Time and again, psychological studies show that one of the main differences between weak and strong students is metacognition (a student’s awareness of his or her level of understanding). Good students know when they have mastered material, but weaker students tend to be grossly overconfident.
Among medical residents, this can certainly be a problem for those struggling to keep up with the pace of clinical duties, daily learning of knowledge and skills, and a myriad of other responsibilities. A new resident coaching model is emerging in residency programs to help these aspiring doctors improve quickly in their training. In the following Q&A with Roy Phitayakorn, MD, I explore the reasons why residents might be having problems and what the mentoring model can do to help.
Dr. Roy Phitayakorn is a general and endocrine surgeon and the Director of Surgical Education Research at Massachusetts General Hospital and an Assistant Professor of Surgery at Harvard Medical School. He is also the Education R&D consultant to NEJM Group.
Josette Akresh-Gonzales: In an article called “Why we overestimate our competence” on the American Psychological Association blog, Cornell University social psychologist David Dunning, PhD, reports that “the least competent performers inflate their abilities the most…[and] the reason for the overinflation seems to be ignorance, not arrogance.” Does this finding apply to resident physicians? If so, what are some ways that residents can become more aware of their need to improve?
Roy Phitayakorn, MD: Resident physicians are under enormous competing pressures with little or no feedback on their actual performance. Sometimes the feedback they do receive is contradictory, so they are uncertain if they really need to improve in a certain cognitive/behavioral domain or not. Therefore, I think the best way for residents to improve is to look at their data as a whole and spend some time doing guided reflection with a coach or mentor on what the data show exactly and how or what they want to improve.
JAG: What are some of the other factors that contribute to a resident failing an in-training or board certification exam, say, or not meeting expectations in clinical tasks?
RP: One approach to classifying resident deficiencies is the KSA approach — Knowledge, Skills, and Attitude. Let’s take them one at a time: Residents’ performance deficits on knowledge-based assessments may be a result of their not prioritizing time to study, studying incorrect materials, or poor test-taking skills.
Skill deficits, such as problems with doing certain clinical procedures, may require more effective practice time as well as expert feedback to accelerate learning of new skills.
Attitude issues may stem from psychological well-being challenges such as burnout. In my opinion, attitude issues are the most difficult ones to address — and are so often the most ignored within a residency program until a critical issue gains the attention of the patient safety group or the hospital’s medicolegal team. Of course, medical problems such as hypothyroidism or attention-deficit disorder may also cause issues in any of these domains and should be ruled out early.
JAG: Can you discuss the recent trend to assign mentors or coaches to struggling residents?
RP: We recognize that all physicians, residents and attendings, benefit from mentorship and coaching. Unfortunately, the ones who need it most are often unsure about how to find a mentor or coach to help them. Therefore, many residency programs have started assigning all resident physicians a mentor and/or coach to help them navigate their development into caring, highly-skilled physicians.
These programs often consist of regular meetings where the residents will review their evaluation data with their mentor/coach and create an action plan about what they would like to improve before their next meeting. NEJM Knowledge+ is a great way to receive objective data about how a resident’s cognitive knowledge is developing and could be used for remediation as well.
JAG: Yes, in fact, program directors have access to numerous reports in NEJM Knowledge+ showing residents’ progress through the learning material and their performance in specific topic areas. Do you think a resident coach can also help to improve a learner’s self-awareness over time?
RP: Metacognition is difficult to develop without both objective data, feedback, and a willingness on the resident’s part to change. I think emotional intelligence is a hidden piece to some of that willingness to accept feedback and change behaviors that do not reconcile with objective data. Regular assessment and development of emotional intelligence is standard practice in many industries except medicine. Hopefully we will catch up someday as more research is published in this area.
JAG: Can you recommend good resources for coaching residents in general and coaching them on self-awareness in particular?
RP: The first thing I’d suggest is to look to working resident coaching and mentoring programs as a model, such as the one at Massachusetts General Hospital (MGH): MGH Internal Medicine Professional Development Coaching Program. There, “Each trained volunteer faculty member coaches two to three residents and remains their coach for their entire residency. All residents are included in the coaching program. Interns and faculty meet quarterly, usually for an hour each quarter.”
And at Stanford School of Medicine, the Stanford Pediatric Residency’s Coaching Initiative provides “longitudinal assessment and feedback to residents throughout their training, and to help residents develop skills of lifelong learning and self-reflection. Each resident is assigned a specific Faculty Coach who observes and guides that resident across multiple rotations, inpatient and outpatient settings, and training years. The Coach observes the resident in multiple clinical situations (rounds, clinic, initial H&P, handoffs, supervisory encounters, care conferences, and others) and provides specific and directed feedback aimed at strengthening clinical skills.”
Another resource is this slide set provided by the Massachusetts Medical Society, entitled “Physician Coaching and Mentoring Programs: Surviving the Tsunami of Change,” Presented by Susan F. Reynolds, MD, PhD., President and CEO of The Institute for Medical Leadership, to the Massachusetts Medical Society’s Physician Leadership Institute, on February 1, 2012. It includes information on setting up a trusting relationship between coach and resident, and using goal setting and accurate data to drive ongoing conversations. Here’s a sample piece of advice from that presentation:
Best Physician Coaching Strategies
- Listen/Build Rapport/Trust – in person meetings
- Identify resistance issues (e.g. past training, law suits)
- Define clear coaching goals and timeline
- Emphasize patient safety and quality of care (motivators)
- Accept that cost savings may not be a motivator
- Give timely feedback
- Avoid email except for scheduling meetings
- Give Rewards!
Have you participated in a mentorship or resident coaching program at your residency? If so, how did it work and did you find it helpful?
I can see, that Residents, are practically alone, without supervision in many Universities and Teaching Hospitals and Clinics., practically asking for supervision.Residents , are in those places, only Working Force, and they fill all the needs and vacancies , doing their work,without the necessary feed-back that they need, because , , they are still Drs in Training, looking for to achieve an Speciality, and they are doing his/her job, in the best way they suspect, but without the guide of an skilled Physician, , who always must check the work they are doing
This is not the idea , because they are still preparing to obtain all the good experience needed and someone must give them the right evaluation they need, including critics about the performance they are realizing, and their instructor must always be present
I think feedback has to be balanced with the learner’s needs and goals at heart. Sometimes feedback from continuous supervision is not what the resident needs to learn and grow as a physician. It is definitely not an easy process!
I was thought that there are 4 levels of competency.
1. Unconsciously Incompetent
2. Consciously Incompetent
3. Consciously Competent
4. Unconsciously Competent
I agree that attitude is the most difficult challenge to correct as in #1. Irregardless, everyone needs mentoring. Attitude is not everything. Residency training is work & work is equal to force x distance. You have to go above & beyond the call of duty. Go the distance!
In other aspects, knowledge based assessment requires mentoring a resident on how to study & how to take a test.
Skills are learned by mastering the right technique and repeated practice.
Being agree in general , about differences between students and the necessity of always addressed by an Mentor , that must check all kind of knowledges and Skills when Residency is starting and after, to check again the progress of that students .Obviously, the mentor must advise to the Student, looking for him/her, can obtain (and how and where) all the knowledges, Skills and Psychological Maturation to be a good physician and being able to handle with good outcomes all the Prevalent Diseases and Syndromes, in the many ways that they can present.
I think, that is an oversimplification about the levels of competence = It is impossible that no one Resident, can not be aware of the level and limits of his/Her competence..That statement, would say that the Resident , has limitations in the level of his intelligence :The problem, goes by other side=Resident with Competence Limitation, for many reazons, they don´t do what they must to do(to study-to look for advise-to work harder)A Dr, that has limitations in competence, frequently will be facing problems with Patients and Drs.Besides this, he will be a serious problem for the integrity of patients .and will be a real threat
I think it depends on the goals and objectives the resident is ultimately trying to achieve. Competency is very difficult to assess as it implies expertise in all situations. In education research, proficiency in knowledge and skills is a more realistic assessment target and has ultimately led to the entrustable professional activities movement. A coach or mentor can be very valuable and help a resident realize when their performance is not at expected proficiency levels and also give advice on how to improve. Now we just need more formal coaching/mentoring programs as part of our routine faculty development!
I think , that a Resident, must be able to handle all cases of Prevalent Diseases and Syndromes, and this must do it , in all with the many ways, these Prevalent Diseases and Syndromes can present to Physicians.It is important, to rule out all rare disorders or very less frequent diseases and Syndromes..
EX in MI, you can have many different types of presentation=
1)Typical MI, with Chest Pain, positive ECG and High levels of Troponin and others enzymes
2)Atypical MI= only with pain in the left arm
3)Posterior Wall MI=with pain specially in Epigastrium
4)MI, with cardyogenic Shock
5)MI,silent, how happen in Diabetics
6)Non STEMI MI
7)Non-Q MI
Etc Etc .There are more types,But I hope to present my point. So, Medical School, must prepare their Program, taking this Diseases-Sydromes in consideration..THe same, must be considered for all specialties.Complex medical problems and less frequent disorders, one will learn in the future, when you have more experience