“How can I handle a difficult resident in my program?” asked a newly-appointed Chief Resident at a recent Leadership Forum for Chief Residents in Ophthalmology.

Learning how to create positive resolutions with a problem resident or fellow can change the direction of their career, according to Anthony Arnold, M.D., Program Director of the Jules Stein Eye Institute at UCLA. It can also enhance the quality of your own career, and strengthen your program overall.
Dr. Arnold conducted a workshop at the Leadership Forum on dealing with problem residents. While he noted that he was approaching the subject from a Program Director’s point of view, he made it clear to the new Chiefs that their participation in creating solutions was of vital importance.
Problems with residents can arise in four general categories:
•    knowledge-base
•    clinical competence and judgment
•    surgical skills
•    professionalism

Dr. Arnold recommended that by establishing and implementing certain key actions, you, as Chief Resident, can keep these problems under control.  These steps are :
•    outline your expectations clearly at the beginning of the year
•    document any deficiencies
•    provide timely counseling
•    provide appropriate remedial training quickly
•    follow up on your actions
•    initiate academic actions if necessary

Outline expectations
“Your goals and objectives for the year should be provided to your residents as a written document when they join the program,” Dr. Arnold advised the Chief Residents.

“Your written  document should cover both the overall program and specifics on each rotation. It should be extremely detailed and should outline the specific requirements for advancement in the areas of knowledge-base, clinical competency and judgment, surgical skills, and professionalism,” he said.

“Then, remember to consistently reinforce your message with personal contact,” he added. “Residents should understand that their contract renewal is not automatic.”

The best way to prevent the necessity of dealing with a problem resident is to preempt the problem from the start.  A proactive approach to expectation medical management is the best way to accomplish this sometime tricky task.

Communicating and explaining the measurements for success is critical to making your program work. As a Chief Resident, you should expect the highest level of professional behavior from the residents in the following areas:
•    honesty and integrity
•    compassion for others
•    advocating for the patient in the physician/patient relationship
•    interpersonal relationships with families, support staff, other residents
•    ethical decision-making
•    proper personal hygiene
•    attendance, punctuality, work volume
•    acceptance of responsibility, particularly on-call response
•    compliance with institutional policies, i.e. records and licensing
•    collaboration – understanding limitations

Document Deficiencies
Dr. Arnold gave some practical practice managment advise to Chief Residents to provide written rotation evaluations and follow up with oral communications on any deficiencies noted. He suggested that Chiefs review the OKAP/in-service written examination results and seek faculty feedback on the resident’s surgical skills. It’s also important to document conference attendance, incident reports, medical records issues, clinical volume issues and licensing issues.

Provide Timely Informal Counseling
Early problems or isolated incidents can be handled informally (Level 1)  according to Dr. Arnold. Examples of this could include tardiness, poor surgical preparation, lack of response to calls or consultation requests. Timely, in person counseling may often be sufficient, and remedial actions should initially be educational rather than punitive – the resident should re-do the call or consultation. At this stage, it remains optional as to whether an official written entry should be put into the resident’s file.

“What about home and family problems?” one of the Chiefs asked. “I don’t want to punish someone for having personal problems.”

Dr. Arnold believes that a proactive approach is best in this situation. As a Chief, you should be aware of your resident’s personal or family problems that might affect their work. Get to know them as people with family, friends and a life outside the training program.  Meet with the resident and try to work out a solution before a crisis develops.

“What about two residents who just don’t get along? asked another.

According to Dr. Arnold, it’s generally not advisable  to get too involved in other people’s personal differences. Your role as Chief is to be a role model – set the standards for appropriate behavior and make your expectations clear.  And communicate them consistently and frequently.

“Will I need a lawyer if I find myself dealing with a serious problem?” asked another Chief.

The best legal protection and insulation from liability is always a commitment to thorough and ongoing documentation of potential problem situations.  This “dedication to documentation” is crucial at all stages of resolving a problem with a resident, according to Dr. Arnold. Dismissal from a program is serious, for all involved, especially the resident.  If a legal action is brought upon your employer full and complete documentation of an ongoing problem will prove invaluable.

Formal Academic Actions
More serious, or repeated problems demand  a frank and candid one-on-one meeting with the resident. The deficiency should  be identified and documented, the method of correction and it’s timeline defined, and the consequences of noncompliance specified. All parties’ signatures are required and remedial training assigned if indicated should be implemented.

Major deficiencies can lead to an escalating series of academic actions, including a Letter of Counseling (Level II), Notice of Concern (Level III), Probation (Level IV), Suspension (Level V), Non-renewal of Contract (Level VI), and Dismissal (Level VII).

Remedial Training
The timing of remedial training might vary from during rotations, to replacing an elective, to using vacation time, escalating  to repeating a rotation after the rest of the class has graduated, or even repeating an entire year.

As Chief, you should be sure, at the beginning of the year, that residents understand the implications of formal academic actions and remedial training. These actions can seriously affect future letters of recommendation, including those for Board eligibility, credentialing and future employment. Post-residency fellowship eligibility may be delayed or denied. The overall reputation of the residency program itself can be adversely affected.  These are all compelling justifications for following the core principles of defining expectations, ongoing communications, and a dedication to documentation, since there is a lot at stake when problem resident situations reach this level,

Remedial training itself can consist of supervised reading and tutorials, supervised clinical activities, increased surgery supervision, and additional supervised emergency experience.

What Can Chief Residents Do?
Be proactive, Dr. Arnold advised the Chief Residents. Outline your expectations in writing at the beginning of the year and be sure that the residents understand what’s expected of them. When you become aware of deficiencies, identify and document them and bring them to the attention of the resident. Provide timely counseling and remedial training, and follow-up diligently.

A central responsibility of your job as Chief is to recognize problems early and bring them to the attention of the faculty. Although some of the Chiefs expressed concern about being seen as a “snitch”,  Dr. Arnold reminded them that a Program Director will not be pleased at being blindsided and surprised if a major crisis develops without his prior knowledge. Chiefs should recognize that their goal is to improve the deficient behavior in the resident and to maintain the high standards of their program.

Scrupulous documentation is essential to the fairness and clarity of the process, Dr. Arnold stressed.  As Chief Resident, you must take this responsibility seriously, right from the start, even with minor transgressions such as tardiness. This vigilant and consistent approach to documentation will establish the standards of your program clearly to all residents and other stakeholders. Just as importantly, it sets the framework within which you and your residents will  develop and execute  solutions that ultimately benefit and assist the problem resident and ultimately strengthen your program as a whole.

About the Author:

Wesley D. Millican, MBA, CEO and Physician Talent Officer of CareerPhysician Advisors, LP, and CareerPhysician, LLC, provides comprehensive talent solutions for academic children’s hospitals, colleges of medicine and academic medical centers across the nation. He possesses a longstanding passion for career development of all young physicians and serves as a go to career resource for training program directors and their residents and fellows. In continuing his commitment to the “future of medicine”, Mr. Millican speaks nationally at residency and fellowship programs. His Launch Your Career® Series is a proven resource for today’s residents and fellows and has served as a go to resource for program directors over the last 15 years.