Innovative Strategies for Coaching Residents who Struggle with Time Management, Organization and Efficiency Allison Dekosky, MD Eric Goren, MD Mina Sedrak MD Karen Warburton, MD University of Pennsylvania Department of Medicine Objectives Assess a resident who is struggling with time management, organization and efficiency Construct a coaching plan for such a resident, based on specific deficits Incorporate elements of an organization and efficiency toolbox into a comprehensive strategy for coaching residents on the job
Outline Background Small group exercise Assessment of a struggling learner Development of coaching plan Wrap-up Background The struggling learner Scope of problem What do learners struggle with? Remediation and coaching How frequent or successful? Models for remediation
Scope of the Problem 2000 survey of US IM Program Directors 94% of Program Directors reported problem residents Point prevalence of problem residents 6.9% Repeat survey in 2008 Similar results Outside of internal medicine 30 year retrospective review in a single surgery program-> 17 struggling learners Outside of the US 10 year retrospective review of Canadian GME programs- > 3% of residents What do Residents Struggle With? Yao et al. JAMA 2000 Dupras DM et al. Am J Med 2012
What s the Differential Dx? Psychosocial stress Psychiatric diagnosis Depression Personality disorder Impairment Learning disability Poor preparation Wrong career (or program) choice How Frequent or Successful is Remediation? Not happening very often 2008 IMPD Survey Only 38% of residency program directors reported remediating any resident Retrospective review of surgical residents 15/17 graduated with same deficits that were first reported Learners are identified late Barriers = Inaccurate evaluations, denial, remediation time-intensive
University of Colorado School of Medicine Remediation Program Largest, most comprehensive study to date 151 learners referred over 6 year period 43% residents Standardized assessment process by a remediation specialist Individualized learning plans Independent reassessment Guerrasio J et al. Acad Med 2014 Resource-intensive Mean number of hours of faculty face time require for remediation was 18.8 per learner Guerrasio J et al. Acad Med 2014
but Successful Poor professionalism was the only predictor of being placed on probation (P < 0.001) Per hour, faculty face time reduced the odds of probation by 3.1% and all negative outcomes by 2.6% Guerrasio J et al. Acad Med 2014 At the University of Pennsylvania Clinical Coaching Committee Department of Medicine
UME Clerkship/SubI Course Directors Clerkship/SubI Grading Committees Struggling Learner GME Program Director Clinical Competency Committee Clinical Coaching Committee Assessment Pre interview Assessment Interview Exacerbating Factors Present? No Diagnosis of Clinical Deficiency Yes Outside Referral EAP CAPS Fund of Knowledge Clinical Reasoning Organization & Efficiency Professionalism Communication Skills Development of Written Coaching Plan Fund of Knowledge Clinical Reasoning Organization & Efficiency Professionalism Comm Skills Coaching Reassessment
Principles of Coaching Requires direct observation, real-time feedback and time for reflection Learner must know the stakes and know there are no guarantees Must involve reassessment Small Group Exercises Evaluate an intern who is struggling Break out session #1 Formulate an assessment of the struggling learner Learn what questions to ask about and to a learner who is struggling Break out session #2 Create a coaching plan for the struggling learner Goal and objectives of coaching 1-2 practical coaching exercises Take homes
Break Out Session #1 We can t just give you the tools, though we will.. Learners have deficits in a variety of areas that make them struggle Need a more specific target to design an effective plan Goal- Perform the initial assessment of a struggling learner Objectives- List what information to gather Ask proper questions to a learner Develop a working diagnosis UME Clerkship/SubI Course Directors Clerkship/SubI Grading Committees Struggling Learner GME Program Director Clinical Competency Committee Clinical Coaching Committee Assessment Pre interview Assessment Interview Exacerbating Factors Present? No Diagnosis of Clinical Deficiency Yes Outside Referral EAP CAPS Fund of Knowledge Clinical Reasoning Organization & Efficiency Professionalism Communication Skills
Break Out Session #2- Coaching Plan Difficult and time intensive and will depend on resources at your institutions. We can t build a full plan today With every individual learner Clear goals and objectives. in writing; SMART Goals and objectives clearly conveyed to learner and program leadership More generalizable Develop a tool kit Break Out Session #2- Coaching Plan
Break Out Session #2- Coaching Plan We will give goal for coaching plan based on bucket Create 2-3 SMART objectives for coaching plan Develop 1-2 coaching tools Coaching Toolbox The deficit is diagnosed and objectives are in place What s next? The key is naming the steps and creating systems and frameworks for things we often take for granted Think about it: How do you admit a patient efficiently? What are the components of pre-rounding? How do you break down the generic contents of a care plan for a progress note?
Example: Applying 3Rs/3Ws A&P for Hospital Day 1-2 (from H&P): Mr. Grady is a 65 yo M former smoker with a history of CAD s/p NSTEMI and HTN admitted with symptoms meeting SIRS criteria (fever, tachycardia, leukocytosis), infectious work-up ongoing, as well as renal insufficiency of unknown chronicity. # SIRS: This is likely sepsis with undetermined source; upper respiratory or lung etiology is highest suspicion. His SIRS criteria are fever, tachycardia, and leukocytosis. He needs a broad infectious work-up including UA with urine cx, although less likely given lack of symptoms and he is localizing more URI complaints, RRP given flu season. Blood cultures are also pending. CXR is currently negative for frank infiltrates but viral syndrome is possible. Need aggressive ABC support in the meantime. IVF with goal MAP of >65 and follow HR and oxygenation r/o MI as this can cause SIRS in some circumstances or he could have an MI induced by underlying illness Send RRP Cover empirically for CAP with ceftriaxone/azithro given cough, sputum and leukocytosis # AKI: Cr is elevated at 1.8 from an unknown baseline; the etiology and chronicity of this is unknown. Pt is very dry and tachycardic on exam so I suspect hypovolemia/prerenal etiology. This could also be a chronic hypertensive nephropathy in a gentleman lost to MD follow-up. Continue isotonic fluid hydration and follow Cr and UOP Send a spot Urine Na if <10, help confirm prerenal.
A&P for Hospital Day 4: Example: Applying 3Rs/3Ws Mr. Grady is a 65 yo M with a history of CAD s/p NSTEMI and HTN admitted with AKI and sepsis secondary to community-acquired pneumonia, improved as volume resuscitation and antibiotics but whose stay has been complicated by new onset atrial fibrillation. # Atrial fib: New, now rate controlled. Could be 2/2 sepsis and subsequent hypoxia after volume resuscitation, or less likely underlying CM. Unlikely acute ischemia as cardiac enzymes neg x3 and no other EKG changes. Do not suspect thyroid or thromboembolic dx given time course. Continue rate control with metoprolol 25mg po q6h TTE to eval for structural heart disease CHA2DS2-VASc score elevated will start anticoagulation Diurese and manage infection per below # Hypoxia: Improving with diuresis, likely multifactorial due to PNA and pulm edema from volume resuscitation vs A fib- unclear which happened first. Do not suspect PE given improvement as above. A fib mgmt above Furosemide 20mg IV this morning and reassess this afternoon # Sepsis 2/2 CAP: Sepsis resolved, CAP Improving. CXR revealed new lobar infiltrate after volume resuscitation. Sputum cx no growth. Cont empiric Ceftriaxone (day 4 of 5), completed 3 days of azithro. # Prerenal AKI: Resolved after IVF. Cr now 0.9 from initial 1.8. Wrap-Up Assessing residents struggling with time management, organization and efficiency takes thoughtful analysis Constructing a coaching plan for such a resident, based on specific deficits, requires a multi-pronged and realistic longitudinal approach Creatively incorporating elements of an organization and efficiency toolbox allows for coaching residents on the job QUESTIONS? COMMENTS?
3Rs/3Ws: Guide to Composing Daily Notes You ve finished PRePPING your patient! Before you start your note or give your oral presentation on rounds, think broadly about your patient: R Reassess Is the patient better, worse, or the same? Is the current diagnosis still the most likely? Is your current therapeutic plan still effective? R Rename Are the problem names as specific as possible, based on TODAY s data? Gram- negative rod UTI! Klebsiella UTI SOB! Pneumonia R Reprioritize Is the most active problem listed first? Can you move resolved or chronic problems lower? W What Name the problem, with current clinical status (eg Improved, Stable, Worse, New) Community Acquired PNA: Improved. W Why Describe the differential diagnosis and discuss how the current clinical exam, vitals, labs, and studies support your likely diagnosis. W What Next What is the plan for the day? Will you be ready to discharge soon? What do we need to do in order to get the patient to move towards discharge? Sedrak/DeKosky 10/7/2015
Here is an example for patient Mr. Grady, admitted with a few evolving problems: A&P for Hospital Day 1-2 (from H&P): Mr. Grady is a 65 yo M former smoker with a history of CAD s/p NSTEMI and HTN admitted with symptoms meeting SIRS criteria (fever, tachycardia, leukocytosis), infectious work- up ongoing, as well as renal insufficiency of unknown chronicity. # SIRS: This is likely sepsis with undetermined source; upper respiratory or lung etiology is highest suspicion. His SIRS criteria are fever, tachycardia, and leukocytosis. He needs a broad infectious work- up including UA with urine cx, although less likely given lack of symptoms and he is localizing more URI complaints, RRP given flu season. Blood cultures are also pending. CXR is currently negative for frank infiltrates but viral syndrome is possible. - Need aggressive ABC support in the meantime. IVF with goal MAP of >65 and follow HR and oxygenation - r/o MI as this can cause SIRS in some circumstances or he could have an MI induced by underlying illness - Send RRP - Cover empirically for CAP with ceftriaxone/azithro given cough, sputum and leukocytosis # AKI: Cr is elevated at 1.8 from an unknown baseline; the etiology and chronicity of this is unknown. Pt is very dry and tachycardic on exam so I suspect hypovolemia/prerenal etiology. This could also be a chronic hypertensive nephropathy in a gentleman lost to MD follow- up. - Continue isotonic fluid hydration and follow Cr and UOP - Send a spot Urine Na if <10, help confirm prerenal. Again, the summary statement is updated, concise, and informative, and incorporates current condition. A&P for Hospital Day 4: Mr. Grady is a 65 yo M with a history of CAD s/p NSTEMI and HTN admitted with AKI and sepsis secondary to community- acquired pneumonia, improved as volume resuscitation and antibiotics but whose stay has been complicated by new onset atrial fibrillation. # Atrial fib: New, now rate controlled. Could be 2/2 sepsis and subsequent hypoxia after volume resuscitation, or less likely underlying CM. Unlikely acute ischemia as cardiac enzymes neg x3 and no other EKG changes. Do not suspect thyroid or thromboembolic dx given time course. - Continue rate control with metoprolol 25mg po q6h - TTE to eval for structural heart disease - CHA2DS2- VASc score elevated will start anticoagulation - Diurese and manage infection per below # Hypoxia: Improving with diuresis, likely multifactorial due to PNA and pulm edema from volume resuscitation vs A fib- unclear which happened first. Do not suspect PE given improvement as above. - A fib mgmt above - Furosemide 20mg IV this morning and reassess this afternoon # Sepsis 2/2 CAP: Sepsis resolved, CAP Improving. CXR revealed new lobar infiltrate after volume resuscitation. Sputum cx no growth. Cont empiric Ceftriaxone (day 4 of 5), completed 3 days of azithro. # Prerenal AKI: Resolved after IVF. Cr now 0.9 from initial 1.8. The summary statement is concise and informative, and incorporates current condition. Note the 3 Rs in this example: SIRS is Renamed to a more specific diagnosis ( Sepsis 2/2 CAP ), and is Reassessed to be improving or resolved. It is also Reprioritized (now lower acuity than the new onset Afib). Note 3 Ws in this example: What New onset Afib. Why sepsis and hypoxia, along with what is unlikely to be the cause. What next the plan. Note that the What includes descriptor of time course and is followed by a characterization of better/same/worse. What next flows logically from the What and the Why. Sedrak/DeKosky 10/7/2015
TRIAGE An H&P : Guide to Admitting a Patient T R Triage Key Patient Data Review Clinical Overview Obtain current objective data Vital Signs / CC / ED TRIAGE Notes Quick review of Labs/Micro Data Quick review of Current Imaging Chart Biopsy / "Clinical Overview" Medview Trend vitals Trend labs (find out baseline Hgb, Cr, etc.) Review PMH/Meds/Allergies Review last EPIC outpatient progress note Review last discharge summary / signout Review pertinent prior imaging Review last EKG / echo I Investigate/Inquire Review current ED MD or Clinic Note In- depth review of Vital Signs/ CC Medications Given (abx, IVF, etc.) U- dip, pregnancy tests, other ED work- up ED MD/Clinician HPI and assessment Doc- 2- Doc from ER/Clinic Provider A Admit Orders / Organize Thoughts Place General Admissions Orders in SCM Compose a draft problem list in signout document Acute (i.e. Neutropenic fever, SOB, etc.) Chronic Problems (ie AML, HTN, DM, etc.) G Go see the Patient See the patient (problem- based, focused H/P) E Evaluate Orders Place detailed orders in SCM Interventions (abx, IVF, heparin gtt, etc.) Medication Reconciliation Diagnostic tests (echo, CT, other labs, etc.) An Assess, Formulate Plan Formulate Assessment & Plan (complete signout) Prioritize acute problem list Each problem should include 3 Ws: o What, Why, What next What else? Chronic Problem List H&P Write it / Put it in Chart Complete H&P and place in chart Sedrak/DeKosky 9/22/2015
PRePPING the Patients: Guide to Pre- Rounding P Plan the day Re Review signout On your way to work, think about: Planned discharges vs ongoing care plans Current patient plans for the day (CT scan, OR plan) Obtain written and verbal signout, review overnight events P Prioritize Make game plan: Assess need for urgent/emergent interventions based on signout do you need to contact supervising resident? Decide on rounding order based on acuity, geography, and discharge planning P Prepare Scan vitals, talk to RN, review individual overnight events I Inside the room Perform focused ROS and physical exam, to answer these key questions (at least): Is the primary reason for hospitalization/primary complaint better, worse, or same? Are the relevant physical exam findings better, worse or same? Is the patient ready for discharge: Have you achieved all medical goals and they are eating, drinking, walking, and have a place to go? N Note your findings Complete S and O sections of note G regroup After you have seen all your patients, you should: Check labs Replete electrolytes, transfuse blood Put in other routine orders Reassess, Rename and Reprioritize each problem Within each problem, compose the What, the Why, and the What Next? Sedrak/DeKosky 9/22/2015