Time frame 4 week internal medicine rotationObjective measurements Preceptor will:

‐ review previous residency evaluations regarding communication skills‐ facilitate guided self‐reflection with trainee‐ follow preceptor roles (modeling coaching with direct observation facilitation)

Ashley will be asked to resolve conflict with nurse and return to patient room with preceptor to complete patient education

Follow‐up intervals Rotation mid point and completion

Comprehensive Remediation Plan

Remediation Components Comprehensive Remediation Plan for HeidiIndividualized plan ‐Ashley will be asked to complete assigned

readings regarding communication in healthcare and provide a verbal/written synopsis and reflection to preceptor

‐Ashley will be guided in self‐reflection after each modeling/coaching session for patient education over the next 2 weeks utilizing the What‐So What‐Now What format

‐Preceptor will utilize effective feedback models to provide constructive, explicit, and direct feedback regarding Ashley’s communication style (e.g., ARCH; Start, Stop, Continue)

‐ If needed, role‐playing and further evaluation of case studies will be employed

Consequences of failure Failure of residency rotation and/or programReview/obtain signatures from key stakeholders

Transparency is a key factor to plan success

Summary• Assess the challenging trainee and circumstances

– Knowledge, Attitudes, Skills– Teacher, Learner, System

• Identify level of prevention and intervention required– Primary → Secondary → Ter ary

• Preven on→ Solu on → Concession – Utilize 4 preceptor roles in stepwise fashion

• Direct instruction Modeling Coaching Facilitation• Don’t forget that coaching implies direct observation!

– Employ resources of rotation, program, stakeholders, and literature• Develop highly individualized plan• Implement plan and provide reassessment

Special Thanks To My Colleagues

Monica Miller, Pharm.D., M.S.Clinical Associate Professor – Purdue University College of Pharmacy

Eskenazi Health Internal Medicine Specialist Purdue University Global Health PGY2 Residency Co‐Director

Justine Gortney, Pharm.D., BCPSClinical Assistant Professor, Eugene Applebaum College of Pharmacy and

Health Sciences, Wayne State UniversityCoordinator of Postgraduate Pharmacy Teaching & Learning Curriculum

2014 Annual Fall ISHP Meeting Preventing, Identifying and Remediating Challenging Trainees in Experiential Education

ConsiderationsforDefiningandAnalyzingChallengingTraineesinExperientialEducation

Vignette1:

HeidiisaPGY1residentinher4thmonthofresidencyonaninternalmedicinerotation.Duringthisrotationsheisexpectedtoattendmedicalrounds

independentlyafterreviewingherpatientswithherpreceptor.

1. What is the problem and whose problem is it?

a. Identify the PRIMARY trainee problem:

Knowledge Attitude Skills None of the above, this is a teacher/preceptor or system problem

b. Identify contributing problems:

TRAINEE PROBLEMS

Knowledge Attitude Skills

STAKEHOLDER PROBLEMS

Teacher / Preceptor Learner System

2. Are the identified problems concerns that must be resolved? Why or why not?

ASHP National Pharmacy Preceptors Conference 2014 – Miller, Davis, Gortney Constructive Ways to Develop, Motivate, and Remediate a Challenging Trainee

Framework for Analysis of Challenging Trainees in Experiential Education*

Trainee Competency Domains KNOWLEDGE ATTITUDES SKILLS

e.g., Gaps in knowledge of basic or clinical sciences

Be sure to identify both challenges and strengths.

PROBLEM IDENTIFICATION:

POTENTIAL SOLUTIONS:

e.g., Difficulties with motivation, insight, self‐assessment, pharmacist‐patient relations, pharmacist‐healthcare

professional relations

Attitudinal problems, which are usually manifested by behaviors, are often easy to identify but challenging to address.



e.g., Difficulties with interpreting information, interpersonal skills, technical skills, clinical

judgment, or organization of work

Skill‐deficits often overlap with gaps in knowledge. Strengths must be identified as well.



Key Stakeholders in Experiential Education TEACHER / PRECEPTOR LEARNER SYSTEM e.g., Teachers’ perceptions,

expectations or feelings; personal experiences or stresses; colleagues’ perceptions, expectations or stresses



e.g., Relevant life history or personal problems, including acute life stresses, learning disabilities, psychiatric illness,

or substance abuse; learner expectations and assumptions; learner

reactions to identified problems



e.g., Unclear standards or responsibilities; overwhelming workload; inconsistent teaching or supervision; lack of ongoing feedback or performance appraisal; lack of support from academic institution or postgrad training program; lack of communication between

experiential preceptors



*Permission granted from the original author to utilize and adapt this framework for this educational session Steinert Y. Teaching rounds: the “problem” junior: whose problem is it? BMJ. 2008;336:150‐3.


ConsiderationsforDefiningandAnalyzingChallengingTraineesinExperientialEducation

Vignette2:

AshleyisaPGY1residentinher3rdmonthofresidencyonaninternalmedicinerotation.Duringthisrotationsheisexpectedtocompletepharmacyconsults,includingthoseforpatienteducation,anddevelopindependenceinevaluation

andimplementationofherrecommendations.

1. What is the problem and whose problem is it?

a. Identify the PRIMARY trainee problem:

Knowledge Attitude Skills None of the above, this is a teacher/preceptor or system problem

b. Identify contributing problems:

TRAINEE PROBLEMS

Knowledge Attitude Skills

STAKEHOLDER PROBLEMS

Teacher / Preceptor Learner System

2. Are the identified problems concerns that must be resolved? Why or why not?


Framework for Analysis of Challenging Trainees in Experiential Education*

Trainee Competency Domains KNOWLEDGE ATTITUDES SKILLS

e.g., Gaps in knowledge of basic or clinical sciences

Be sure to identify both challenges and strengths.



e.g., Difficulties with motivation, insight, self‐assessment, pharmacist‐patient relations, pharmacist‐healthcare

professional relations

Attitudinal problems, which are usually manifested by behaviors, are often easy to identify but challenging to address.



e.g., Difficulties with interpreting information, interpersonal skills, technical skills, clinical

judgment, or organization of work

Skill‐deficits often overlap with gaps in knowledge. Strengths must be identified as well.



Key Stakeholders in Experiential Education TEACHER / PRECEPTOR LEARNER SYSTEM e.g., Teachers’ perceptions,

expectations or feelings; personal experiences or stresses; colleagues’ perceptions, expectations or stresses



e.g., Relevant life history or personal problems, including acute life stresses, learning disabilities, psychiatric illness,

or substance abuse; learner expectations and assumptions; learner

reactions to identified problems



e.g., Unclear standards or responsibilities; overwhelming workload; inconsistent teaching or supervision; lack of ongoing feedback or performance appraisal; lack of support from academic institution or postgrad training program; lack of communication between

experiential preceptors



*Permission granted from the original author to utilize and adapt this framework for this educational session Steinert Y. Teaching rounds: the “problem” junior: whose problem is it? BMJ. 2008;336:150‐3.

annual meeting learning objectives preceptor development · med educ. 2004;38:1044‐52. acad med....

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