I welcome your comments about this feature, which is also published
on the STFM Web site at www.stfm.org. I also encourage all predoctoral
directors to make copies of this feature and distribute it to
their preceptors (with the appropriate Family Medicine citation).
Send your submissions to Paul Paulman, MD, University of Nebraska
Medical Center, Department of Family Medicine, 983075 Nebraska
Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501.
E-mail: ppaulman@unmc.edu.
Submissions should be no longer than 3–4 double-spaced pages.
References can be used but are not required. Count each table
or figure as one page of text.
John P. Langlois, MD; Sarah Thach, MPH
(Fam Med 2000;32(5):307-9.)
Clinical teaching goes off without a hitch the majority of the
time. Occasionally, a difficult situation can develop during
a clinical rotation despite one’s best efforts to prevent problems
(see earlier column on “Preventing Difficult Learning Situations”1).
It is key to think ahead and have an organized approach in place
before you find yourself in the midst of a problem. This column
will briefly outline a strategy for diagnosing and managing
a difficult learning situation.
SOAP: An Approach to Problem Interactions
Just as a Subjective Objective Assessment Plan (SOAP) format
can help you and learners organize your clinical notes, it can
help you organize management of difficult learning situations.
This approach, adapted from Quirk,2 allows you to gather basic
data, make objective assessments, and develop a differential
diagnosis and plan of action (Table 1).
Table 1
|
Subjective Objective Assessment Plan:
An Approach to Problem Interactions
|
| • Subjective—What do you/others think and say? |
| • Objective—What are the specific behaviors that
are observed? |
| • Assessment—Your differential diagnosis of the
problem |
| • Plan—Gather more data (on your own,
from learner, from school)? Intervene (give feedback, recommend
changes, follow up)? Get help? |
SOAP: Subjective
In assessing a potential difficult preceptor-learner interaction,
the subjective is usually the “chief complaint.” What was it
that made you think there might be a problem with this interaction?
Often, the first indication is when a learner is labeled by
you or someone in your office as slow, uninterested, angry,
lazy, etc. To flesh out the history, you can ask what others
in the practice think of this learner’s performance. Office
staff who have had experience with several learners can be insightful
assessors of learners’ interpersonal skills. Obtain data from
all readily available sources and determine if a pattern of
behavior exists.
These labels and impressions are not a “diagnosis” of the
problem. Just as fever is a symptom of an underlying condition,
your impressions may just be symptoms of a more specific underlying
diagnosis. In teaching, as in clinical practice, it is important
not just to recognize and treat symptoms but to determine and
act on an appropriate diagnosis.
SOAP: Objective
Once you have identified a pattern of behavior, it is essential
to document specific instances. Some examples of specific behaviors
you might list are, “More than 20 minutes late to the office
on Monday, Tuesday, and Thursday this week.” “Visit Thursday
morning with Joe White: took 40 minutes to assess this patient
with a cold.” “Unable to recall info on symptoms of UTI on Wednesday
morning after we had reviewed it on Tuesday at lunch.” Having
a list of specific behaviors and specific instances (preferably
written down) will be extremely important in helping you assess
the problem, develop a plan of action, and then initiate it.
SOAP: Assessment
The next challenge is to work from the symptoms and manifestations
of the problem to determine a diagnosis. Trained clinicians
are highly effective at considering a wide range of possible
explanations for a medical condition. Unfortunately, preceptors
are less confident when it comes to assessing learning situations.
This comes not from an inherent inability but from lack of experience.
Just as learners produce short and incomplete differentials
for clinical problems, preceptors tend to come up short in assessments
of potential sources of learning difficulties. With practice
and a little help, you can produce an accurate differential
of learning issues.
Table 2 outlines some of the potential diagnoses for difficult
preceptor-learner interactions. In developing your differential
diagnosis, you might consider: cognitive problems (such as limited
knowledge base, learning disabilities, or lack of effort); affective
problems (learner anxiety, depression, fear, or anger); a mismatch
between the values and expectations of the learner and the preceptor
(if the learner does not value your clinical area or is too
forceful in presenting values to staff and patients); environmental
problems (if a learner used to hospital care struggles in the
outpatient setting); or a medical diagnosis (major depression
or anxiety/panic disorder; a recent illness, such as mononucleosis;
a previously undiagnosed illness, such as hypothyroidism; a
preexisting illness that is now in poor control, such as diabetes
or an eating disorder; or a newly presenting illness, such as
schizophrenia or substance abuse).
The assessment can seem daunting. However, as a health care
provider, you are trained to make diagnoses, and the same skills
you use to develop a differential diagnosis on a patient will
work with learning difficulties. Also, it is not necessary to
have a firm diagnosis in hand to determine a plan and get the
help you need.
Table 2
|
Assessment: Differential
Diagnosis
|
| Cognitive |
| • Knowledge base/clinical skills less than
expected |
| • Spatial perception difficulties |
• Communication difficulties |
| • Lack of effort/interest |
• Dyslexia |
| Affective |
| • Anxiety |
• Depression |
| • Anger |
• Fear |
| Valuative |
| • Expects a certain level of work |
• Expects a certain grade |
| • Does not value the rotation |
• Does not want to be at your site |
| • Does not value your teaching |
• Has principles that conflict with yours
or patients’ |
| Environment |
| • Hospital-care oriented |
• Not used to undifferentiated patient |
| • Not time sensitive |
• Not patient-satisfaction oriented |
| Medical |
| • Clinical depression |
• Anxiety/panic disorder |
| • Recovering from recent illness |
• Hypothyroidism |
| • Preexisting illness in poor control |
| • Substance abuse |
• Psychosis |
SOAP: Plan
Your next step is to decide on a plan that reflects your differential
diagnosis and the impact of the situation on you, your practice,
and the learner. Your first step may be to gather more data.
To produce a more-accurate differential diagnosis, you may need
to observe and record more behavior-specific data. Consider
discussing the issue with the learner; you may learn that he
or she is aware of the problem and seeking to remedy it. For
example, when you tell the learner, “I notice you’ve been late
to the office twice this week,” he/she responds, “I know, sorry!
My alarm clock hasn’t been working. I was planning on buying
a replacement tonight.” A learner’s lack of awareness of the
problem may indicate a more-significant issue and/or the need
to be more directive. It is all right to contact the school
or training program early on, even when the concern seems relatively
minor; they can provide guidance and moral support and may have
relevant information about the learner’s performance on previous
rotations.
Intervene
For difficult learning situations that seem straightforward
and are having limited impact on the practice, the staff and
patients may be amenable to intervention in the practice setting.
Detailed, specific feedback is the cornerstone of your intervention.
Share your detailed observations with the learner, recommend
specific changes, and set a time to reassess the learner’s performance
to see whether there has been improvement. Many learners will
be able to act on good feedback and make dramatic improvement.
If an intervention is not successful, it may be that the problem
is larger than you thought and requires external help.
Getting Help
Getting help should not be a last resort. As in clinical practice,
the plan depends on the seriousness of the situation. Just as
you would not treat a myocardial infarction at home, you do
not need to handle complicated learning issues on your own.
The primary responsibility for learners’ well-being rests with
the school or program, which has significant resources to help
learners in need. In some cases, it may not be appropriate for
the learner to remain in your office. A transfer back to the
school or program should not be seen as a failure of the preceptor
but rather as success for the educational system in getting
learners what they need most.
Preceptor Issues
Up to this point, we have focused on issues related to the learner.
There are times when difficult learning situations can occur
due to preceptor-related issues. Unanticipated events, such
as personal illness or illness in family members, loss of a
partner or key staff, or unexpected financial or schedule-related
pressures, can have a significant effect on a teaching experience.
At times, an unanticipated personality clash with a learner
will make it impossible to establish the close working relationship
needed to teach effectively.
Most clinician teachers do not take their commitment to teach
lightly and will often try to work through unexpected difficulties
and personal issues. These are two important questions to ask
when preceptor issues are present: 1) Is the presence of the
learner preventing you from doing what needs to be done? 2)
Are your issues seriously affecting the education of the learner?
There is a tendency to ignore problems rather than decline
to take an agreed-on difficult learner. The result could be
a lose/lose situation for the preceptor and the learner. Recognizing
your limits and being able to transfer a learner back to the
school when necessary is an important skill that can help ensure
a positive educational experience for learners and preserve
your long-term commitment to teaching.
Conclusions
This column has focused on the identification and management
of difficult learning situations. It is important to put things
in perspective and remember that learner-teacher interactions
go well the vast majority of times. Maintaining a vigilance
to detect issues early and using the SOAP approach to assess
and intervene early can reduce the impact of the occasional
difficulty. When the rare significant problem occurs, it is
important to seek help early. Getting the resources needed for
the learner as soon as possible benefits you, the learner, and
future learners.
Corresponding Author: Address correspondence
to Dr Langlois, MAHEC Family Practice Residency, 118 W.T. Weaver
Boulevard, Asheville, NC 28804. 828-258-0670. Fax: 828-257-4738.
E-mail: johnl@mtn.ncahec.org.
References
1. Langlois JP, Thach S. Preventing the difficult learning situation.
Fam Med 2000;32 (4):232-4.
2. Quirk ME. How to teach and learn in medical school. Springfield,
Ill: Charles C. Thomas, 1994.
