Defining the problem

My resident seems to be struggling. What’s my next step?

Most students and residents thrive in rural community placements and easily meet rotation objectives. Unfortunately, though, many learners (up to 10% of residents) will encounter difficulties during their program. Frequently problems will surface for the first time in family medicine attachments. It’s much harder to hide deficits in rural rotations because of the breadth of practice and the one – to – one relationship between rural preceptor and learner.

Once a problem is apparent, it’s vital to deal with it. Often the initial thought is to ignore the issue and hope it disappears. It never does!

Just like a clinical problem the first step is to develop a differential diagnosis and define the difficulty. Although the problem may appear to be a simple lack of book knowledge or poor clinical reasoning skills, often the underlying causes are more complex. There may be issues with mental or physical health or distractions related to debt or relationships. As the preceptor, you may even be part of the problem if your teaching style is not a good match for the learner, or if your expectations are unreasonable.

The SOAP format used for formulating clinical notes can be a helpful way to analyze an apparent educational problem.

S – Subjective:

• What do you and others think and say?
• Don’t dismiss those early warning feelings that things are not going well in the rotation.

O – Objective:

• Write down specific instances of problem behaviour
• Poor examination skills, unacceptable behaviour, clinical errors, etc
• Triangulate with others – clinicians, nurses, clinic staff and even patients – to see if your concerns are shared.
• Include the learner at this step; maybe she’s worried too.
• Call the program director or faculty advisor and see if this is a recurring issue.

A – Assessment

• What is the “differential diagnosis?”
• Is the problem Real?
  • Maybe there was a miscommunication
  • Are your expectations reasonable? Don’t judge the clinical clerk by the standards of the residents you have worked with before.
  • Were you or the learner simply having a bad day?
• Is the problem Important?
  • Is this simply a difference in styles of practice rather than wrong practice? (eg choice of antibiotic, informal approach to the patient)
  • Is it a mannerism that irritates you but doesn’t affect patient care?
• If it’s not real or important – quit worrying!
• If it is real and important define the problem
  • Knowledge issue
  • Skill issue
  • Attitude issue
• Don’t forget Health concerns and System issues
  • Depression or substance abuse
  • Physical illness
  • Financial or personal stressors
  • Excessive workload / inappropriate rotation schedules / poor match with preceptor

P – Plan

• Fixing the Problem
• The educational plan often derives easily from the assessment
• Include the learner in developing the plan
• Don’t become the learner’s physician or therapist
• Ask for help – involve the program director or faculty advisor
• Document the plan and monitor progress

Adapted from:

1. Mountain Area Health Education Center Preceptor Development Program http://www.mahec.net/celt/acroread/Difficult_Situation.pdf
2. UBC Faculty of Medicine Teaching Skills for Community Preceptors  http://www.facdev.med.ubc.ca/Web Admin/Documents/Teaching Booklet (reprint 2005).pdf

The following framework may assist with analyzing the issues..
Sample: Assessment Framework document

For more about defining the problem visit: The junior doctor in difficulty

Assessing learners in difficulty If you suspect a problem exists, it probably does Use SOAP to analyze the issues Call for help early