Transcript Managing Problem Interns and Postdoctoral Residents

Difficult Interns and Postdoctoral
Residents:
Identification, Assessment,
and Interventions
APPIC Pre Conference Workshop
Nadine Kaslow, Ph.D., APPIC Chair
Mona Koppel Mitnick, JD, APPIC Public Member
Jeff Baker, Ph.D., APPIC Board Member
DEFINITIONS
• Competence
– Professional competence is the habitual and
judicious use of communication, knowledge,
technical skills, reasoning, emotions, values,
and reflection in daily practice for the benefit
of the individual and community being served
(Epstein & Hundert, 2002)
DEFINITIONS
• Historically, the term impairment has been used
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to describe problematic knowledge, skills,
attitudes, and behaviors of trainees and
professionals
The term impairment has a specific meaning
within the context of the ADA (e.g., medical or
mental health disability)
Therefore, we will focus on trainees with
problems, referred to as “difficult” trainees
Sometimes these trainees also have impairments
according to the ADA
DEFINITIONS (cont.)
(Overholzer & Fine, 1990)
• When supervisees have difficulties it is
likely due to:
– Lack of knowledge
– Inadequate clinical skills
– Deficient technical skills
– Poor judgment
– Disturbing interpersonal attributes
DEFINITIONS (cont.)
(Lamb et al., 1987)
• Difficult trainees exhibit interference in
their professional functioning as reflected
in one or more of the following ways:
DEFINITIONS (cont.)
(Lamb et al., 1987)
– Inability and/or unwillingness to acquire and
integrate professional standards into one’s
repertoire of professional behavior
– Inability to acquire professional skills in order
to reach an acceptable level of competency
(performance problem)
– Inability to control personal stress,
interpersonal difficulties, psychological
dysfunction, and/or excessive emotional
reactions that interfere with professional
functioning (conduct or emotional problem)
DEFINITIONS (cont.)
(Lamb et al., 1987)
• An trainee’s behavior is considered difficult when
characterized by one or more of the following:
– The trainee does not acknowledge, understand, or
address the problem when it is identified (lack of selfawareness and interpersonal responsiveness)
– The behavior is not merely a reflection of a skill deficit
that can be rectified by academic or didactic training
– The quality of the trainee’s services is sufficiently
negatively affected
DEFINITIONS (cont.)
– The problem is not restricted to one area of
professional functioning
– A disproportionate amount of attention by
training personnel is required
– The trainee’s behavior does not change as a
function of feedback, remediation efforts,
and/or time
DEFINITIONS (cont.)
(Chapman et al., 2002)
• Incompetence in clinical skills or
inadequate fund of knowledge
• Lack of awareness or disregard for
professional behavior and responsibility
• Problematic interpersonal issues
• Demonstrates problems in two or more
areas
DEFINITIONS (cont.)
• These definitions of difficult trainees do not
include a trainee’s behavior, attitudes, or
characteristics that are developmentally
normative, such as:
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Transition issues
Mild performance anxiety
Mild discomfort with diverse client groups
Initial lack of understanding of the facility’s norms
Lack of certain skills sets, but an openness and
readiness to acquire them
CONTEXT
• The identification of a trainee’s behavior
as problematic needs to take the context
into account. It is key to assess if trainee
difficulties reflect a mismatch between
the:
– Philosophy of the site and the trainee’s
orientation
– Skills and competencies of the trainee and the
demands of the site
CONTEXT (cont.)
• A number of contextual factors in the life
of the trainee need to be considered when
assessing problematic behavior
– Adjustment issues to new setting (not site)
– Adjustment to new site
– Separate from established support systems
– Status change
– Personal life events/changes
CONTEXT(cont.)
(Sherman & Thelen, 1998)
• Various life events are work factors are
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associated with different amounts of distress
and functional difficulties; personal relationship
problems and work with difficult clients are most
troublesome
People with the greatest number of life
events/work factors have the greatest distress
Non-work related activities and vacations are the
best preventive behaviors
CONTEXT (cont.)
• When the aforementioned issues appear
salient, recommend the following
– Suggest options for better stress management
and self-care
– Provide more support to the trainee
PERSONAL RISK FACTORS
• History of childhood trauma
• Substance use disorders
• Major Axis I disorder
• Axis II disorder
• Wounded healer
• False self
• Attachment difficulties
PROCESSES ASSOCIATED WITH
PROBLEMATIC BEHAVIOR
(Lamb et al., 1991)
• Setting the Stage
• Orientation
– Direct communication of the site’s
expectations regarding professional
standards, skill competency, personal
functioning
– Communication regarding evaluation
guidelines and processes
– Provision of Due Process Guidelines
PROCESSES (cont.)
• Reconnaissance and Identification
– Gathering on-going evaluative information and
observing the trainee’s initial response to the setting,
training experience, and feedback
– Discussion among all training faculty/staff
– Identify areas of concern orally and in writing –
express concerns as hypotheses and define problem
behaviors in concrete and specific terms
– Early and continuous monitoring
– This process often enough to manage many problems
PROCESSES (cont.)
• Discussion and Consultation when problem
behavior persists
– Discussion among all training personnel
regarding other interventions and next steps
– Such discussion should consider
• Actual behaviors of concern (e.g., nature,
frequency, severity)
• Settings that behaviors occur in
• Negative consequences of the behaviors
• Trainee’s response to feedback
PROCESSES (cont.)
• Discussion and Consultation (cont.)
– Review of these questions is likely to be time
consuming and stressful
– Important to thoroughly explore the behaviors
in question, full range of interventions, and
effects of interventions on all concerned
– Interventions (see remediation section)
PROCESSES (cont.)
• Implementation and Review
– Implement intervention plans
– Review progress and response to
interventions
– Communicate with all relevant parties
– Provide ongoing feedback
– Document all problem behaviors and changes
in behavior
PROCESSES (cont.)
• Implementation and Review (cont.)
– Ongoing meetings of faculty/staff for review
– Consultation from other training personnel
– Consideration of possible alternative actions
– External consultation
PROCESSES (cont.)
• Anticipating and Responding to
Organizational Reaction in Cases of
Termination
– Support trainee and help him/her consider
alternatives
– Support training personnel
– Determine how to communicate what and to
whom (e.g., other current and future trainees,
staff)
– Management of clinical services
REMEDIATION
CONSIDERATIONS
(Lamb et al., 1987)
• Once problems have been identified, there
need to be several meaningful ways to
address them. These need to be clearly
stated and presented in a written
document and the remediation plan needs
to be discussed and agreed upon. Possible
and perhaps concurrent courses of action
designed to remediate problems include,
but are not limited to, the following:
REMEDIATION
CONSIDERATIONS (cont.)
– Increasing supervision, either with the same
or other supervisors
– Changing the format, emphasis, and/or focus
of supervision
– Recommending and/or requiring personal
therapy in a way that all parties involved have
clarified the manner in which therapy contacts
will be used in the evaluation process
REMEDIATION
CONSIDERATIONS (cont.)
– Reducing and/or shifting the trainee’s
workload
– Requiring specific academic coursework
– Recommending, when appropriate, a leave of
absence and/or a second internship or
residency
– Collaborating with the graduate department
on the remediation plan in accord with the
CCTC Communication Guidelines
REMEDIATION
CONSIDERATIONS (cont.)
• When a combination of the above
interventions do not, after a reasonable
time period, rectify the problem, or when
the trainee seems unable or unwilling to
alter his/her behavior, the program may
need to take more formal action in accord
with their due process guidelines
FORMAL ACTIONS
(Lamb et al., 1991)
• Probation
– In writing,
• Identify specific behaviors or areas of professional
functioning of concern
• Directly relate these behaviors to written evaluations
• Provide specific ways deficiencies can be remedied
• Identity specific probationary period
• Stipulate how functioning will change at site during
probation, of applicable
• Reiterate the availability of due process procedures
FORMAL ACTIONS (cont.)
• Giving the trainee a limited endorsement,
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including the specification of those settings in
which he/she could function adequately
Terminating the trainee from the program and
communicating this to the appropriate parties
Recommending and assisting in implementing a
career shift for the trainee
*All
of the above steps need to be documented
appropriately and implemented in accord with
the due process guidelines
TERMINATION
(Lamb et al., 1991)
• Steps to take prior to notifying trainee
– Review agency and institutional implications
of the decision
– Letter sent to trainee and other relevant
parties reiteration probationary conditions,
trainee’s response, and reasons for dismissal
– How and when the trainee’s status will
change at the site needs to be determined
TERMINATION (cont.)
• Steps (cont.)
– Trainee must be given the opportunity to
appeal in accord with due process guidelines
– Proposed action and corresponding written
statement should be reviewed in consultation
with relevant internal and external parties
– Consult with legal counsel at the facility
– Notify up the chain of command
TERMINATION (cont.)
• Once these steps have been taken
– Hold meeting between the trainee and
relevant training and site personnel
– Inform trainee of the decision
– Provide a written statement
– Provide statement of revised responsibilities
– Remind trainee of due process guidelines
CHALLENGES IN EVALUATING
INTERNS & RESIDENTS
(Robiner, 1993)
• Definition and Measurement Issues
– Lack of clear criteria and objective measures
of competence/incompetence in psychology
– Lack of clear criteria and objective measures
of problematic behavior in psychology
– Supervisor awareness of subjectivity inherent
in evaluation
– Apprehension about defending evaluations
due to lack of clear criteria and objective
measures
EVALUATION CHALLENGES
(cont.)
• Legal and Administrative Issues
– Concern that negative evaluations may result
in administrative inquiry, audit, grievance or
litigation
– Lack of awareness of internship/residency or
institutional policies and procedures involved
in negative evaluations
– Social and political dynamics – concerns about
lack of support from administrators and
colleagues
EVALUATION CHALLENGES
(cont.)
• Legal and Administrative Issues (cont.)
– Concern that failing to “pass” an intern or
resident may result in loss of future training
funds or slots or the need to find additional
funds to extend the trainee’s training
– Concern that failing to “pass” an intern or
resident may result in adverse publicity that
could affect institutional reputation and the
number of applicants
EVALUATION CHALLENGES
(cont.)
• Interpersonal Issues
– Fear of diminishing rapport or provoking
hostility from supervisees
– Fear of eliciting backlash from current or
future trainees
– Anguish about damaging a supervisee’s
career or complicating or terminating their
graduate training (in the case of an intern)
EVALUATION CHALLENGES
(cont.)
• Supervisor Issues
– Supervisors’ wish to avoid scrutiny of their
own behavior, competence, ethics,
expectations, or judgment of their clinical or
supervisory practices
– Limited supervisory experience with problem
trainees
– Difficulties in imparting negative evaluations
– Indifference to personal responsibility for
upholding the standards of the profession
EVALUATION CHALLENGES
(cont.)
• Supervisor Issues (cont.)
– Inappropriate optimism that problems will
resolve without intervention
– Preference to avoid the substantial energy
and time commitment necessary to address or
remediate the behavior of problem interns
and residents
EVALUATION CHALLENGES
(cont.)
• Supervisor Issues (cont.)
– Discomfort with “gatekeeper” role
– Identification with supervisee’s problems
– Inadequate attention to supervisee’s
performance or problems
– Supervisors’ presumption of supervisee
competence
– Minimization of supervisee’s problem behavior
TYPOLOGY OF MENTORSHIP
DYSFUNCTION
(Johnson & Huwe, 2002)
• Dysfunction connotes a relationship that is
•
unproductive,characterized primarily by conflict,
or is no longer functioning effectively for one or
both partners
Dysfunction may be rooted in
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Behavior or personality features of either person
Contextual factors
Poor matching
Effects of otherwise healthy maturation
MENTORSHIP DYSFUNCTION
(cont.)
• Typology
– Faulty mentor-protégé matching
– Mentor technical incompetence
– Mentor relationship incompetence
– Mentor neglect
– Relational conflict
– Boundary violations
MENTORSHIP DYSFUNCTION
(cont.)
• Typology (cont.)
– Exploitation
– Attraction
– Unethical or illegal behavior
– Abandonment
– Cross-gender and cross-race issues
– Protégé traits and behaviors
MENTORSHIP DYSFUNCTION
(cont.)
• Common Self-Defeating Responses to
Mentorship Dysfunction Include:
– Paralysis
– Distancing
– Provocation
– Sabatoge
MENTORSHIP DYSFUNCTION
(cont.)
• Strategies for Preventing and Responding
to Mentorship Dysfunction
– Administrative Strategies
• Create a culture of mentoring
• Scrutinize new hires
• Prepare faculty/staff for the mentor role
• Monitor and reinforce mentoring
MENTORSHIP DYSFUNCTION
(cont.)
• Strategies (cont.)
– Individual Strategies
• Slow down the process
• Honestly evaluate personal contributions
• Consider ethical/professional obligations as a
mentor
• Be proactive, cordial, and clear in communicating
concerns to protégés
• Seek consultation
• Document
TIPS
• Provide thorough due process guidelines
• Make expectations clear from the outset
• Identify problems early
• Provide rationale for change
• Be aware of the consequences of failure to
act
• Consult colleagues (internal, external)
TIPS (cont.)
• Monitor in multiple ways
• Document
• Keep the lines of communication open
• Inform relevant parties
• Stay informed of current practices
• Use APPIC’s Informal Problem Resolution
Process and Consultation Service as a
Resource
FUTURE DIRECTIONS
• Guidelines on handling difficult trainees
• Better articulation of assessment
strategies
• More rehabilitation programs for
professionals
• Greater support for seeking assistance
• Continued education
LEGAL ISSUES AND
DUE PROCESS
• Simple and easy to understand
• Written and communicated to each
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intern/trainee/post doc at the time he/she
begins the internship or post doc
Applied uniformly and in a timely fashion to all
such problem or substandard
interns/trainees/post docs and to any
intern/trainees/post docs complaints about the
actions of training program staff
Applied to all serious performance, conduct, and
ethical problems of interns/trainees
DUE PROCESS PROVISIONS
• Description of the types of problems and behavior covered, which should be
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broad enough to cover all performance, conduct, and ethical deficiencies, as
well as any combination of these deficiencies
Description of the persons covered., making clear that all
interns/trainees/post docs, at whatever stage of training, are covered
A clear statement of the time limits at different stages of the process, and
whether and for what reasons) such time limits may or may not be waived
Both informal and formal procedures for correcting deficiencies, and
appealing any dissatisfaction with the program’s compliance with the
procedures, the notification of deficiencies and any penalties
A clear statement at each stage identifying the decision maker, and the
contents of the decision
A clear statement at each stage of whether and to whom the complainant
or training program official may appeal the decision
A clear statement of when the decision becomes final
SUGGESTIONS FOR
DEVELOPING DUE PROCESS
• Informal Stage
• Formal Stage
INTERN/POSTDOC COMPLAINTS
• Filing of Informal Complaint
• Decision on Informal Complaint
• Filing of Formal Complaint (ASARC)
• Decision on Formal Complaint
• Appeal from Decision on Formal Complaint
DISABILITY ISSUES
• A great deal of confusion has arisen
among interns/postdoctoral residents and
their sites /programs as to what
constitutes disability, as defined by the
Rehabilitation and Americans with
Disabilities Acts; and what, if any,
obligation an internship/program site has
to provide reasonable accommodation to
an applicant or an intern/postdoc after
selection
CLAIMING AND
PROVING DISABILITY
• Qualified
• Responsibility for Determination
• Toyota vs. Williams
• Rehabilitation Act or ADA
• Correctible
ACCOMMODATION
• When and to What Extent Reasonable
Accommodation is Required
– Reasonable Accommodation
– Establish Meeting the Definition
HANDICAP DISCRIMINATION
• Avoiding a Successful Claim of Handicap
Discrimination
REFERENCES
• Rehabilitation Act of 1973, as amended (29 U.S.C. sec.
791 et seq.; and Americans with Disabilities Act of 1990
(ADA (42 U.S.C. sec. 12101 et seq.; 29 C.F.R. sec. 1630;
1997; EEOC Enforcement Guidance on the Effect of
Representations Made in Applications for Benefits on the
Determination of Whether a Person Is a "Qualified
Individual with a Disability" Under the Americans with
Disabilities Act of 1990 (ADA) (Feburary 12, 1997);
Enforcement Guidance: Reasonable Accommodation and
Undue Hardship Under the Americans With Disabilities
Act (March 1, 1999).
TYPES OF DIFFICULT
TRAINEES
Slackers
Mild Manipulative Behaviors
Personality Disorders
Unusual Situations
REFERENCES:
DEVELOPMENTAL PERSPECTIVE
• Developmental Issues in Internship & Postdoc Training
– Kaslow, N. J., & Rice, D. (1985). Developmental stresses of
psychology internship training: What a training staff can do to
help. Professional Psychology: Research and Practice, 16, 253261.
– Kaslow, N.J., McCarthy, S.M., Rogers, J.H., & Summerville, M.B.
(1992). Psychology Postdoctoral training: A developmental
perspective. Professional Psychology: Research and Practice, 23,
369-375.
– Lamb, D. H., Baker, J., Jennings, M., & Yarris, E. (1982).
Passages of an internship in professional psychology.
Professional Psychology: Research and Practice, 13, 661-669.
– Solway, K. (1985). Transition from graduate school to
internship: A potential crisis. Professional Psychology: Research
and Practice, 16, 50-54.
MODEL BEHAVIOR
• Model Behavior
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Energetic
Responsible
Keeps up in their readings
Keeps appointments, has great foundation in
treatment, assessment, and professional behavior
– Takes on more responsibilities than expected, but has
excellent follow through
– Looks for ways to increase their skills and is
appreciative of training experience
LESS THAN DESIRABLE BEHAVIOR
• Less than Desirable Behavior
– Slacker, does less than expected
– Hides important information (i.e. has only seen an MMPI in the
book, has only read about CBT, etc)
– Never volunteers for important tasks (i.e. applicant interviews, lit
searches, etc)
– Criticizes experience, concerned about how much time they are
putting in within the first week of the program
– Spends less and less time with other trainees and/or supervisors
– Lack of Competence (little or no therapy experience, no
assessment experience)
DISRUPTIVE BEHAVIORS
• Disruptive Behaviors
– Mildly manipulative behavior (gets others to do their work,
implies they do not recall certain conversations, etc)
– Shows up late for supervision
– Unprepared for didactics
– Unprepared for treatment with patients
– Encourages subgrouping and divisiveness among
intern/residents
– Interpersonal Difficulties (avoids relationships, focuses on own
projects, not a team player)
– Never attends social functions
AXIS I DISORDERS
• Axis I Disorders
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Difficult, but some are manageable
Have made it through a rigorous program
Has some strengths and compensatory strategies
Can be disruptive to others
Can lead to withdrawal or break in program
Poor performance may lead to dismissal
Substance Abuse
AXIS II DISORDERS
• Axis II Personality Disorders
– Passive Aggressive (i.e. misses didactics for dental/dr
appointments, uses copier for personal convenience, leaves work
early often)
– Dependent (overly dependent on others)
– Narcissistic (needs constant attention for the smallest of tasks or
acts out in other ways)
– Borderline (impassioned relationships with colleagues, looking
for intense support, ends up destroying any chance of
cohesiveness in trainee group)
– Avoidant (no desire for relationship with fellow trainees, cannot
connect with patients)
– Antisocial (substance abuse, walks off with textbooks, etc.)
AXIS II DISORDERS (cont.)
• Combination of Axis II and lack of
competence will usually be extremely
disruptive to the training program
UNUSUAL SITUATIONS
• Unusual Situations
– Pregnancy
– Death or serious illness of a child
– Death or serious illness of a close relative
– Death of a fellow trainee
– Serious illness
– Chronic medical condition
– Acute psychiatric difficulty
PURPOSES OF SUPERVISORY
EVALUATION
• Necessary to ensure that training
programs achieve educational objectives
and produce competent trainees
• Provide objective assessment of trainees’
competence and progress
• Summative assessment provides input for
decisions of warning, probation, or
dismissal
EVALUATION DIFFICULTIES
• Evaluation is an essential aspect of supervision
• Develop explicit standards and more uniform
•
expectations regarding the knowledge, skill, and
judgment necessary for practice
Clearer competencies and standards for verifying
the readiness of interns for practice
EVALUATION OF PERFORMANCE
BY SUPERVISORS
• Greater consensus on evaluation seems possible
•
through research and dialogue within the
profession.
A procedure for comparison of ratings across
supervisors may increase the reliability of
evaluation.
– Fosters consensual expectations and by exposing
personal biases.
Robner, W., Fuhrman, M., and Ristvedt, S. (1993) The
Clinical Psychologist, Vol 45, 1.
Guidelines for Supervision
• Expectation of meetings (format, frequency and content, missed
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meetings, etc)
Goals and outcomes of supervision
Establishing expectation of ongoing feedback including strengths
and areas of weakness (Both written and verbal feedback)
Supervisors have an ongoing awareness of the patients who
comprise the intern or postdoc’s caseload
Reviewing and signing co-signing all notes
Awareness of agency policies and procedures
Contact supervisor for input regarding all “at risk” patients
Supervisors are aware of and behave consistently with the Ethical
Priniciples
Supervisors are aware of the power differential that exists
Supervisors and intern or resident keeps supervision notes
IDENTIFICATION OF TRAINEES – USE OF
EVALUATION FORMS
DETAILED
EVALUATION FORM
DOCUMENTATION
• Orientation
– Evaluation Forms (Supervisee/Supervisor)
– Suggested Guidelines for Supervision
– Due Process/Grievance Documents
– Time/Activity Sheets
– Ethical/Problematic Situations
• Expectations of Behaviors (dating, interaction with
supervisors, attendance, professional
responsibilities
APPIC TRAINING RESOURCES
www.appic.org
• Training Resources
– By Subject
– For Trainers
– Reference Lists
SUPERVISOR EVALUATIONS
MONTHLY ACTIVITY SHEETS
• Hours of supervision
• Contact with diverse populations by
ethnicity/age
• Writing (Reports)
• Didactics
• Other professional activities
(consultations, library research, etc)
DUE PROCESS GUIDELINES
EUGHS
• 1) an inability and/or unwillingness to acquire
•
•
and integrate professional standards into one's
repertoire of professional behavior,
2) an inability to acquire professional skills in
order to reach an acceptable level of
competency, and/or
3) an inability to control personal stress,
psychological dysfunctions, and/or excessive
emotional reactions which interfere with
professional functioning.
DUE PROCESS DOCUMENTS – INFORMAL USE OF
GRIEVANCE PROCEDURE - UTMB
• 1. Informal
• a. After receiving an evaluation which a resident wishes to challenge, the resident
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should schedule an appointment with the supervisor issuing the Detailed and Frequent
monitoring, stating the reason for the appointment. The appointment with the
supervisor should be established within five working days following the official
evaluation appointment with the Training Director. In extenuating circumstances,
where it would be difficult or impossible for the resident or the faculty member to
schedule the appointment within the designated time limit, the appointment should be
scheduled as soon thereafter as possible, in no case exceeding ten working days
from the official date of the posting.
b. Should the issue fail to be resolved in the meeting with the faculty member to the
resident's satisfaction, the resident may request that a conference be scheduled with
the Training Director. The conference with the Training Director should be held within
three working days of the resident/faculty conference. The resident conference with
the Training Director will be held at such a time that the faculty member will be
available to participate in the conference. The Training Director shall render an opinion
regarding the resident's challenge of the evaluation within one working day of the
conference with the resident.
Up to this point, the grievance procedure has been informal with all information being
exchanged orally. This guideline should serve to facilitate open communication
between the faculty member and the resident without intimidating either party
involved. It is hoped that the majority of resident grievances will be resolved at the
informal level, with the inclusion of only the essential parties involved and preservation
of confidentiality as no formal documentation has been generated.
FORMAL GRIEVANCE PROCEDURE UTMB
• 2. Formal
• a. Should the Training Director rule in favor of the supervising
faculty member, the psychology resident has the right to appeal to
the Ad Hoc Student Grievance and Appeals Committee (the
Grievance Committee). The Grievance Committee is made up of four
training team members (one whom is appointed chair), none of
whom have had direct supervisory responsibility with the resident in
question. An outside member will also be appointed to the
committee with approval from the psychology resident and the
Director of Training. This appeal represents the initial step in the
Formal Grievance Procedure. The appeal of the grievance must be
submitted in writing by the resident to the Chairperson of the
Grievance Committee, stating clearly and concisely the
circumstances and particulars relating to the evaluation or
circumstance which initiated the grievance. The resident's written
report to the Chairperson of the Grievance Committee must be
submitted within five working days following the conference with
the Training Director. Failure to submit the report within the
designated time will nullify the resident's right to challenge the
evaluation in question which will stand as assigned.
OTHER DUE PROCESS AND
TRAINING DOCUMENTS
• APPIC Web site at www.appic.org
• Additional UTMB Web Examples
– https://www.utmb.edu/psychology
VIGNETTES
• Vignette #1
– The psychology intern has been slowly withdrawing
from their cohorts and you as the TD notice this.
When asked, her response is they just seem to be on
different wave lengths. You also are getting a couple
of complaints from patients that the psychology intern
is rude. She seems pleasant to you and has denied
this problem with patients and you acknowledge that
patients with chronic pain can be difficult to work
with. On further inquiry, the secretary in the office
notices that the psychology intern is very short with
her and other office personnel. What do you do?
VIGNETTES
• Vignette #2
– The psychology postdoc has very good clinical skills
and seems to have very good work habits the first 6
months. You have noticed that he is not taking much
initiative lately and seems to be slacking off. He has
begun looking depressed and lacks energy. This
problem was addressed 1 month ago but the number
of sick days have increased substantially and non
attendance at grand rounds and other functions has
become non existent. He always seems to have a
good excuse (dental appointment, need to see
physician, etc.). What do you do?
VIGNETTES
• Vignette #3
– The psychology intern is a quad that ambulates in a
motorized wheelchair. She is quite eccentric in her
dress (always extra nice) and has fingernails that
draw a lot of attention (extra long and ornate). She
also has several visible body piercings that she is
quite proud of and discusses the importance of her
individuality at length. Her skills are average and she
has an aide that helps with moving things around
(files, test protocols, etc). She has recently received
complaints about racing her wheelchair (going at fast
speeds) through the hallways of the rehab unit
sometimes startling patients. What do you do?
VIGNETTES
• Vignette #4
– The psychology postdoc has several research
projects going on and has not been very good
about following through on their
responsibilities. You are not sure if they are
overwhelmed, just a poor organizer or poor
research skills. What interventions might you
consider before it becomes a major problem?
VIGNETTES
•
Vignette #5
– The psychology intern has been unusually helpful during the year and has always
completed tasks in a reasonable fashion. He is very independent and you
sometimes wonder if they are expressing contempt for their colleagues and
supervisors. Several things have happened to initiate you taking a closer look:
– 1) An MMPI was returned by mail from the prison system and he claims the
hospital inmate had taken it while they must not have been looking.
– 2) One patient called to state dissatisfaction with the way she was treated by this
intern stating that the intern blew up and lashed out at her by tearing up her
MMPI and saying it was just worthless. He states that never happened.
– 3) The secretary went to lunch with him one day and reported to you, the
training director, that the intern had made disparaging remarks about the
program, the training director and one supervisor, stating the supervisor had
made sexual advances toward the intern. The intern and the secretary met with
the TD and the intern claimed they had never made those remarks, that
everything was fine.
How would you proceed?
REMEDIATION OPTIONS
• Remediation
– Informal Problem Resolution with Supervisor
– Contracts that spell out expectations
– Formal Sanctions (videotape all sessions,
coursework, etc.)
– Options
MANAGING DIFFICULT
TRAINEES
• Managing Difficult Students
APPIC Resources
Colleagues
Professional Organizations
Literature
RESOURCES
• Lamb, Presser, Pfost, Baum, Jackson, & Jarvis
•
(1987) Confronting Professional Impairment
During the Internship: Identification, Due
Process, and Remediation
Lamb, Cochran, and Jackson (1991) Training
and Organizational Issues Associated with
Identifying and Responding to Intern
Impairment
INFORMAL PROBLEM
RESOLUTION
• Dr. Nadine Kaslow
• Department of Psychiatry and Behavioral
Sciences
• Emory University School of Medicine