Case

UMMS CRIT Teaching & Leadership:The Reluctant Learner

Catherine DuBeau, MDClinical Chief of Geriatric MedicineDirector, Geriatric Fellowship Program

UMMS CRIT 2012 Teaching & Leadership: The Reluctant Learner

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

Your intern admitted an elderly patient from a nursing home with change in mental status. She did a very cursory workup, and did not speak to the family at all. When you question her, she says, “I don’t have time for this. He’s just demented. All these resources going to waste.”

Case



You point out the features suggestive of delirium, and discuss the importance of prompt dx and management.

Your intern rolls her eyes.



What is your working diagnosis?



• Definition– A learner who appears not to be eager,

willing, and ready to learn what you want to teach

• Examples…

The Reluctant Learner



Approach the reluctant learner as you would a “tough clinical case”

How should you respond to your uneager intern?



• Subjective: Use your experience and opinion to gain an individualized impression of the student’s difficulty.

• Objective: Document specific examples of the problem• Assessment: Diagnose the problem• Plan: Develop and implement a plan to address the problem.

Use a S.O.A.P. Approach



Subjective: The Learning Process

TEACHER LEARNER

CONTENT



1. Take a History

2. Examine the Problem

3. Make the Diagnosis

Objective: Be a cool observer, take notes Assessment: Why the reluctance?



Remember to ASK



ASK - Does the learner:

• Have a problem with Attitude? Lack of professionalism Judgmental

“Bleeding heart” who can’t set limits“Sociopathic”

• Lack Skill? Unable to put knowledge to

practical use Uncomfortable asking the questions

Disorganized Stress, depression

• Lack Knowledge? Clinical relevance of material Missing some “background information”/content



Plan – Treat the Problem:

“The Therapeutic Trial”• It usually takes more than one try• Keep the focus on the behavior• Keep your goal realistic



Denial “This is not important for good patient care”“I already know all I need to”

“There may be an easier way to deal with this kind of problem, but I am doing fine”Contemplation

“There are some concrete skills that I can learn and use”

“Mastering these skills will make me a better doctor”

“Stages of Change” for the Reluctant Learner

Determination



“RECOVERY”

RELAPSE

• Fatigue• Burn out• Personal issues• Substance use

“I understand the importance of this skill to good patient careI can do this”



•Other Chief Residents• Program Director•Other faculty

If you need help – Get a Consult!



• Apply educational theory to your practice:– Learner as active contributor– Take into account their knowledge/ experience– Opportunities for self-learning– Opportunities for self-assessment, reflection– Role modeling

The Best Defense…



• “Reluctance is in the eye of the beholder”• The same skills that work with challenging patients work with

challenging (reluctant) learners

–Use SOAP–Don’t forget to ASK–Get a consult

Take Home Points:



1. Get a commitment

2. Probe for supporting evidence

3. Reinforce what is right

4. Give guidance about errors or omissions

5. Teach general principles

6. Conclusion

Use the One-Minute Preceptor Method

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Case