What I Wish I Knew - Managing Difficult Situations With Learners

Bridgette Gleisner, PharmD, BCPP

Dr. Bridgette Gleisner is a Clinical Pharmacy Specialist in Internal Medicine and Psychiatry at Beth Israel Deaconess Medical Center (BIDMC) in Boston, MA. She received her PharmD from the University of Maryland School of Pharmacy and completed her PGY1 Pharmacy Practice Residency at Conemaugh Memorial Medical Center and PGY2 Psychiatric Pharmacy Residency at Fulton State Hospital. Dr. Gleisner is a Board-Certified Psychiatric Pharmacist (BCPP) and an active member of the American Academy of Psychiatric Pharmacists (AAPP). Throughout her career, Dr. Gleisner has learned to navigate difficult situations that arise with learners and has helped create institutional guidelines to help other pharmacists navigate these situations. 

Credit to Dr. Clint Ross PharmD, BCPP as well who previously provided input to this article

Despite strong training, new psychiatric pharmacists will encounter challenging learners throughout their career. Each trainee on rotation presents with various levels of baseline knowledge, clinical reasoning, and aptitude that can result in a multitude of unique scenarios. While stories of challenging trainee scenarios can be attention-grabbing, it is better to focus on ways to prevent or mitigate problems on rotation from the beginning.

Guidelines to Prevent Rotation Problems:

  1. Establish clear expectations from Day 1 (or before)
    1. Anecdotally, most problems on rotation are related to unmet expectations. Despite what may seem obvious to a preceptor, trainees may not be aware of your expectations. For instance, if a rotation doesn’t allow students (or potentially residents) to make recommendations prior to preceptor approval, make that clear early on through a document such as a syllabus supplement or “Top 10 Rules” (see below). Additionally, if appropriate, make the consequences clear. For example, “Plagiarism (of any kind or level) will not be tolerated. Your work is always expected to be your own. If it is not, this is grounds for immediate failure/dismissal from the rotation. If you are ever unsure if your work could be considered plagiarism, ask for help”.
    2. Take-home tip:
      1. Create a “Top 10 Rules” document for your rotation and have trainees review and sign on day 1. This proved useful when a student did not follow the required dress code and was sent home early. Their school was also notified of a professionalism violation.
  2. Always provide direct, specific, and timely feedback
    1. Despite how busy preceptors are, it is crucial to provide feedback quickly and clearly. Rotations are short, and if you don’t address things as they come up, trainees will likely continue to behave or perform similarly throughout the rotation. Feedback should occur before the trainee is formally evaluated, allowing the trainee time to correct the behavior or improve their performance before the end of the rotation. For instance, if a trainee’s “assertiveness” is argumentative or aggressive, it is more helpful to professionally and privately correct that in the moment than it is to become a surprise on a midpoint or final evaluation. At times this can be uncomfortable, but it will save a lot of trouble later!
    2. Take-home tip:
      1. Create a calendar reminder for “Feedback Friday.” In-the-moment verbal feedback is beneficial, but can be too rushed to allow trainees to comprehend it in the scope of the rotation. Frequently scheduled sessions with specific examples allow trainees to self-evaluate and receive timely formative feedback to improve their performance. This practice helped when I had a struggling student who was underperforming. I had documented feedback and strategies to improve in key areas. At the final evaluation, the learner did not implement the discussed areas of improvement, and I was able to justify their failing grade to the school.
  3. Make a habit of self-evaluating and requesting feedback
    1. Incorporate regular self-evaluation into the rotation strengthens teaching skills and models professional communication for trainees. Additionally, it can be helpful to ask trainees at the beginning of rotation about characteristics of their most/least effective preceptors (anonymously).
    2. Take-home tip:
      1. Immediately following your feedback sessions with trainees, make a habit of verbally providing your own self-evaluation — what is going well and what you plan to change — then asking your trainee for feedback on your performance. I first encountered this during my residency, where my preceptor asked for feedback weekly regarding the rotation and the preceptor. I found this practice developed my ability to assess different aspects of a rotation and help the preceptor adapt the rotation as necessary.
  4. Be willing to ask for help
    1. Some of the most challenging rotation situations occur when a preceptor cannot pinpoint the problem with a trainee’s performance or behavior. For instance, students who perform at drastically varying levels on different days, residents who can’t seem to recall any previously-discussed information, or a trainee becoming tearful when the situation doesn’t seem to warrant it. This can be for any number of reasons. When needed, asking for help from available resources (e.g., mentors, experiential departments at the school) can often assist you and the trainee in progressing rather than risking failure. If the issue is particularly confusing or concerning, asking “Is there anything else I should be aware of that might be preventing you from performing your best on this rotation?” can be helpful while waiting for assistance.
    2. Take-home tip:
      1. Identify your support resources early - experienced preceptors, school contacts, rotation coordinators, or studen health. Keeping this list accessible allows quick guidance when concerns arise. Over the past few years, I have come in contact with students struggling with their own mental health, anxiety regarding next steps, and long commutes (sometimes upwards of two hours). A key strategy that has been beneficial is setting clear expectations regarding available resources and the benefit of transparency.
  5. Documentation is everything
    1. Pharmacists get tired of hearing it, but documentation is critical. When you are faced with providing a low or potentially failing grade, you must have documentation to justify it. Particularly given how busy preceptors can be, a method for efficiently collecting this is necessary.
    2. Take-home tip:
      1. Create a de-identified physical or electronic document to take notes daily on your trainee’s performance. Small notes by date can help you keep up with progress, provide meaningful “Feedback Friday” sessions, complete your formal evaluations, and justify any grade/score that comes into question. As a preceptor, the most important thing is to keep track of progress, even for a learner who is excelling. Having a list of examples regarding performance is key for both residency applications and grade justification.