Lars DesmetIntensive Care Medicine

LeuvenLeuven

26th International Winter Symposium Anesthesia 2011

I Introduction and examplesI. Introduction and examples

Wh lki b ?II. What are we talking about ?- Definition, prevalence, presenting symptoms

Underlying reasons stressors- Underlying reasons, stressors

III ManagementIII. Management- confirm the diagnosis- assistance and remediationassistance and remediation- early detection, or prevention

IV. Conclusion

Terminology in the literature- The trainee in difficultyy- The disruptive resident

The impaired physician- The impaired physician- The problem junior

What do we spontaneously think of ?

- Well-beingChallenges and stressors- Challenges and stressors

- Coping strategiesl d- Sleep deprivation

- Work-life balance- Burnout, substance abuse, depression- ….

Wh l i th ’ bl ?- Who claims there’s a problem ?the attending physician, peers, the resident him/herself the ward staff the patient orhim/herself, the ward staff, the patient orfamily ?

- 3 examples

- Why could this be particular to residency ?Learning the job, building professional Learning the job, building professional identity, uncertainty, heavy duty load,…

The rigors of training can challenge the idealismand compassion that most aspiring physiciansp p g p ybring to their chosen field. The high rate of burnout during residency reflects a failure to

d l t th i t it f th i fmodulate the intensity of the experience fromthe trainee’s front-row seat at the drama of life, illness suffering and death illness, suffering and death. Whether physicians’ emotional development is optimally supported during training remains a optimally supported during training remains a question that should drive effort to improve ourprograms.p g

Hasan Bazari. Gratitudes, Memories and Meaning in Medicine .N Engl J Med 2010;363:2187

What is the problem ?p

Definition- Definition- Prevalence

i- Presenting symptoms- Underlying reasons, stressors

- American Board of Internal Medicine (1999) :‘a trainee who demonstrates a significant

h bl h benough problem that requires intervention bysomeone of authority, usually the program d h f d ’director or chief resident.’

- Steinert (2008)‘a learner who does not meet the expectationspof a training programme because of a problemwith knowledge, attitudes or skills.’

- 6 -15 % of residents- Possible underestimation- Variability according to

.surveyed group.su veyed g oup

.residency programme

.district/academical centre/

.national training cultureEvolution through years of residency- Evolution through years of residency

Yao D, Wright S. J Gen Intern Med 2001;16:486Yao D Wright S JAMA 2000;284:1099Yao D, Wright S. JAMA 2000;284:1099Satterfield J, Becerra C. Med Educ 2010;44:908Prins JT et al. Med Educ 2010;44:236

M diff t fMany different faces- Insufficient medical knowledge, poor clinical

judgmentjudgment- Critical incidents

Inefficient use of time difficulty prioritising- Inefficient use of time, difficulty prioritising- MD difficult to find (‘disappearing act’), tardiness

I i t i t ti ith t i k t l- Inappropriate interaction with team, quick to losetemper (‘ward rage’)Poor performance at transfer- Poor performance at transfer

- Lacking insight in own limitsUnacceptable moral or ethical behaviour- Unacceptable moral or ethical behaviour

Yao D, Wright S. J Gen Intern Med 2001;16:486Cohen D et al. Understanding medical education 2010;366

Who spots the problem ?- Programme director, attendings, chief resident g g- Peers

Rarely the resident- Rarely the resident

Wa s of spotting ?Ways of spotting ?- Direct observation in workplace- Formal assessments/chart review- Critical incidents

Yao D, Wright S. J Gen Intern Med 2001;16:486Steinert Y. BMJ 2008;336:150

Reflection categories- knowledge, attitudes, skillsg- learner, teacher, system

Poor performance is a symptom, not a diagnosis.

Steinert Y. BMJ 2008;336:150

Burnout is a prolongued respons to stressors on the job defined by emotional exhaustion, depersonalisation

d d d l li h tand reduced personal accomplishment.- High prevalence- Continuum between medical students, residents and

attending physicians- Array of personal and professional factors, including

the learning environment- linked with reduced professional conduct

Dyrbye L et al. JAMA 2010;304:1173D b L l M d Ed 2010 44 1016Dyrbye L et al. Med Educ 2010;44:1016Dyrbye L et al. Med Educ 2009;43:274Prins J et al. Med Educ;44:236

1. Behavioural issues2. Medical conditions and illness3. Stressors and insufficient coping4 Substance abuse4. Substance abuse5. Cognitive issues

Levey R. Acad Med 2001;76:142Yao D, Wright S. J Gen Intern Med 2001;16:486ten Cate T et al. Opleiden medisch specialisten 2005;105R d R Ed ti l S i i 2009 29Roden R. Educational Supervision 2009;29Satterfield J, Becerra C. Med Educ 2010;44:908Montgomery V. Ped Crit Care Med 2007;8( suppl): S11

1. Behavioural issuessuch as related to professionalism- motivation- integrity

b ll- bullying- doctor-patient relationships

2. Medical conditions and illness- physical disease- emotional impairment (depression,..)- cave: work related health complaints

3. Stressors and insufficient coping- Situational stressors

workload, duties, sleep deprivation (and error), inadequate support from staffq pp

- Personal stressors:family (+/-), finances, loss of self controly ( / ), ,work/life balance, lack of copingProfessional stressors- Professional stressorsinadequate responsibilities for patients or team, career planning difficult patients (ethics) errorcareer planning, difficult patients (ethics), error

4. Substance abuse5. Cognitive issues (the easiest)g ( )

- inadequate knowledge base- lack of integration/interpretation of datag p- (unknown) learning disability

Special subtypesThe marginal resident- The marginal resident

- The mismatched resident

Well being a positive conceptWell-being – a positive concept- Developmental challenges (positive stress)- Adaptive coping (details)- Personal growth, with facilitators and barriersg ,- Job satisfaction

The absence of well being can result in struggling.Levine R et al. J Gen Intern Med 2006;21:564Ratanawongsa N et al. Med Educ 2007;41:273Cefeldt A et al. Med Educ 2010;44:977L J S M B J A th 2010 105 34Larsson J, Sanner M. Br J Anaesth 2010;105;34Satterfield J, Becerra C. Med Educ 2010;44:908Wright S et al. Med Educ 2006;40:737

Ratanawongsa N et al. Med Educ 2007;41:273

The Economist June 17th 2006

Setting the sceneSetting the scene1. The framework of training

Obli i f i & i- Obligations of trainers & trainees- Responsibilities of programmes- Possible conflict of providing a service to

patients, while trainingp , g2. Assistance necessary: for the good of the trainee,

the patients and the training programmethe patients, and the training programme3. A late diagnosis is common

Redfern N, Bartley C. Best Prac & Res Clin Anaesth 2006;20:619Evans D, Alstead E. Clinical Teacher 2010;7:230

Solving the problem ?g pAssistance and remediation

1. Confirm the diagnosisD i d i l t i t ti2. Design and implement an intervention

3. Early detection and preventionCohen D et al. Understanding medical education 2010;366Yao D, Wright S. J Gen Intern Med 2001;16:486Steinert Y BMJ 2008;336:150Steinert Y. BMJ 2008;336:150ten Cate T et al. Opleiden medisch specialisten 2005;105Roden R. Educational Supervision 2009;29

- Broaden the assessment terrain, explore possible underlying reasons

- Documentation- Communication: talk to the residentCo u cat o : ta k to t e es de t

.e.g. as part of assessment

.who will do it ? (don’t shoot the messenger)( g )

.exploratory, non-judgemental

.in confidentialityy

The aim is to remediate, not to dismiss.Make a realistic action planpTailored to the problem and the person

Direct measures: closer supervision release of - Direct measures: closer supervision, release of some responsibilities (safety), ..Self help- Self help

- Counselling- Referral to specific services: coaching,Ψ,.. - Focused (re)training( ) g

- (Re)Assessment- Followupp- Documentation of evolution

Changes to the training programme- Changes to the training programme- Do we inform further rotations (cave bias) ?

d l- Is dismissal an option ?

A learning plan may be as much about moving a situation forward as about solving a problem.g p

Redfern N, Bartley C. Best Prac & Res Clin Anaesth 2006;20:619

P di ti bl id t ld l l t- Predicting problem residents could solve a lot.Are we able to ?Q lit f th l ti- Quality of the selection process

- Rigourous appraisal systems- Objective, systematic screening for certain

difficulties ? - Role modelling- Pre-emptive: coaching, discussion groups,..p g g p

Paice E et al. Hospital Medicine 2004;65:238Brenner A et al Acad Med 2010;85;1147Brenner A et al. Acad Med 2010;85;1147Papadakis M et al. N Engl J Med 2005;353:2673Satterfield J, Becerra C. Med Educ 2010;44:908

R id t i diffi lt i t i i Residents in difficulty are common in training programmes. Helping them is a prime responsibility but will be a challenging and responsibility, but will be a challenging and rewarding process for those involved.

A supportive but fair approach is vital, with the following four essential components :following four essential components :

- recognition of the problemd d t ti- good documentation

- clear communication- an agreed action plan

And, will we get there ?