My name is Mona Patel, I'm a clinical pharmacist in the surgical ICU at Newark-Presbyterian Hospital, and I'm going to be talking about Crucial Conversations, the Difficult Trainee. There's no consistent definition of a difficult learner. The literature describes several different definitions. Problem learner has been described as a learner with academic performance that is significantly below performance potential because of special affective, cognitive, structural, or interpersonal difficulty. Problem resident is described as a trainee who demonstrates a specific enough problem that requires intervention by somebody in authority, usually the program director or chief resident. And then pharmacy literature describes a challenging trainee as a learner who is performing below preceptor expectations with regards to knowledge, attitude, or skillset. Now whatever terminology one may use for their learner, one should keep in mind not to mislabel or stigmatize a learner because there's many different reasons as to why a learner may have difficulty achieving goals and objectives that you've set for that learner. It could be a bigger problem, such as a personality issue, which might lead to increased patient harm, or it could be a smaller problem, more easier to manage problems, such as a miscommunication between the learner and the teacher. There are many causes of suboptimal learner performance. It could be because of a personality issue, professional maturity issue, communication, life circumstances, motivation, poor academic or clinical performance, time management, or confidence. All can lead to frustration, disappointment, sadness, and anger, not only for the learner, but for the teacher as well. We're going to spend some time and focus on poor academic or clinical performance, time management, and underconfidence as causes of suboptimal learner performance. Let's start with scenario A, which is about AP who is having difficulty with gathering, assessing, interpreting, and presenting patient data. AP is a PGY-1 internal medicine resident who started his ICU rotation three days ago. He and his attending meet to discuss his patients. He is able to identify the patient's primary problems leading to their ICU admission, but unable to list active problems, summarize a hospital course, interpret laboratory results, or evaluate their pharmacologic therapy for appropriateness and effectiveness. He states he is overwhelmed with trying to make sense of the data. How can a teacher work through this scenario? Well, one can consider applying the four preceptor roles, with the first one being instruction. The preceptor could highlight the importance of a thorough patient review. So that means highlighting to the learner that there's a patient at the end of these decisions and discussions, and we should do right by the patient every single time. The preceptor should standardize data collection if at all possible. So that means the preceptor really highlights to the learner key pieces of information that learner needs to pay attention to and to assess in order to make clinical meaningful decisions for their patients. And then the preceptor could explain interpretation of labs, common disease states, and how to present their thoughts to others. Consider teaching through your experiences. Next, the preceptor can model where they talk through their thought processes when working up patients. So, for example, why is the preceptor looking at these particular lab values? What do those lab values mean for the patient? And then how can we use those lab values in order to make clinically meaningful decisions for our patients? And then the preceptor could then coach where the preceptor and learner data collect independently followed by comparison. So what exactly did the learner miss whenever working up their patients? And then why is that lab value so critical and important to know in order to take care of that patient appropriately? And then finally, the learner leads the preceptor through chart, through the chart during data collection. Now let's go through scenario B where AD is having difficulty with underconfidence. AD is a PGY-2 pharmacy resident in critical care starting her second week of the MICU rotation. Her preceptor notices that despite creating a plan for patients with their preceptor during pre-rounds, interventions are just not being made. The preceptor attends ICU rounds with the resident the next day and notices that the resident was reluctant to participate in the rounding circle and communicate interventions on rounds. So how can we tackle scenario B? Well, again, we could think about the four preceptor roles where the preceptor could discuss the role of a pharmacist in the ICU team and their importance to patient care. This would be good to review published literature on the impact of a pharmacist in the ICU team. The preceptor can also share their past experiences. We've all had moments of underconfidence. And if you feel comfortable doing so, talk about those experiences with the learner and really share how you overcame those feelings. The preceptor could demonstrate appropriate interactions with others and just show how helpful you can be by interacting with patients, families, and interdisciplinary team members. The learner can also review and practice on how to deliver recommendations with the preceptor during pre-rounds. So set aside maybe 30 minutes before rounds to meet with the resident and run through recommendations and rationales for those recommendations that the learner would like to make on rounds. It increases the chances of the team accepting the recommendation, which would further increase their confidence. And then lastly, the preceptor could also offer words of encouragement. Words of encouragement can go a long way to increase confidence of the learner. Next, let's go through scenario C, where JD is having difficulty with time management. JD is a pharmacy student on his internal medicine rotation. He and his preceptor reviewed expectations of the rotation on day one of the learning experience, which included a case presentation and an in-service and patient care responsibilities. The preceptor and JD create and agree upon a timeline for his presentations. JD has missed his first deadline for his in-service. He and his preceptor meet for a topic discussion about pneumonia, and he is unable to present key concepts and management strategies. His preceptor asks for an update on his in-service and progress of the case. He reveals he has not made much progress on the case, but emails the preceptor the in-service document later that night. That document has numerous grammatical and content errors. Now, how should we tackle scenario C? Well, the preceptor could review various time management techniques with the learner, and this process might be one of trial and error and one that might take several meetings with the learner, but the eventual goal is to find a method that works best for that learner. The preceptor and learner can identify reasons for procrastination and barriers for not meeting deadlines. There could be many different barriers that the learner is facing. For example, the learner may not be getting enough sleep because they're getting up early to prepare for the next day. Perhaps the learner is trying to juggle multiple jobs. Maybe the learner has a long commute that's taking time away from their responsibilities. So the learner and the teacher should sit together, identify these barriers, and try to figure out ways to overcome these barriers. The preceptor could share their time management methods. What exactly are you using? Why is it working for you? What have you used in the past and why did those methods work well for you in the past? The preceptor and learner should set specific, measurable, attainable, realistic, timely goals. So take these bigger goals and break them down into smaller, more manageable goals. Put these smaller, more manageable goals into a timeline. And as a preceptor, take a look at that timeline. Take a look and see if that learner created a timeline that's actually achievable and realistic. As you can see, there's many ways the preceptor can help a learner who's struggling to meet objectives. Whatever method is chosen, though, make sure to have open communication with your learner. Review expectations and goals at the start and throughout the learning experience and review established objectives, responsibilities, and evaluation methods. Ideally, have all this information in writing, if at all possible, because not only will having it in writing give the learner the ability to go back and review the information as necessary, but it also decreases the chances of any sort of misinterpretations of any expectations. Ask the learner what they expect from the preceptor. Maybe the learner is a visual learner, and you can incorporate more visual aids to any discussion that you have with your learner. Maybe the learner is a morning person, and perhaps any sort of discussions or time spent with the learner can be ideally pushed up in the day rather than have bigger meetings in the afternoon. And then give and accept feedback. Goals of feedback can be several. It could be improved performance. You should motivate the learner, achieve objectives and goals, encourage good performance, and then accept learner feedback. There are many different methods to document feedback, which we're not going to go through for the purposes of this talk, but whatever method you end up choosing as a preceptor, make sure to have specific key concepts incorporated. So, for example, the environment that you use should be neutral and private. Try to give face-to-face feedback as best as you can and minimize your interruptions. The last thing you want to do is to have somebody overhear your feedback sessions. It can quickly make the environment unsafe for the learner. Feedback should be immediate and ongoing. So midpoint evals and final evals are important, but try to meet with your learner at least once a week. It gives opportunity for you to give feedback, sure, but it also gives the learner the opportunity to give you feedback so both of you can improve on a timely basis. Feedback should be individualized as best as you can. Try to provide as many examples and as many observed behaviors in these sessions. Document feedback as best as you can as well. Again, midpoint evals and final evals are a great way to document behaviors and examples, but snapshots could be very helpful as well. If your learner is just not improving, then elevate your concerns using the appropriate documentation to the program director.

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