How I Teach
“How I Teach” is ASH Clinical News’ forum for sharing best practices
in teaching hematology to medical students, residents, and fellows.
We invite essays providing insight into teaching and modeling
clinical practice (history-taking, the physical exam, informed
consent, giving bad news), successful research mentoring, diseasespecific tips, or more general advice.
This month, Lisa M. Bellini, MD, professor of medicine and Internal
Medicine Training program director at the Hospital of the University of
Pennsylvania, shares insight into dealing with the problematic trainee.
DIAGNOSING THE
“PROBLEMATIC TRAINEE”
By Lisa M. Bellini, MD
n my early years as program
director, my approach to difficult
or unprofessional trainees was
very black-and-white: There
were very clear rules and very
clear consequences if those rules
are broken. As I have grown in this role
over the past 20 years, my approach has
evolved to account for the various shades
of gray that occur when the same rules
are applied to a spectrum of trainees.
Now, I know that some those rules can
be interpreted differently depending on
the situation. The shades of gray cannot
be overlooked, and each situation needs
to be evaluated independently and on its
own merit.
Spotting a Problem
How do I know when a trainee is in
trouble? First, I compare how trainees
are performing against their peers. If an
individual trainee is lagging behind his or
her peers, it will become obvious quickly, as
other staff and colleagues start to complain
about a trainee’s fund of knowledge or
clinical skills.
Of course, part of being a program
director is interacting with both physician
colleagues, and nursing and support staff
in the hospital. One of my priorities has been
to break down hierarchical barriers so that any
nurse or patient services representative – anyone
who comes into contact with a trainee – feels free
to share his or her concerns about any trainee.
These relationships are invaluable, and important
sources of feedback; without it, I could not be a
successful training program director.
There are many subtle cues to pay
attention to and many different ways that the
stress of being a trainee can manifest. The
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problem is identified when a pattern starts to
emerge; for instance, if a resident has severe
depression, he or she might not attend social
events with the rest of the group or he or
she may not communicate with colleagues
at work. Such a person may have started the
year engaged but has become less so as the
fellowship progresses. Or, a fellow with poor
clinical reasoning skills may overcompensate
and divert clinical presentations with humor
or questions.
Many programs, such as ours at
University of Pennsylvania, now have Clinical
Competency Committees that assess whether
individual fellows have met the standards in
the various competency domains (such as
medical knowledge, professionalism, etc.)
identified by the training program as requisite
for promotion or graduation. Additionally,
this group can help identify disturbing
patterns of behavior, thus validating what the
program director has been witnessing.
May 2015