Competency Problems: Managing Performance

Slide 1:Competency Problems: Managing Performance, Attitudinal, Ethical, and Legal Issues with Interns and Postdoctoral Fellows

Nadine Kaslow, Ph.D., ABPP, APPIC Past-ChairJeff Baker, Ph.D., ABPP, APPIC Vice-Chair/CoA Rep Mona Koppel Mitnick, JD, APPIC Public Member

Slide 2:ACKNOWLEDGE PROBLEM STUDENT WORKGROUP

Nadine Kaslow, Ph.D. Sue Jacobs, Ph.D Nancy Rubin, Ph.D. David Miller Stephen Behnke, Ph.D. Laurie Mintz, Ph.D. Sherry Benton, Ph.D. Victor Pantesco, Ph.D. Steve Dollinger, Ph.D. Rebecca Schwartz-Mette Nancy Elman, Ph.D. Craig Shealey, Ph.D. Linda Forrest, Ph.D. Beverly Thorn, Ph.D. Catherine Grus, Ph.D. Barbara Van Horne, Ph.D. Steven Huprich, Ph.D. Kristi Van Sickle

Slide 3:GUIDING PRINCIPLE #1

Define key terms (competence, competencies, capability, impairment, benchmarks), establish benchmarks for performance, and develop a categorization schema

Slide 4:COMPETENCE

Personal ability, adequacy, capability, capacity, efficacy, efficiency, and proficiency

Slide 5:COMPETENCE

Habitual and judicious use of communication, knowledge, technical skills, reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served that involves habits of mind, critical thinking and analysis, professional judgment in assessing situations and ascertaining appropriate responses, and evaluating and modifying decisions via reflective practice (Epstein & Hundert, 2002)

Slide 6:COMPETENCIES

Knowledge, skills, and attitudes, and their integration Correlate with performance Can be enhanced through training and development Knowledge Skills Attitudes

Slide 7:CAPABILITY

Extent to which individuals can adapt their skills, generate new knowledge, improve their performance, and engage in life-long learning Fraser & Greenhalgh, 2001

Slide 8:IMPAIRMENT

Historically, has described interference in professional functioning associated with substance use, mental illness, or personal conflict

Slide 9:IMPAIRMENT

Recently, characterized as a condition that interferes with professional functioning to the extent it negatively impacts clients/patients or makes effective service delivery impossible APA Board of Professional Affairs Committee on Colleague Assistance, 2006

Slide 10:IMPAIRMENT

Impairment has a specific meaning in the context of the ADA (medical or mental health disability) and thus legal implications ensue for its use Some trainees with competence problems also have impairments according to the ADA

Slide 11:BENCHMARKS

Reflect standard for measurement of performance that can be used for comparison and to identify where needs for improvement exist Connote task or performance indicators Can capture minimal level of each competency for each stage of professional development

Slide 12:COMPETENCE PROBLEMS

Indicate interference in professional functioning Can be observed though maladaptive patterns of behavior or performance or via critical incidents May occur when performance fails to meet expected benchmarks, repeat patterns of mistakes occur, or as acquired incompetence or impairment in the form of diminished functioning

Slide 13:COMPETENCE PROBLEMS

Can be categorized based on Origin (situational, developmental, problematic personality and interpersonal dynamics) Severity and chronicity Potential for remediation Manifestation

Slide 14:COMPETENCE PROBLEMS

May be exhibited when individuals Do not have adequate training, education, or experience opportunities Are unable to acquire professional skills and reach an accepted level of competency (performance problem) Are unable or unwilling to acquire and integrate professional standards into their behavior Fail to respond to feedback or remediation efforts Do not continuously grow, change, or make progress

Slide 15:COMPETENCE PROBLEMS

May be exhibited when individuals Lack self-awareness with regard to weaknesses Have problems with professionalism and/or interpersonal interactions Exhibit prejudicial attitudes and values Lack high levels of integrity Have personal problems, emotional reactions, or distress that they are unable to control and that affect their professional functioning (conduct or emotional problem)

Slide 16:COMPETENCE PROBLEMS

Insufficient professional competence can be manifested in foundational competencies, such as Errors in judgment, ethicality, and professionalism (e.g., boundary violations) Maladaptive interpersonal attributes Problematic character or fitness Lack of self-awareness of areas of weakness Lack of progress toward achieving benchmarks Lack of response to feedback

Slide 17:COMPETENCE PROBLEMS

Insufficient professional competence can be manifested in functional competencies, such that people do not exhibit the expected level of knowledge, skills, and attitudes in one or more domains

Slide 18:PERSONAL RISK FACTORS

History of childhood trauma Substance use disorders Major Axis I disorder Axis II disorder Interpersonal insensitivity History of parentification Wounded healer False self Difficulties with attachment and separation-individuation

Slide 19:PROFESSIONAL RISK FACTORS

Prejudicial attitudes and values Difficulties managing multiple roles The role requirement for heightened sensitivity to people and the environment Isolation in the work place Vicarious traumatization and compassion fatigue Lack of time for self-care Limited capacity for self-reflection and self-assessment

Slide 20:COMPETENCE PROBLEMS

Do not include a trainee�s behavior, attitudes, or characteristics that are developmentally normative, such as: Transition issues Mild performance anxiety Mild discomfort with diverse client groups Initial lack of understanding of the facility�s norms Lack of certain skills sets, but an openness and readiness to acquire them

Slide 21:CONTEXT

Identification of a trainee�s behavior as reflecting competence problems needs to take the context into account Key to assess if trainee difficulties reflect a mismatch between the: Philosophy of the site and the trainee�s orientation Skills and competencies of the trainee and the demands of the site

Slide 22:CONTEXTUAL FACTORS

Contextual factors in the life of the trainee need to be considered: Adjustment issues to new setting (not site) Adjustment to new site Separate from established support systems Status change Personal life events/changes When the aforementioned issues appear salient, Suggest options for better stress management and self-care Provide more support to the trainee

Slide 23:GUIDING PRINCIPLE #2

Prepare the system so that decision-makers undertake appropriate assessment processes and make and communicate assessment decisions

Slide 24:CHALLENGES IN EVALUATING TRAINEES (Gizara & Forest, 2004: Robiner, 1993)

Definition and Measurement Issues Lack of clear criteria and objective measures of and competence problems Supervisor awareness of subjectivity inherent in evaluation Apprehension about defending evaluations due to lack of clear criteria and objective measures

Slide 25:EVALUATION CHALLENGES

Legal and Administrative Issues Concern that negative evaluations may result in administrative inquiry, audit, grievance, or litigation Lack awareness of internship/residency or institutional policies and procedures involved in negative evaluations Concern about lack of support from administrators and colleagues Concern that failing to �pass� an intern/resident may result in loss of future training funds or slots or the need to find additional funds to extend the trainee�s training Concern that failing to �pass� an intern/resident may result in adverse publicity that could affect institutional reputation and number of applicants

Slide 26:EVALUATION CHALLENGES

Interpersonal Issues Fear of diminishing rapport or provoking hostility from supervisees Fear of eliciting backlash from current or future trainees Anguish about damaging a supervisee�s career or complicating or terminating their graduate training (in the case of an intern)

Slide 27:EVALUATION CHALLENGES

Supervisor Issues Lack preparation for the evaluative components of supervision Wish to avoid scrutiny of their own behavior, competence, ethics, expectations, or judgment of their clinical or supervisory practices Have limited supervisory experience with trainees with competence problems Have difficulties in imparting negative evaluations Indifferent to personal responsibility for upholding the standards of the profession Display inappropriate optimism that problems will resolve without intervention

Slide 28:EVALUATION CHALLENGES

Supervisor Issues (cont.) Prefer to avoid the substantial energy and time commitment necessary to address or remediate the behavior of interns and residents with competence problems Have discomfort with �gatekeeper� role Identify with supervisee�s problems Pay inadequate attention to supervisee�s performance or problems Presume supervisee competence Minimize supervisee�s problem behavior

Slide 29:POLICIES AND PROCEDURES

Policies and practices need to Be consistent with local and national professional, ethical, and legal standards, yet tailored to the program Be communicated clearly and explicitly to trainees and others Include knowledge, skills, and attitudes defined as professional behaviors and performance Delineate minimal acceptable standards of professional performance and criterion signaling need for remediation and/or dismissal Convey clear expectations Give trainee a time-limited opportunity to improve Be understood to everyone in the system Articulate defensible practices for assessing competence

Slide 30:DUE PROCESS GUIDELINES

Create in a fashion that is simple and easy to understand Communicate in writing and orally to each intern/post doc at outset of training Apply uniformly and in a timely fashion to all trainees exhibiting competence problems Apply to all serious performance, conduct, attitudinal, and ethical problems

Slide 31:DUE PROCESS PROVISIONS

Describe types of problems and behavior covered, which should be broad enough to cover all performance, conduct, attitudinal, and ethical deficiencies, and combination of deficiencies Describe persons covered, making clear that all trainees are covered State the time limits at different stages of the process, and whether and for what reasons time limits may or may not be waived

Slide 32:DUE PROCESS PROVISIONS

Offer informal and formal procedures for notifying about deficiencies and penalties, correcting deficiencies, and appealing dissatisfaction with the program�s compliance with the procedures Identify clearly at each stage the decision maker and the contents of the decision State clearly at each stage whether and to whom the complainant or training program official may appeal the decision Note when decision becomes final

Slide 33:GUIDING PRINCIPLE #3

Cultivate self-assessment capacity for learning and responding to feedback for the purpose of identifying and addressing competence challenges and preventing competence problems

Slide 34:VALUE OF SELF-ASSESSMENT

Reflective practice/self-assessment is a foundational competence and needs to be taught and encouraged Lacking the capacity to self-assess is tantamount to failing to attain professionalism, missing the skill of thinking like a psychologist, and being insulated against self-corrective behavior

Slide 35:CULTURE OF SELF-ASSESSMENT

Must provide training in self-assessment that is bolstered by concurrent monitoring and feedback from other informants and that offers assistance in incorporating and integrating input from multiple sources Training should emphasize developing the capacity to examine issues that elicit discomfort to master experiences and reduce negative performance impact

Slide 36:CULTURE OF SELF-ASSESSMENT

Cultivating a climate of trust and help-seeking among supervisors, mentors, and colleagues reduces tension that often occurs when addressing competency problems and this climate requires empathy, concern, and respect for others, and is best achieved if evaluators assess fairly and empathically

Slide 37:GUIDING PRINCIPLE #4

Implement remediation strategies to enhance performance and evaluate in a systematic fashion that is balanced in terms of reliability and authenticity and designed to maximize learning, and utilize gatekeeping functions when indicated

Slide 38:FULL DISCLOSURE

Inform trainees at outset that competence will be comprehensively assessed in an ongoing fashion Provide Rationale for such assessment Specifics of assessment system Implications or usage of assessment information

Slide 39:METHODS OF EVALUATION

Consider relevance, fidelity, authenticity, and validity Use direct observation in actual or simulated situations for skills and attitudes Use multiple samples of behavior, multiple evaluators, and multiple methods over time

Slide 40:FORMATIVE AND SUMMATIVE EVALUATION

Formative evaluations Ongoing and regular performance feedback at specified intervals Critical in measuring and remediating competence problems Guide the development of learning objectives in a remediation plan based on strengths and weaknesses Global rating scales, portfolios, 360 degree evaluations

Slide 41:FORMATIVE AND SUMMATIVE EVALUATION

Summative evaluations Measure endpoints or outcomes Less well-suited for guiding the remediation process Can determine success (or failure) of a remediation Both summative and formative methods need to be employed in situations of competence problems

Slide 42:PROCESSES ASSOCIATED WITH COMPETENCE PROBLEMS (Lamb et al., 1991)

Setting the Stage Orientation Communicate site�s expectations about professional standards, skill competency, personal functioning Communicate about evaluation guidelines and processes Provide Due Process Guidelines

Slide 43:PROCESSES

Reconnaissance and Identification Gather on-going evaluative information and observe the trainee�s initial response to the setting, training experience, and feedback Discuss among all training faculty/staff Identify areas of concern orally and in writing � express concerns as hypotheses and define problem behaviors in concrete and specific terms Monitor early and continuously This process often is enough to manage many problems*

Slide 44:PROCESSES

Discussion and Consultation Hold discussions among all training personnel when problems persist regarding other interventions and next steps Consider Actual behaviors of concern (e.g., nature, frequency, severity) Settings that behaviors occur in Negative consequences of the behaviors Trainee�s response to feedback

Slide 45:PROCESSES

Implementation and Review Implement remediation plans Review progress and response to interventions Communicate with all relevant parties Provide ongoing feedback Document all problem behaviors and changes in behavior Hold ongoing meetings of faculty/staff for review Consult with other training personnel Consider possible alternative actions Seek external consultation

Slide 46:PROCESSES

Anticipating and Responding to Organizational Reaction in Cases of Termination Support trainee and help him/her consider alternatives Support training personnel Determine how to communicate what and to whom (e.g., other current and future trainees, staff) Manage clinical services

Slide 47:PROCESSES

Slide 48:REMEDIATION PLANS

Implement to assist the individual in gaining the requisite competence and to avoid gate-slipping Craft a written document with a constructive and educative tone Identify specific deficits and relate these to previously communicated benchmarks

Slide 49:REMEDIATION PLANS

Delineate explicitly expectations for improvement, including Contexts in which the behaviors occur Level at which sufficient competence will have been deemed to have been achieved Projected time line for the achievement of the objective and/or re-evaluation of both the competence and plan efficacy Present objectives, followed by descriptions of the training methods for achieving the objective, as well as roles and responsibilities for all parties and for the institution (if applicable)

Slide 50:REMEDIATION PLANS

Incorporate one or more strategies to remediate problems Increase supervision, either with the same or other supervisors Change the format, emphasis, and/or focus of supervision Reduce and/or shift the trainee�s workload Require specific academic coursework Provide additional mentoring Recommend personal psychotherapy

Slide 51:REMEDIATION PLANS

Incorporate one or more strategies to remediate problems Recommend, when appropriate, a leave of absence and/or a second internship or residency Collaborate with the graduate department on the remediation plan in accord with the CCTC Communication Guidelines

Slide 52:REMEDIATION PLANS

Personal Psychotherapy Convey that therapy may help with understanding why issues reflect competency problems or overcoming the psychological barriers that hinder the making of required changes Consider ethics and due process rights in ascertaining if a referral is appropriate

Slide 53:REMEDIATION PLANS

Personal Psychotherapy Be mindful of informed consent, avoid dual relationships, attend to cultural background, use qualified providers, clarify confidentiality, tend to financial concerns, and clarify the manner in which therapy contacts will be used in the evaluation process Establish written plans regarding recommending psychotherapy and strategies for evaluating the outcomes of personal psychotherapy

Slide 54:REMEDIATION PLANS

Use measures and methods of assessment of competence problems that complement and can be integrated into such plans (e.g., behavioral observations, review of work samples) View objectives, assessment, training, and evaluation as a continuous process Discuss and agree upon the plan

Slide 55:FORMAL ACTIONS

When a combination of the above interventions do not, after a reasonable time period, rectify the problem, or when the trainee seems unable or unwilling to alter his/her behavior, the program may need to take more formal action in accord with their due process guidelines

Slide 56:FORMAL ACTIONS(Lamb et al., 1991)

Probation In writing, Identify specific behaviors or areas of professional functioning of concern Relate these behaviors to written evaluations Provide specific ways deficiencies can be remedied Identity specific probationary period Stipulate how functioning will change at site during probation, of applicable Reiterate the availability of due process procedures

Slide 57:FORMAL ACTIONS

Give the trainee a limited endorsement, including the specification of those settings in which he/she could function adequately Terminate the trainee from the program and communicating this to the appropriate parties Recommend and assist in implementing a career shift for the trainee *All of the above steps need to be documented appropriately and implemented in accord with the due process guidelines

Slide 58:TERMINATION(Lamb et al., 1991)

Steps to take prior to notifying trainee Review agency and institutional implications of the decision Determine how and when the trainee�s status will change at the site Review proposed action and corresponding written statement in consultation with relevant internal and external parties Consult with legal counsel at the facility Notify up the chain of command

Slide 59:TERMINATION

Once these steps have been taken Hold meeting between the trainee and relevant training and site personnel Inform trainee of the decision Provide a written statement to trainee and other relevant parties reiterating probationary conditions, trainee�s response, and reasons for dismissal Provide statement of revised responsibilities Remind trainee of due process guidelines and appeal options

Slide 60:GUIDING PRINCIPLE #5

Consider the impact of beliefs, values, and attitudes about individual and cultural differences on decisions regarding problem identification, assessment, and intervention

Slide 61:DIVERSITY AND COMPETENCE PROBLEMS

Must attend to diversity in remediation and dismissal to not perpetuate divergence between cultural and professional norms Must be cognizant of the role that individual and cultural differences may play in identification or action taken with students perceived as having competence problems

Slide 62:DIVERSITY AND COMPETENCE PROBLEMS

Be mindful of over- or under-identifying problematic behavior due to Cultural naivete Fear of appearing racist or sexist Difficulty addressing the complexity in the intersection of cultural difference and competence problems Inverted positional power Differential standards based on bias Fear of litigation

Slide 63:GUIDING PRINCIPLE #6

Communicate across levels of training, professional organizations, and credentialing boards as appropriate

Slide 64:ETHICAL ISSUES

Supervisors should outline their roles at the outset of supervision, which aids in the building of trust relationships (Principle B � Fidelity and Responsibility) Supervisors should define a trainee�s areas of growth and make clear that their behavior (positive and negative) is fair game for evaluation within supervision and for reports to training programs Respect for student rights is important and judicious, balanced, thoughtful communications are essential

Slide 65:LETTERS OF RECOMMENDATION

Tendency to inflate letters of recommendation, despite the fact that the receiver of letters want truthful and complete evaluations May want to consider adopting the CCPPP guidelines for competency-based letters that ask for attention to core competencies, skills (work, communication, interpersonal), personal resources, and professional conduct, as well as areas for growth and development

Slide 66:INCREASED COMMUNICATION

More frequent and direct communication across levels (e.g., graduate school � internship) is desirable Graduate schools and internship trainers should collaboratively address students� insufficient professional competence

Slide 67:GUIDING PRINCIPLE #7

Maximize transparency through the identification and communication of limitations to the individual�s rights to privacy and confidentiality

Slide 68:ETHICAL, LEGAL, & REGULATORY STANDARDS

Limitations to individuals� rights to privacy and confidentiality need to be publicly identified in advance of any actions and must be appropriate and sensitive to ethical, legal, and regulatory standards Family Educational Rights and Privacy Act (FERPA) American�s with Disabilities Act (ADA) Health Insurance Portability and Accountability Act (HIPAA)

Slide 69:ETHICAL, LEGAL, & REGULATORY STANDARDS

APA Ethics Code provides guidance on the conditions under which students may be required to disclose personal information (i.e., program identifies in its materials when such an exception might occur and the information is needed to evaluate or obtain assistance for students whose personal problems may prevent them from competently performing or pose a threat to others (7.04)

Slide 70:ETHICAL, LEGAL, & REGULATORY STANDARDS

Appropriate use of confidentiality should not interfere with sufficient assessment and intervention Limits on confidentiality protect the public and the profession Profession needs to distinguish between real and presumed constraints on confidentiality that apply to the training of psychologists

Slide 71:TRANSPARENCY

Enhancing transparency measures we should not use the cloak of confidentiality to create barriers to assessing and remediating competence problems When problematic professional behavior jeopardizes professional standards, the right to confidentiality needs to be limited due to substantial consequences to the public and profession When rights to confidentiality conflict with professional standards, confidentiality automatically becomes limited

Slide 72:CONFIDENTIALITY & INTERVENTION

Concerns about protecting the confidentiality of individuals with competence problems frequently contribute to a failure to intervene in a way that prevents or remediates problems until they are severe and/or have caused harm When psychotherapy is part of remediation, assumptions about confidentiality often keep key information from being usable in remediation outcomes (not necessary for specific information to be disclosed, but attestations of gains in understanding and modifying professional competence are helpful)

Slide 73:CONFIDENTIALITY & INTERVENTION

Ethics Code addresses Balance between concerns about privacy and due process rights and need for accountability to protect the profession and the public Fact that students do not have to disclose personal information unless it is a program requirement or the information is needed to ensure competent functioning Fact that if therapy is mandated then students can opt for therapists unaffiliated with the program and that those who evaluate students can not serve as their therapists

Slide 74:CONFIDENTIALITY & INTERVENTION

Consider (Behnke et al., 2003) Law of no surprises � people are informed in advance what will be disclosed and to whom Parsimony principle � What is disclosed is limited to what is required to achieve the purposes of the disclosure (i.e., issues related to professional competence and only to those who need to know)

Slide 75:CONFIDENTIALITY & INTERVENTION

Concerns about protecting the confidentiality of individuals with competence problems frequently contribute to a failure to intervene in a way that prevents or remediates problems until they are severe and/or have caused harm When psychotherapy is part of remediation, assumptions about confidentiality often keep key information from being usable in remediation outcomes

Slide 76:GUIDING PRINCIPLE #8

Ethical, regulatory, and legal implications must be considered

Slide 77:ETHICS

Competence is the cornerstone of ethics (APA Ethics Code) Only by practicing in a competent manner can one fulfill the 1st principle (Beneficence and Nonmaleficence) �Psychologists strive to benefit those with whom they work and take care to do no harm� �Psychologists provide benefit and avoid harm by being competent at what they do; conversely, incompetence increases the risk of harm and minimizes the likelihood of benefit�

Slide 78:REGULATIONS

Competence is central to the regulations of many jurisdictional psychology boards Regulations emphasize competence in 3 ways Set forth the conditions by which to determine if applicants for licensure have achieved the necessary competence to practice independently May provide continuing education requirements for maintenance of competence and identify areas for specific attention Dictate the adjudicatory processes that govern allegations of incompetence in the provision of services and the consequences that follow when psychologists fall below the necessary standard of competence

Slide 79:LEGAL IMPLICATIONS

Actions in malpractice or negligence lawsuits are based upon breach in the standard of care Psychologists owe a duty to their clients/patients to exercise reasonable care (legal �gold� standard) When psychologists fall below the standard and cause harm, they may be liable in malpractice actions To practice in an incompetent fashion would be to fall below the standard of care

Slide 80:LEGAL IMPLICATIONS: DISABILITY ISSUES

A great deal of confusion has arisen among interns/postdoctoral residents and their sites /programs as to what constitutes disability, as defined by the Rehabilitation and Americans with Disabilities Acts; and what, if any, obligation an internship/program site has to provide reasonable accommodation to an applicant or an intern/postdoc after selection

Slide 81:CLAIMING AND PROVING DISABILITY

Qualified Responsibility for Determination Toyota vs. Williams Rehabilitation Act or ADA Correctible

Slide 82:ACCOMMODATION

When and to What Extent Reasonable Accommodation is Required Reasonable Accommodation Establish Meeting the Definition

Slide 83:HANDICAP DISCRIMINATION

Avoiding a Successful Claim of Handicap Discrimination

Slide 84:REFERENCES

Rehabilitation Act of 1973, as amended (29 U.S.C. sec. 791 et seq.; and Americans with Disabilities Act of 1990 (ADA (42 U.S.C. sec. 12101 et seq.; 29 C.F.R. sec. 1630; 1997; EEOC Enforcement Guidance on the Effect of Representations Made in Applications for Benefits on the Determination of Whether a Person Is a "Qualified Individual with a Disability" Under the Americans with Disabilities Act of 1990 (ADA) (Feburary 12, 1997); Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans With Disabilities Act (March 1, 1999).

Slide 85:REFERENCES

Sutton v United Airlines, 527 U.S. 471 (1999) Murphy v U.S. Parcel Service, 527 U.S. 516 (1999) EEOC Enforcement Guidance on ADA and Psychiatric Disabilities (1997); Addendum (2000) Instructions for Field Offices: Analyzing ADA Charges after Supreme Court Decisions Addressing �Disability� and �Qualified� (1999)

Slide 86:APPIC RESOURCES

Informal problem resolution and consultation process Formal complaint process (ASARC)

Slide 87:APPIC TRAINING RESOURCESwww.appic.org

Training Resources By Subject For Trainers Reference Lists

Slide 88:VIGNETTE #1

The intern has been slowly withdrawing from their cohorts and you as the TD notice this. When asked, her response is they just seem to be on different wave lengths. You also are getting a couple of complaints from patients that the psychology intern is rude. She seems pleasant to you and has denied this problem with patients and you acknowledge that patients with chronic pain can be difficult to work with. On further inquiry, the secretary in the office notices that the psychology intern is very short with her and other office personnel. What do you do?

Slide 89:VIGNETTE #2

The postdoc has very good clinical skills and seems to have good work habits the first 6 months. You have noticed that he is not taking much initiative lately and seems to be slacking off. He has begun looking depressed and lacks energy. This problem was addressed 1 month ago, but the number of sick days have increased and non attendance at grand rounds and other functions has become non existent. He always seems to have a good excuse. What do you do?

Slide 90:VIGNETTE #3

The intern is a quad that ambulates in a motorized wheelchair. She is eccentric in her dress, has fingernails that draw attention, has visible body piercings that she is proud of, and discusses the importance of her individuality at length. Her skills are average. She has recently received complaints about racing her wheelchair through the hallways of the rehab unit sometimes startling patients. What do you do?

Slide 91:VIGNETTE #4

The postdoc has several research projects going on and has not been very good about following through on their responsibilities. You are not sure if they are overwhelmed, just a poor organizer or poor research skills. What interventions might you consider before it becomes a major problem?

Slide 92:VIGNETTE #5

The intern has been unusually helpful during the year and has always completed tasks in a reasonable fashion. He is very independent and you sometimes wonder if he is expressing contempt for his colleagues and supervisors. Several things have happened to initiate you taking a closer look: 1) An MMPI was returned by mail from the prison system and he claims the hospital inmate had taken it while they must not have been looking.

Slide 93:VIGNETTE #5

2) One patient called to express dissatisfaction with the way she was treated by this intern, stating he lashed out at her by tearing up her MMPI and saying it was worthless. He states that never happened. 3) The secretary went to lunch with him and reported that the intern had made disparaging remarks about the program, the training director and one supervisor, stating the supervisor had made sexual advances toward the intern. The intern and the secretary met with the TD and the intern claimed he never made those remarks, that everything was fine. How would you proceed?

Slide 94:QUESTIONS?