By Jonathan Sherbino (@sherbino)
This guy (Vilfredo Federico Damaso Pareto) makes my life as a Clinician Educator hard.
An Italian economist from the 19th Century, he derived the 80:20 rule, or in the case of medical education, the 95:5 rule. The rule is simple. 95% of my headaches as an educator come from 5% of the learners. I’m sure the modified Pareto rule rings true for you.
At times, my base temptation is to ignore this small minority. But there is a danger in writing off inappropriate behaviour as simply a “bad day.” A “bad day” is often a signal of underlying problems that have not been explored, nor addressed. As an example, one study demonstrated an eight-fold increase in the probability of unprofessionalism in future practice if a medical student acted irresponsibly during training.[i]
One definition of a learner in difficulty that I like is this: “A trainee whose competence, health, or behaviour is below expectations such that this is a threat to their professional success.”
So, what to do?
Act. This is the hardest part. The rest comes easy.
I often use an approach to the learner in difficulty that parallels my clinical practice of medicine.
Step 1 – Diagnose (the problem)
Step 2 – Design (an intervention)
Step 3 – Develop preventive measures
Step 1 – Diagnose
What are the factors related to the learner?
- Clinical performance / behaviour
- Personal issues (I do NOT advocate for CEs to diagnose mental health or addiction problems. This requires specialized care from a mental health / addictions expert.)
What are the factors related to the teacher?
- Unspoken expectations / assumptions
- Lack of experience (as a teacher or clinician) to provide appropriate direction / supervision
What are the factors related to the system?
- Demanding clinical responsibilities
- Standards unclear
Confirm the problem
- Collect data
- Consult with other faculty / team members
- Test a hypothesis
- Engage the learner in the process
Step 2 – Intervention
Occasions for immediate action
- Patient safety
- Substance abuse
- System disruption
Principles of an effective intervention include:
- Early intervention
- Clear timeframe / schedule
- Expectations for behaviour
- Consequences
- Iterative feedback
- Confidentiality
- Documentation (as appropriate)
Step 3 – Prevention
Certainly not every difficulty a learner experiences can be prevented. However, a learning environment with clear expectations and a culture of feedback (coaching) can help identify borderline behaviour early. A system that promotes regular meetings with learners and integrates all feedback from all members of the clinical team can prevent recurrent patterns of problem behaviour.
I’m incredibly fortunate to enjoy a career as a Clinician Educator. The vast majority of learners that I teach are professional, thoughtful, innovative and engaging. The learner in difficulty is not intended to be a value judgment. In many instances, the factors contributing to difficult behaviour arise from circumstances beyond the control of the learner. However, when this scenario is encountered, I hope that we all would acknowledge that is NOT “just a bad day” and begin the process of supporting the learner in addressing the issue.
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[i] Papadakis M et al. Disciplinary action by medical boards and prior behavior in medical school. NEJM 2005;353(25):2673-82
