Preparing program directors to address unprofessional behavior

Abstract

All medical educators will inevitably need to manage challenging trainees. Even one "difficult" resident or medical student can wreak havoc on an educational environment. Program directors must manage this maelstrom and as a result tend to experience especially high levels of distress in relation to difficult trainees. Frustrated and resentful, they often feel "deskilled" or ill- prepared to manage these unwelcome challenges. In this chapter, the authors provide a framework for understanding and working with this group of trainees and the problems they engender. The practical strategies that flow from this framework allow program leaders to develop realistic expectations and informed management approaches in relation to the predictable problems that arise in relation to difficult trainees. The authors further provide definitions of personality traits and personality disorders as a means of offering an explanation of how certain residents might pose problems in various aspects of training, and how to distinguish between those likely to do well with effective intervention and those likely to do poorly. Case vignettes illustrate examples of how maladaptive personality traits, across a range of severity, might manifest in a resident's behavior. Finally, the authors provide an outline for how to approach an intervention with a resident exhibiting problematic behavior, including recommendations for managing the difficult aspects of the experience for the program director, communicating effectively with the resident, collaborating with faculty, and supporting other trainees.