Supervising a Slow R1 soon to be R2...how to make him faster???

[siamesekat]

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Hi everyone,

Here's my dilemma....I'm a R2 the "senior" working in the psych ER. I work with a R1 who is my "junior." So, my attending that runs the show tells us the first day of the rotation that the junior will see and write up all the patients, the senior will supervise and does not have to see all the patients, and only if it is very busy (eg multiple patients come in all at one time) the senior should step in and help out in seeing patients.

Enter the slow R1 (mind you soon to be R2 in a few weeks). Very meticulous, obsessed with making writeups legible, detail orientated...maybe TOO much? but very very slow........to the point where patients pile up and I end up seeing the majority of the patients while he finishes up the writeup on previous patient. Initially, I thought that he was slow just because he wants to be very through, but now I really don't know. I'm beginning to suspect that he's slow deliberately. 😡Today, postcall he pretended that he was tired in order to get out of seeing a new patient. And its really getting on my nerves.

And the thing, is that I'm caught between a rock and a hard place. He's so slow that I need to pick up most of the slack otherwise things will never get done in the ER, yet he knows that he should be seeing most of the patients. But he makes comments to the effect where he expects me to carry the same if not more patients evaluated. Either he just doesn't get it or he is deliberately going by what he thinks is fair (ie we see the same number of patients.) I really want to tell him to shape up, it's a psych ER for crying out loud! It's not an inpatient unit, we are here to triage and dispo....quickly! This junior once spent 2 HOURS on one patient. 😱 His average is 1 hour a patient. And he just doesn't seem to get it that if more patients come in, well he needs to speed up. I am so frustrated, but if I tell him to hurry up or that he is supposed to see most of the patients, well...it would make me the bad cop and hated. And the bad thing is, if I just leave all the work for him to do, very little will be done and then, as the "senior" I'll be blamed for doing poor supervision/managing. How can you manage a stubborn cow? I don't want to make enemies, I just want the junior to make a genuine effort to be more efficient and fast in the ER.

I asked the attending to remind the junior of his responsibility to see the majority of the patients and that as the senior, I am under no obligation to see patients that he should be able to handle. But, my attending does not want to, and instead said that I should talk to him and gently but firming tell him the rules. The turtle doesn't like to be told what to do. (no one really does) ...and it doesn't help that I'm younger than he is.

I don't know what to do. Any suggestions? (Besides suck it up, deal with it, the guy is never going to change, he will always be slow, sucks to be you.....which is basically my conclusion at this point.) Sorry for the long post, I guess I need to vent. Thanks!!!!

 

[sunlioness]

Well, part of residency is also learning how to be in a position of authority and supervise others. So it sounds like you're getting a good lesson in how to do that.

If you haven't talked to the R1 about this and gently, but firmly laid out what the expectations are for this rotation and his work, I would do so. I would also say that I was not going to pick up the slack anymore because he needs to learn how to be efficient. And then stop picking up the slack. Definitely stay there and be a back-up and a resource (and this will probably mean that you'll end up staying later too), and make sure you have a general idea of what the patients' issues are so nothing acute is missed, but step back and let him do the work that is his to do.

Having said that, I don't think any resident should be expected to pick up new patients post-call. In my program, this was not done.

 

[Tradewind]

I have a few thoughts, but it sort of depends on the specifics...

What are the work hours for this rotation? Is it shift work, or on a call schedule? Are you in-house or at home? Has the volume been up? How many patients have there been in a shift (eg how many per hour), and how many have been unseen at any given time? Are the patients first seen by an Emergency room resident, or not? Do they get labs before you see them? Do you have a separate location in the ED for psychiatry patients? Is the attending not wanting confrontation, or is s/he thinking you ought to help out?

At first glance, I agree with Sunlionness that removing/distancing yourself from the situation makes sense to see how this resident works when he realizes he is going to have to do the work by himself. He may simply want to take longer for each patient, but plan to see all of them during his shift. You wouldn't know that if you only saw him for the first couple of hours.

It sounds like you're supporting him and being available for curbsides and emergencies via phone/beeper.

 

[siamesekat]

Thanks for both your replies. We work in a Psych ER...standalone facility with limited medical support (eg pt. stroking out, MI, bleeding send to ER stat). As psych residents we do the medical clearance. Work hours are 8 to 5 on the most part, no shift work. A whole 4 weeks at this rotation location, at 5 pm the oncall resident takes over for the night then signs off at 8 am.

In regards to pace and waiting to see patients later, the junior takes so long on one patient that as more come in, the new ones are not seen (another 2-3) so that I need to step in to see some (sometimes all the new ones) just so there is not backup. As the senior, from past experiences I like to keep the ER as clean as possible, which makes sense cuz you never know what will hit the door next. The pace of the ER is usually clean up from night before, very slow 2-4 in the am and then more in pm 5-6. So...technically the junior could see them all eventually in the day, but as I said he's really slow. The attending likes to see pts dispositioned and moved out of the ER fast.

So, if pts not moved out fast enough it looks bad on me. I've given the guy 2 weeks now to get his act together. First, I thought hey he's coming from another off rotation so he's getting back in the swing, and I gave sublte hints..but now, idk what to do. Standing back and letting him do all the work isn't really cutting it...unless I want to be blamed for the pile up of pt.

 

[Regnvejr]

I don't know what to do. Any suggestions? (Besides suck it up, deal with it, the guy is never going to change, he will always be slow, sucks to be you.....which is basically my conclusion at this point.) Sorry for the long post, I guess I need to vent. Thanks!!!!

Keep clarifying thei with the R1. Make sure it is clear that you have discussed this, and tried to make this work so the R1 meets obligations. Because somewhere, you as supervisor, will also be writing an evaluation.

Make it clear to the R1 that unless the work becomes up to par, you will be noting this in your evaluation. Then the R1 will either be angry (in which case it was deliberate) or panicky (in which case they need help and training instead).

 

[Tradewind]

Yeah, that's sticky...The best way to make yourself look good is to make the intern look good and show a good working relationship, which sounds challenging here.

Could you do the medical clearance (make sure no CVA, MI, etc..) and assess for psychiatric emergencies, then just wait for the intern to finish his detailed w/u's? An hour to completely wrap up a case isn't bad. You could give him a deadline (eg 3pm) for all the patients, so he has time to present the detailed cases to the attending who can then go home at a decent hour. Phrase it this way to the intern. He's gotta understand that the attending doesn't want to stick around until 8pm regularly to hear his presentations.

I agree, you shouldn't be taking on >50% of w/u's, or the attending may think the intern is doing a great job because his writeups are so thorough!

It sounds like the attending doesn't really care who does the work, s/he just wants it done. It's too bad s/he isn't able or willing to give you better tips on how to deal with this situation. Hopefully, it's only a couple more weeks.

 

[sunlioness]

Keep clarifying thei with the R1. Make sure it is clear that you have discussed this, and tried to make this work so the R1 meets obligations. Because somewhere, you as supervisor, will also be writing an evaluation.

And I would imagine that part of your evaluation in this rotation will be around your skills as a supervisor. I would not mark a resident highly in this skill if s/he avoided the responsibility of holding a junior accountable to his work. So you say you are afraid of "looking bad" if the work piles up, but you might want to consider that you are already "looking bad" because part of your task this rotation is to learn how to supervise those junior to you.

Your attending has already told you that you need to address this with the junior yourself. I would do so, if you have not already. And depending on how that goes, I might say to the attending, "Hey, I know you like a clean ER, but I am thinking of stepping back so the junior can learn to be more efficient. I don't think he's going to learn if I keep bailing him out like I am doing." And see what he says. Or even instead of asking the attending to step in and fix it for you, ask his advice for how YOU should handle the situation.

Good luck!

 

[strangeglove]

I agree with sunlioness that part of your responsibility as a senior (and what you are likely being evaluated on) is your ability to supervise junior residents. I would add that you can draw on your training as a psychotherapist (this is where these skills come in handy) to try to be directive with this junior resident while not coming across as punitive or judgmental. Validate that it is normal to have a hard time in the ED (which it is for most juniors, so try to remember your own experience at that stage). Acknowledge things that he is doing well (if there is nothing, then be creative). Then let him know about what he is doing wring while maintaining some neutrality about this, i.e. don't let on that you feel slighted by his actions (which comes across in your description of the situation). Most of all, manage your own anger and don't make him feel small. Otherwise you may find that you are perceived as the punitive father, or something like that. Think of how you might handle the borderline patient who acts out.

 

[fMRI]

Two ideas:

1. recommend that he focuses on psychoanalysis. (He will be able to spend years with his patients.)
2. print out this thread and give it to him. (If you can say it to us, you can say it to him.)

😀

 

[Ollie123]

Don't know much about the hierarchy involved here, but have plenty of experience dealing with slow-workers.

I'd approach him first, going straight to the higher-ups to complain without talking to him first is just...bad. I mean, if your supervisor felt you needed to do something better, would you rather he talk to you about it, or tell the chief of medicine "Wow, resident x is really bad at this, what do you think I should do about it?" Unless you are 100% convinced it is deliberate, I think he deserves the chance to shape up before talking to others.

As for him being older than you...that's his problem and if he gets pissed off he'll have to deal with it. If he works as slow as you say he is, he better get used to people younger than him ending up in charge of him because its probably going to be an issue for the rest of his career! Part of management is finding that careful balance between being enough of a jerk to make sure the work gets done, and nice enough that everyone still gets along. I might try to reframe it in a positive way....i.e. "You've been really thorough with all your reports and that's fantastic but its time to work on getting through the patients faster." Then talk about it, troubleshoot, come up with a game plan. Share a personal anecdote about something you struggled with. Again, it can be tricky to find balance since you need to make it clear it is a problem, while being nice and supportive, but not to the point where you come across as demeaning.

 

[whopper]

Whether or not this resident is of good qualit you still have to do your end of the deal & try to properly instruct this person.

In ER psychiatry, things like psychoanalytic treatment are moot. The bottom line most of the time is--is the person truly medically clear? Do the labs show any need for acute treatment? What is the chief complaint? Is the person commitable or not? If not--refer to outpatient or offer voluntary hospitalization (if appropriate). IF commitable--commit. In the meantime keep them stable.

Yeah there's exceptions, but that's the algorithm for most cases. You need to get this person to understand that.

How to do that? Carrot &/or stick. Carrot--you help the person, tell them what's expected, tell them what they need to improve upon. Ask the person to ask you for help if they don't understand why they aren't getting the job done faster. Stick--give them deadlines & minimum standards that need to be passed, and if not you need to let them know that the attending has to be made aware that they are significantly slow. My general approach was use carrot. Only use stick if you gave the person enough chances, and they still did not improve. 3 mistakes in the same exact thing without a justifiable reason why IMHO was enough for me to report what was going on to the attending.

After that, IMHO its in the attending's hands. Rules may differ in the program, but where I did training, residents did not have the power to call upon the program to initiate extra help of a person specific nature or to punish. Attendings are supposed to pick up the problem after it hits a certain extreme. If you've done your end, you need to report to the attending.

Do not enable. Don't fix messes for this person. You're there to teach them to do better, not do their job for them. However at the same time, double check yourself to make sure you're doing what's needed.

From my own perspective, when I did ER psychiatry as a PGY 1, no one explained to me that the people are their just for assessment & processing. The real treatment the'yre going to get will be inpatient or outpatient. I did keep up with the pace, but wasn't cognizant that they were going to get better treatment elsewhere. I eventually figured that out, but noticed other incoming PGY1s going through the same problem that took them about a few weeks to figure out as well. Several PGY1s for example would try to do psychotherapy on a patient they really were only supposed to see for about 20 minutes. To combat that problem, when I became chief, I wrote a manual that had a section that helped to explain these things.

On a tangent, I saw a resident while in my 2nd year who in her 4th year spent about 3-4 hrs on an H&P--a lame one at that, that would've taken me about 25 minutes to do. In fact my 20 minute H&Ps were better than her 4 hr ones.

 

[siamesekat]

thanks everyone for your suggestions....

I think that I'm gonna sit back and wait to see how the intern handles me not jumping on new cases....of course, I'll be there to help. I just think that people are inherently lazy, and well, if someone doesn't want to work no matter how many carrots or sticks you pull out...they will find some way to not work. Instead of getting angry about it....just go with the flow. If that means I have to work harder, well so be it.

I've run out of carrots....soon, it'll be time to bring in the big guns.

 

[kugel]

To combat that problem, when I became chief, I wrote a manual that had a section that helped to explain these things.

I hope you had it published. Where could one find that manual?

Could SDN (or some other forum that you know of) support a group project of producing a generic residents' manual for Psych Emerg Service, one for C/L, one for inpt psych, one for general clinic? Then each hospital/residency could add their own rules, local laws, shift report specifics, etc. Do you think such a thing could be produced using a Wiki format which allowed any "certified" user to alter/adjust the text?

I know, I know. I tend to think very broadly late at night. I get very idealistic and optimistic and think of these grand projects. ("Hey, kids! Let's put on a show!" for those of you who remember teenage Mickey Rooney movies.)
But every once in a great while it leads to a good idea.

 

[CaMD]

As an upcoming intern I would love such a manual. My med school's medicine department had an awesome manual an I wish psych had had the same.

I hope you had it published. Where could one find that manual?

Could SDN (or some other forum that you know of) support a group project of producing a generic residents' manual for Psych Emerg Service, one for C/L, one for inpt psych, one for general clinic? Then each hospital/residency could add their own rules, local laws, shift report specifics, etc. Do you think such a thing could be produced using a Wiki format which allowed any "certified" user to alter/adjust the text?

I know, I know. I tend to think very broadly late at night. I get very idealistic and optimistic and think of these grand projects. ("Hey, kids! Let's put on a show!" for those of you who remember teenage Mickey Rooney movies.)
But every once in a great while it leads to a good idea.

 

[whopper]

I hope you had it published. Where could one find that manual?

Its an in house thing becuase it was specifically geared towards dealing with the issues & questions a PGY 1 would have that culturally within my program--those things weren't being answered.

E.g. I thought of the most common questions I & several residents had that attendings weren't answering--and put it all in the manual, put in a section on the most common issues the resident would have to deal with depending on the rotation, and cheat sheets--e.g sample admission orders depending on the diagnosis, common pitfalls (e.g. don't order lithium & ibuprofen do together unless there's very good reasons).

I don't think that would apply to all programs since a lot of the things were program specific.

The APA however does have a residency training manual online that's available for download. I don't have the link on me offhand (though it has been put on this forum before). If no one has put it up within the next few hours to days I'll try to do so.

I went out of that way making that manual because I was sick & tired of seeing PGY1s go through the same exact problem each year, and then not seeing the attendings or senior residents try to answer those questions.

After it came out I received a lot of positive feedback. The year I released it, the residents were operating about 4-6 weeks ahead of what the previous classes were doing. I also received positive feedback the following year.

The only disappointment I had was I designed that thing to be upgraded each year. I had a meeting at the end of my stint and asked what changes should be made to the manual. I tallied them up, then told the program that they needed to add it themselves since I would only be chief for a few more weeks and things change. That was something several of them didn't want to seem to do. I also wanted to see future chiefs act as a type of editor-taking people's suggestions, filtering them, and making updates themselves. I don't know if that will happen, and would bet it wouldn't.
Its residency politics. There were few residents where I did training in psychiatry, and as a result, the chief often times was a lesser of evils. My chief my PGY 1 year was of little help, fouled up the call schedule big time, played favorites, and never would have gone out of her way to make a manual, while she complained about the same type of problems I tried to address when I made a manual.
There's certain issues that require constant maintenance by future generations. You can't change oil just once in a car. If its going to be handed down, they need to keep them up. So by the time my stint was ending as chief, I reminded people that the manual was only going to be as good as the residents that on their own decide to maintain it. I did the core work, all they had to do was once a year add a paragraph or 2 per section, or take away-which really would've only been about 2 hrs of work per year. I was also anticipating that since the hospital had gone through a major expansion, this would require some needed changes. Did they make any changes to the manual? I don't know.
Also, the then interim program director (he was temporary, it was the result of some major changes in the program. That problem was solved as I was leaving.) didn't seem to know what the heck he was doing, and despite me mentioning the manual to him a dozen times, I still don't think he even glanced through it once or even registered in his brain what I was saying. Every I mentioned it, he appeared to react as if he never heard of it. Fortunately someone took over that was very competent (in fact so much so that I was regretting leaving that hospital after graduation) so I am hoping she'll put pressure on future generations to upgrade the manual.

 

[235750]

thanks everyone for your suggestions....

I think that I'm gonna sit back and wait to see how the intern handles me not jumping on new cases....

Please, let us know how it goes. Every person who's ever had to pick up the slack of a coworker/classmate understands your pain

We're all pulling for you!

 

[whopper]

Mentioned I'd find the link....


http://www.psych.org/MainMenu/Educa...dentsguidetosurvivingpsychiatrictraining.aspx

 

[siamesekat]

As an update, I basically give up.

There were 3 patients that came in before 4 pm yesterday that still needed to be worked up, it was 3:40 pm and I had not seen the junior start to work on those patients, and still seemed to be moving at his usual pace. So, I reminded the junior that there was still quite a few pts left to be seen. I was then told that he cannot get to all those patients seen, it's already 4 pm. (he was aiming to leave by 5 pm.) "I'm doing you a favor seeing these patients." I was floored, and I decided at that moment.....I give up.

Postcall the next day, I was so mad at the junior because I had gotten no sleep overnight and when the knowledge that work had to be done, he proceeded to sit nearby working on his personal business, as if he did not have to work as he finished his pt. notes. No teamwork, and no sense of accountability/responsibility to see patients.

 

[Doctor Bagel]

As an update, I basically give up.

There were 3 patients that came in before 4 pm yesterday that still needed to be worked up, it was 3:40 pm and I had not seen the junior start to work on those patients, and still seemed to be moving at his usual pace. So, I reminded the junior that there was still quite a few pts left to be seen. I was then told that he cannot get to all those patients seen, it's already 4 pm. (he was aiming to leave by 5 pm.) "I'm doing you a favor seeing these patients." I was floored, and I decided at that moment.....I give up.

Postcall the next day, I was so mad at the junior because I had gotten no sleep overnight and when the knowledge that work had to be done, he proceeded to sit nearby working on his personal business, as if he did not have to work as he finished his pt. notes. No teamwork, and no sense of accountability/responsibility to see patients.

What did you say back to him when he said that? Maybe he's lazy, but maybe he's actually forgotten that talk on the first day that said it was his primary responsibility to see all the patients. It sounds like he needs some explicit reminding of his responsibility, which will give him less room to worm out of stuff.

As for the being older thing, I'm kind of concerned by that comment. I'm older than most residents and would be worried if my superiors were troubled by giving me feedback because of that. Most of the nontrads I know don't come in with a superior attitude and really do value feedback from people ahead of us.

 

[whopper]

At this point its up to the attendings & program director.

Senior residents can only go so far.

 

[billypilgrim37]

To be fair, if your intern class has only one lazy, personality disordered individual, your program ain't doin so bad.

 

[whopper]

if your intern class has only one lazy, personality disordered individual, your program ain't doin so bad.

Funny because its true.

Its interesting to see a resident with a cluster B personality DO get mad at a patient for having a cluster B personality DO.

Actually I find that funny & very sad at the same time.

 

[siamesekat]

At this point its up to the attendings & program director.

Senior residents can only go so far.

exactly.

well, this guy is highly educated, the kind where it makes my MD look like I'm stupid or something. So, it really is not a matter of his "forgeting" or "not comprehending" first day instructions by the attending, it really is all about him not caring crap about them. And the whole older thing, well...I never said ALL nontraditional residents have bad attitudes/work ethic...I would have an equally hard time telling somone my own age....I just don't like being known as the bitch or the bad guy, and really no one does.

I just really hoped that by this point in the game, one would own up and realise that it's not a game of how much work can I get away with NOT doing, but really it is about becoming the best doctor you can be which involves doing your JOB correctly and willingly without having someone prod and nag you. We aren't kids, for crying out loud! Man up! grrrrr

 

[whopper]

There's a nontraditional student in my wife's counseling master's program that is in his 70s and well let's just say that his older age has given him a sense of entitlement that is upsetting several around him.

Tell your attendings your concerns, what you've tried to do to help the guy, what he's messing up with, and ask them if there's anything else you can do. From there, its up to them. If you have concerns that they aren't doing enough, try to address your comments in a manner where there's transparency, however at the same time in a manner that respects privacy. E.g. tell your senior resident as well, or address the issue to 2 people at the same time, (e.g. an attending & the PD or the PD & the coordinator.)

Remember, you're a professional. Your complaints go up, not down or around. Don't complain to fellow or junior residents so much about the problem, but do address it to seniors.

I've had several of my own concerns that I brought up to attendings when I was Chief, and gave my recommendations. If they didn't follow it, and then the dung hit the fan a few weeks later that could've otherwise been avoided, hey, not my fault, I addressed the issue, gave my recommendation (several of which I would've done the extra work to make it happen, and made this known that I would do it), and if it wasn't followed, and an error happened as a result I had plenty of witnesses.