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Introduction | Academic Issues | Professional Behavioral Issues | Personal Issues | Residents in Difficulty

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Appendix A: Areas of Concern | Appendix B: Central Resources | Appendix C: Site Specific Resources

Appendix D: Bibliography | Appendix E: Terms of Reference-Resident Performance Subcommittee

  

Introduction

The purpose of this document is to identify potential concerns arising from evaluation for preceptors, Site Directors and residents, and to suggest ways of dealing with them. All residents enter Family Medicine Residency with some areas of strength and weakness. The areas of weakness may arise from gaps in the undergraduate experience, from differential learning, and from attitudinal or personality differences. Difficulties may exist in academic or cognitive areas, in professional behaviour, or in personal areas. It is the task of the resident, the preceptor and the program to identify those areas of weakness that impact on the education of the resident and work at providing or seeking out learning opportunities to increase the needed knowledge, skills and attitudes. The ongoing process of evaluation, feedback, identification of learning issues and active learning allows the resident to progress appropriately through the two years. The resident is also expected to evaluate his or her own abilities and performance on an ongoing basis in order to identify learning needs. There needs to be a facilitative and open process for addressing areas in which residents are not comfortable and/or competent.

At times, major areas of weakness may be identified. The learning necessary to improve these areas may occur over several rotations, or may require a more structured or intensive process for teaching and learning. An articulated process for correction of difficulties experienced by residents will help clarify communications and expectations for residents, preceptors and Site Directors.

Occasionally, a resident will present with major difficulties and change does not occur through the usual process of teaching and learning, and may result in an escalating situation for the resident and the site or both. Sometimes there is a tendency to avoid issues on both sides which may lead to late awareness and increase the difficulty of working through this situation. Residents may have serious difficulties with their site or preceptor, such as inappropriate belittling, anger, an inappropriate level of autonomy or poor clinical skills. There needs to be a structure to identify concerns early and to work towards a satisfactory conclusion.

The Family Medicine Residency is an academic program and a professional training program. Issues of professional behaviour, including responsibility, ethics, relationships with colleagues and other health professionals are evaluated in both a formative and summative fashion. Processes in this document apply equally to areas of concern involving professional behaviour and responsibility for both preceptors and residents and academic issues. Personal issues such as marital breakdown, depression, and mental illness may also impact resident or preceptor performance. A clear process for identifying, evaluating and remediating these issues will lead to increased support for residents.

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Academic Issues

In-training Evaluation

In all sites, the following processes are in place and should be followed:

• Curricular objectives for medical knowledge, clinical skills and problem-solving in the rotation are outlined and available to residents and preceptors.
• Objectives identified either by the preceptor or by the resident should be identified on the WebEval form at the start of the rotation.
• Halfway through the rotation, a mid-rotation evaluation of a formative type, which identifies areas of strength, and/or difficulties, areas of concern in professional or clinical performance should be provided. If there are major concerns, the feedback should be documented. Areas of academic content and professional performance are listed in Appendix A.
• At the end of the rotation, the final evaluation should be discussed with, and must be signed by the resident. The residents signature indicates that they have seen the evaluation, but not necessarily that they agree with it. If the resident refuses to sign, the preceptor should note on the evaluation that the resident has seen it, and declines to sign. This discussion is best had with the preceptor but can be done by the site director. The University of British Columbia Faculty of Medicine Policy on Resident Evaluation should be followed.
• Residents can appeal an evaluation in accordance with the University of British Columbia Faculty of Medicine Resident Evaluation and Appeals Policy.

Minor Learning Issues

Most residents and preceptors will have minor issues turn up in one rotation or another from time to time. For example, a resident may be uncomfortable examining a child or performing a rectal exam, or a preceptor may have a practice with few children, or with few older men. In general, when the resident or a preceptor identifies a minor issue, the following steps should be taken:

• The resident and preceptor should meet to ensure that both have the same understanding of the issue.
• The preceptor and resident should agree on a process to resolve the issue.
• Further evaluation and feedback should take place to identify the resolution of the minor issue. 

Major Learning Issues

At times an academic issue may arise which needs assessment, resources, or an educational process beyond that provided within the rotation experience.

Difficulties can arise in areas of knowledge base or clinical skills. A difficulty in clinical skills can be the result of a limited knowledge base: the solution to this is to increase the knowledge base rather than to work on clinical skills.

Clinical skills are context-specific: for example, a resident may have excellent problem-solving skills in Obstetrics and poor problem-solving skills in Internal Medicine if the problem is the context rather than the skill.

Some residents may have an identified difficulty with the problem-solving process itself, irrespective of the context. In this situation, the resident may build their problem-solving ability in each rotation but as they move to a new context or a new service the problem-solving difficulty will be identified again. Skepticism on the part of preceptors and programs that change is possible can lead to a fixed view of the resident's abilities that prevents their evaluation in new rotations from being objective.

When an area of major weakness is first identified, it may be difficult to know whether the problem is context-specific (i.e. in one area of medicine only) or whether it is a global problem across all contexts. If the area of weakness is being identified in the R1 year, particularly early in the R1 year, it is hard to predict whether the resident will continue to have difficulties through the Residency Program. Program wide evaluation processes, resources and structure are available at each site.

If an area of major weakness is identified or the resident has failed a rotation, the following steps should be taken:

• The preceptor and Site Director should meet with the resident to discuss the area(s) of concern.
• The Site Director should insure that the resident has access to support, such as a fellow resident, a PAR representative, a Chief Resident, a mentor and/or other personal support.
• A written indication of outlined concerns, problems or weaknesses should be given to the resident after the initial discussion.
• The resident should have an opportunity to write a letter of response which will be placed on file.
• The preceptor, Site Director, Site Evaluation Faculty and resident should agree upon the process used to upgrade skills or knowledge
• If the resident has failed the rotation, the University of British Columbia Faculty of Medicine Resident Evaluation and Appeals Policy should be followed. The Program Diector should be informed.
• If the resident and the site director are unable to reach an agreement, the Site Director should refer the issue to the Resident Performance Subcommittee of the Postgraduate Education Committee.
• The Site Director, the preceptor and the resident should agree as to when the area of concern will be re-evaluated.
• For every remedial rotation, the Remediation Letter, Residency Program, UBC, should be filled out and signed by the relevant parties.
• The resident should, whenever possible, be offered choices of alternative sites for remediation and re-evaluation.

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Professional Behaviour Issues

The area of professional behaviour may present a problem to a Residency site, preceptors or residents. Examples of professional behaviour issues are given in Appendix A. Unlike academic difficulties which are usually well supported to ensure that learning needs are met, issues of professional behaviour can cause significant ill feelings in residents, preceptors, peer groups and other hospital personnel.

Residents are making the transition from being a student with few professional responsibilities to being a professional. It is not uncommon for the occasional incident to occur in the early stages of residency. Most residents quickly learn the spoken and unspoken expectations in the culture in which they are working. Residents may experience discomfort with the professional behaviour of a particular preceptor. This may be a personal style or a more serious issue requiring intervention of the Site Director.

Any major issue of professional behaviour, is an area for concern. All critical incidents should be documented and placed in a temporary file until it is clear whether this is an isolated incident or a pattern of behaviour. Incidents should not be sought retrospectively or documented after it is decided that the behaviour constitutes a pattern.

In the case of concerning behavior, the following steps should be taken:

• The Site Director should meet with the resident or preceptor to see if the documented incidents are an accurate reflection of what occurred.
• Third party witnesses or corroborative evidence should be sought, if possible.
• If the concern cannot be resolved through an informal process, or is an incident that will remain on file, or in the case of a serious incident, the resident or preceptor should be given an opportunity to provide a reply in writing to the allegations against him or her. The Program Director should be informed.
• The Site Director should insure that expectations of behaviour are put in concrete terms, (e.g. you will respond to your pager within 30 minutes), and recorded in writing, signed by both the resident (and preceptor) and the Site Director.
• The resident should be told that the behavioural issues will be monitored throughout the Residency Program, as short term remediation may not be sufficient for a professional behavioural issue.

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Personal Issues

Residency is a stressful time. It occurs at a time of life full of transition. Examples of Personal Issues that may interfere with performance are given in Appendix A.

It is estimated that 30% of resident are clinically depressed. Depression can significantly affect performance. Residents may deny depression or not be aware of, or have insight into their own depression. It can be difficult to diagnose depression in a resident. An awareness of the frequency of depression and its ability to affect performance as well as the resident's tendency to deny may help insure that this diagnosis is not overlooked.

Personal issues may force the resident to take a leave of absence. Although a leave of absence may disrupt scheduling, the priority must be the resident's well-being. An appropriate leave may prevent a larger problem that is more difficult to resolve. Residents may be concerned about completing their program on time or being able to write the CCFP exams at the same time as their peers. There is strong peer pressure to continue to perform against all odds and residents may require considerable support in order to identify a need for time off.

Sites should have an atmosphere that allows free identification of personal issues. Resident should be encouraged to support their colleagues by identifying concerns about a resident's well-being directly with that resident or with the Chief Resident, an appropriate preceptor or the Site Director. Residents facing personal issues should find themselves supported by the program even if the crisis results in difficulties with scheduling and service coverage.

If a resident is identified as having personal difficulties, the following steps should be taken:

• The Site Director and resident should meet to identify the impact of personal crisis on the ability to learn and perform.
• The Site Director should ensure that the resident has adequate support including peer support, a personal physician and ready access to effective counseling.
• If the Site Director feels that the resident is not capable of working and the resident disagrees with this opinion, the resident should be asked to produce a physician's note indicating that they are fit to work. An independent psychiatric opinion can be sought if necessary.
• If a leave of absence is agreed upon, the resident and Site Director should outline the amount of time off, the return date, and the process for modification to this return date. A copy of the agreement should be sent to the Postgraduate Program Office, who will inform the Postgraduate Dean's office.

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Residents in Difficulty

From time to time a resident may be identified as being in major difficulty. These residents may present with difficulties in academic, professional or personal areas which persist in spite of intervention at the site. Issues may be confined to the academic domain or may be a combination of the personal, professional and academic domains.

Program wide evaluation processes, should identify residents in difficulty. In community-based sites, a group process involving all major preceptors has been found to be effective in identifying these residents.

In the community-based sites, the individual community-based preceptor may find it difficult to properly evaluate a resident with major difficulties and may require input or assistance from the Site Director. Site Directors should also have in place resources to ensure that the resident can be evaluated by experienced senior faculty in their site, as well as by his or her particular community preceptor. All sites should have a group process that allows for the identification of the resident in difficulty as difficulties may present as multiple problems across a broad range of interactions.

Adequate support for the resident, including PAR representation and mentoring, is essential for the resident in the stressful position of having been identified as having major difficulties.

Usually for a resident in difficulty, resources external to a program site are needed for both evaluation and remediation. Resources for evaluation are listed in Appendix A for central resources, Appendix B for site-specific resources, and Appendix C for other resources. Site Directors should refer residents in difficulty for discussion at the Resident Performance Subcommittee.

Issues of confidentiality and pre-bias are major issues in effectively managing a resident in difficulty. Discussions and resolution of issues should be kept confidential by the Program Director, the Site Director, the Resident Performance Subcommittee, and all others involved. Residents who are in difficulty should have the opportunity to review any information about their learning needs and performance being sent to the next rotation.

All sites must follow the formal Remediation and Probation Policy for the Faculty of Medicine, University of British Columbia .

Whenever major concerns lead to the Site Director to identify a resident as being in difficulty, whether these issues are academic, professional, or personal difficulties or, most often, a combination of difficulties, the following approach is recommended:

• Document encounters with the resident, preceptors, faculty and other health professionals who are providing you with information.
• Ensure open communication lines with the resident, and/or preceptor. Advise the resident of issues, both in person and in writing.
• Ensure that the resident has adequate PAR representation and personal support such as a mentor or a personal family physician.
• Provide a written outline of identified concerns, problems or weaknesses. Use the checklist in Appendix A to identify areas of concern. Delineate the areas of concern as clearly as possible, recognizing that further evaluation may clarify the issues.
• Identify site-specific and central resources to evaluate the identified problems.
• As soon as the evaluation process is complete, give feedback to the resident and preceptor, and clarify identified concerns.
• Provide the resident and preceptor with a written evaluation of the assessment and the required action.
• Refer the case for discussion with the Resident Performance Subcommittee.
• Determine the resources available for remediation, usually in consultation with the Lead Faculty of Evaluation and the Postgraduate Program Director.
• If the action is a remedial rotation, complete a remediation letter in consultation with the Program Director.
• Avoid pre-bias in remediation and evaluation processes.
• Provide copies of all documentation to the Program Director.
• Identify the process for re-evaluation.
• In the case of weaknesses in specialty rotations, the same process should be followed, with the specialty rotation preceptor or coordinator taking the role of the Family Practice preceptor. In some sites, specialty residents will be involved in the evaluation and teaching, but overall responsibility rests with the specialist and preceptor.

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Appendix A

Areas of Concern:

Possible areas of concern include the following sub-groups:

• Academic
• Professional
• Personal

Academic issues:

Within the area of Academic, the following areas may surface as areas of weakness:

1.    Cognitive or medical knowledge, either generalized or specific to different contexts.

2.    Clinical Skills:

• history taking skills
• physical exam skills
• problem-solving skills
• investigation skills
• management skills
• doctor/patient relationship skills
• procedural skills

3. Problem-solving skills: although listed above, because problem-solving skills often surface, particularly in the PGYI level resident, this deserves a more complete list:

• ability to generate a hypothesis
• ability to organize data to fit hypothesis
• ability to come to a decision regarding working diagnosis
• ability to revisit original hypothesis in the face of conflicting evidence
• ability to avoid dangerous decisions or judgments, including not ruling out, or including a life-threatening diagnosis
• ability to come to the most likely diagnosis
• ability to incorporate all available data
• ability to prioritize or triage with multiple demands
• ability to recognize seriously or acutely ill patients and life-threatening emergencies
• ability to respond appropriately to the severity of a situation or a patient's condition
• clinical judgment

Professional behaviour problems:

• relationships with colleagues
• relationships with peers, including other residents
• relationships with other health professionals
• relationships with patients
• timely response to calls for help (i.e. on-call)
• consideration of patient well-being
• substance use or abuse
• inappropriate anger
• inappropriate relationship: lack of boundaries in professional relationships
• ethical behaviour
• ability to work effectively with colleagues in chosen milieu
• behaviour with patients
• honesty about maneuvers, procedures or work performed

Personal issues:

• anxiety
• depression
• family or personal stressors over a short term
• physical illness
• mental illness
• family stressors, particularly for residents with significant family responsibilities
• pregnancy
• financial issues
• divorce / separation

Appendix B

Central Resources

Resources to diagnose academic issues:

1. Referral to the Clinical Competence Program: This is a program designed primarily to assess the competence of practicing family physicians, but can provide useful information on knowledge bas, history and physical techniques, diagnostic skills, patient management abilities and communication skills.
2. Involve the Lead Faculty for Evaluation and the Postgraduate Program Director to structure an evaluation process that will be effective for the concerns that you have. The Lead Faculty for Evaluation will help you in particular to set up an evaluation process. The Postgraduate Program Director will advise you on process.
3. The main Family Medicine teaching unit at the David Strangway Building can be used for an evaluation period, lasting from one day to two weeks. This unit has the advantage of having several experienced faculty; viewing equipment; video equipment for videotaping the resident on you behalf; and Dr. Garry Grams, Behavioural Medicine specialist, who can review and evaluate videotapes with the resident.

Resources for diagnosing difficulties with professional behaviour:

1. Use the Clinical Competence Program to evaluate doctor/patient relationship skills.
2. Videotaping equipment is available at all sites and should be used to record patient/resident encounters. These tapes should be reviewed with the resident.
3. Patient evaluation forms are available from Lead Faculty and Evaluation to gather feedback on the resident's skills with patients.
4. Utilize the Chief Resident of the program to identify expected professional behaviour to the resident.

Resources for diagnosing difficulties with personal issues:

1. The Resident Committee at each site should have as one of its mandates the identification and support of residents facing personal issues. All residents have access to employee assistance through PARBC.
2. All sites should have an effective referral mechanism and support for counseling as well as an independent psychiatric consultation service to determine ability to work without compromising patient care.
3. Depression can be difficult to diagnose in a resident working closely with a preceptor and may masquerade as performance difficulty. Moving the resident to an alternate site, such as the UBC Health Clinic for short period of time may allow others to make the diagnosis for you.

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Appendix C

Site-Specific Resources

Resources for diagnosing academic difficulty:

1. Within a community-based setting, place the resident with one of the most experienced preceptors for a two week evaluation period.
2. Use your Site Evaluation faculty to observe the resident over several half days, with the resident in an alternate preceptor's site. This allows a more in-depth look of resident abilities than either the busy community preceptor can manage or the Site Evaluation faculty can manage when they are managing their own practice.
3.  Organize several SOO's for your resident with experienced faculty.

Resources for diagnosing difficulties with professional behaviour:

1. Utilize patient evaluation forms to get feedback directly from patients about doctor/patient relationship skills.
2. Use videotaping as a teaching tool.

Resources for diagnosing difficulties with personal issues:

1. All sites should have an available referral pattern residents who are in personal crisis, initially for evaluation and then for treatment. The evaluation should be at a level that should render judgment as to whether the resident is able to perform competently, given the degree of mental stress or psychiatric illness that they are currently experiencing.
2. Site directors can facilitate referral to a family physician or counseling services. The family physician should be outside the Residency training program.
3. The site should have an identified method of proceeding when substance abuse is suspected, following the guidelines of the College of Physicians and Surgeons of British Columbia and of the Physician Health Program.

Supporting the Resident

 When a resident is identified to be in difficulty, the stress they are under increases. The Site Director, the Postgraduate Program Director and the Chief Residents need to insure that the resident is adequately supported. The following is recommended:

1. The Site Director should insure that the resident has adequate personal support, and offer counseling referral, or other referral as required.
2. A mentor should be arranged.
3. The Site Director should insure that the resident has access to PAR representation.
4. The resident should be allowed to bring another resident to meetings for support, usually a PAR representative or another colleague.
5. Wherever possible, input from the resident should be sought in developing remedial plans.
6. The issue of forward feeding, (i.e. giving information about residents' areas of weakness, being on probation, or requiring redemption) should be discussed. The Site Director and the resident should reach agreement as to what information will be sent forward to rotations, remembering that patient safety is of utmost importance.
7. Issues of confidentiality are very important. Rumours should not surface about residents being in difficulty. Lines of communication as to discussions with other preceptors, other faculty, and the program as a whole should be openly clarified.
8. Residents in difficulty may require a stress related leave of absence. This should be openly discussed as an option to provide support to the resident in achieving long term goals.
9. It may be difficult for a resident required to repeat a rotation to re-enter a rotation at a specific site where they have done poorly. A resident, who is required to repeat a rotation, should usually be offered the option to repeat that rotation at one of the other sites within the UBC program.

Revised September 2007

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Appendix D

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 Gordon MJ.  A prerogatives-based model for assessing and managing the resident in difficulty.  Family Medicine. 25(10):637-45, 1993 Nov-Dec.

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Irby DM. Fantel JI. Milam SD. Schwarz MR.  Legal Guidelines For Evaluating and Dismissing Medical Students.  The New England Journal of Medicine. 1981. Vol. 304, No. 3:180-184.

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Kahn NB Jr. Addison RB.  Support services for family practice residents. (Review)  Journal of Family Practice. 34(1):78-85, 1992 Jan.

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Smith, C. Scott; Stevens, Nancy; Servis, Mark.   A General Framework for Approaching Residents in Difficulty.   Family Medicine 2007; 39 (5) 331-6.

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Appendix E

Resident Performance Subcommittee - Terms of Reference

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