Medical teachers often face situations where students or trainees are problematic or challenging. All clinical teachers want their team members to be competent, compassionate, cooperative and constructive. Medical Council of India (MCI) describes the role of Indian medical graduates beyond being a clinician, to be a leader, professional, communicator, and a lifelong learner who is ethical and committed to excellence [1,2]. Qualities of a ‘great resident’ or a ‘high performing resident’ include being trustworthy, hardworking, efficient, and self-directed learner [3]. It is, however, not unusual to encounter trainees with a deficit in knowledge, lack of clinical judgment, annoying behavior, inappropriate interaction with colleagues, or being late or absent. All these serve as significant obstacles in the attainment of the desired competencies [4-8].

Problem behavior of one resident sometimes spoils the reputation of the entire department and hampers training of fellow residents. Such a resident often diverts the time and energy of other fellow residents and faculty members. Improper handling may result in violent behavior to self or others. It is thus essential to recognize the problem resident, and institution of remedial measures at earliest.

Myriads of terms are used for a problem resident: troublemaker resident, problem learner, difficult resident, the burned-out resident, disruptive resident, and so on [6-8]. A ‘problem learner’ has been defined as one whose academic performance is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty [8]. American Board of Internal Medicine defines problem resident "as a trainee who demonstrates a significant enough problem that requires intervention by someone of authority, usually the program director or chief resident." In simple terms, a problem resident is the one who does not meet the expectations of the training program owing to the deficit in knowledge, skill or attitude.

In a study by Reame, et al. [5], the prevalence of ’resident in trouble’ was estimated to be 9.1%. They observed psychiatric illness, substance abuse, attitudinal problems, interpersonal conflicts and insufficient knowledge to be the common reasons. In another internal medicine residency program, the prevalence of problem resident was estimated to be 6.9%. The most common attributable causes included insufficient medical knowledge, poor clinical judgment, and inefficient use of time [4]. In a nationwide survey of psychiatry residency program in the United States, it was observed that 3.3% of residents were terminated in a four-year period for unacceptable performance [9]. Data from India on this issue are lacking.

One of the most common attributable cause of problem resident is insufficient knowledge [5]. The resident may have poor baseline subject knowledge or is slow to grasp the basic concepts leading to an unsatisfactory performance at work (Box I). The regular internal assessment might detect academic deficiency and provides an opportunity to rectify the deficit. Lack of organizational skills and ineffective time management are some of the other hurdles in acquiring the requisite knowledge.

Skills required from clinical residents include the art of history taking, correct method of clinical examination, interpreting the clinical findings to reach a diagnosis, plan investigation and managing the patients. One of the most essential skills is communication of the plan to relatives and ability to discuss the idea with colleagues and taking constructive criticism. Communication difficulties, especially of those who travel from other states to pursue their higher education, might have trouble communicating in the local language. Majority of residents face problem in skills during the first few months of residency that tends to improve with time. Surgical hands-on skills often need constant supervision. The persistent deficit of skill development despite repeated reinforcement leads to a problem.

Attitude or personality problems stem from a deficit in motivation. The problem resident often has a poor interpersonal relationship and is not dependable for independent patient care (Box 2). Residents with attitude problems are the most difficult ones to handle.

Personal problems like bereavement from loss of loved ones, struggle in the family, or difficulties in personal relations may affect the performance of residents. Poor interpersonal relationships lead to prejudiced work atmosphere and impair learning. Psychiatric illness and substance abuse among residents needs early identification and correction. These problems often result in stress, depression, low self-esteem, and fear of failure.

Many students choose a medical or surgical specialty based on their score rather than their interest. Such discordance may result in a problem during the early days of residency. Few residents have adjustment issues considering the latency of 2-3 years after completion of medical school before they get into a specialty. In a study by Hunt, et al. [10], it was observed that most common problem learners were those with cognitive issues and poor interpersonal relationship.

Faculty members with unrealistic expectations, stressful personal life, or working in an unsatisfactory workplace often vent out their anger and frustrations at the resident. The behavior may initiate or exacerbate problems in the resident. An excellent role model faculty produces better professional behavior among residents [11,12]. A problematic faculty; however, is more likely to produce a problem resident.

The teacher is often assigned the dual role of clinician and teacher, and a few fail to live up to the expectations. Few teachers may become oblivious to the problem resident altogether so as to avoid direct confrontation and few may vent out their anger by scolding the resident. On the other hand, few faculty members suddenly become soft, primarily to avoid any possible personal litigations. Often, faculty members are reluctant to provide an honest assessment of the residents, and mark them as satisfactory despite being problematic [13]. This only aggravates the situation.

Workplace learning varies widely between different institutions, depending on opportunity, motivation, and capabilities [14]. In government facilities, barriers to effective workplace learning might include deficient infrastructure, deficient manpower, and unmanageable patient load [15]. In addition, lack of access to peer, lack of management support, lack of access to technology, lack of funding, and unsupportive staff attitude are other barriers to workplace learning [14]. Certain institutions despite having excellent infrastructures may lack expertise and teaching exposure required during residency training [16]. Many students migrate from one state to another state for pursuing postgraduate residency. Relocation to a new institution often invites financial concerns, isolation, and social problems leading to resident stress and adjustment issues [17]. All these factors may contribute to the making of a problem resident.

Some of the professional etiquettes expected from residents include being courteous to your colleagues and seniors, being on time to work, wearing appropriate clothes to the hospital, showing appropriate gestures while speaking to patients, and most importantly to keep one’s grudges and egos away while dealing in a professional atmosphere. Unprofessional blogs and social media posts such as binge drinking, posting sexually appealing photos, sharing patient videos on social media, posting raw or confidential data of institute, and personal comments on faculty members or peer colleagues are some of the commonly encountered problems [18,19]. Fabricating patient reports to meet preoperative criteria, and verbal or physical abuse of junior doctors are some of the extreme behaviors encountered among few residents [20]. There is rising intolerance about relations of doctors with pharmaceutical companies or private laboratories for some financial or other favorable incentives [21].

The first step in the evaluation of a problem resident is to be sure about the diagnosis [7]. A single adverse incident, personal grudges, and overheard conversation may end up in wrongly labelling a resident as a problem resident. Residents obviously do not like to be outcasted as a problem resident [22]. It affects their relations with peers, patients and teachers. A resident erroneously blamed for any wrong happenings results in denial, anger and loss of self-confidence [6].

Sharing all concerns over a faculty meeting is essential [23]. A group consensus on a resident being a problem resident is necessary before proceeding to determine the problem and its remedial measure. Once the problem is identified, it would be useful to determine how frequently do we encounter this problem, how difficult is it to handle this problem, and how much is it affecting the ongoing learning of the student and his/her peers [10]. For example, a resident who is frequently absent from his duties owing to excessive alcohol abuse is not a frequent but quite a difficult problem to handle. Likewise, a disorganized first year with poor knowledge base is quite a common problem, but it improves with interventions (Box 2).

The resident should be called for a meeting with the program director who should list the concerns without criticizing or discriminating the resident [23]. Perception of the problem by resident and its possible remedial measures that he/she perceives should be considered. Enquire about personal problems of the resident, including those from family.

Feedback from other supportive staff including peers, nurses, support staff, and patient attendants might help [12]. It is essential to identify the occurrence and frequency of problem and situations where such a problem emerges. History of drug or alcohol abuse needs to be ascertained from the peers [24]. Inter-resident scoring cards are used to assess a resident as perceived by their peers in an objective manner.

Fictitious Dr. Y was disorganized and had a gross deficit in knowledge and skills (Box 2). Owing to repeated complaints from casualty team members, she was rotated to the general pediatric ward. She was tagged to a mentor faculty and chief resident who would intensely monitor his progress. They would conduct one to one tutorial, assign her the additional reading task with fixed timelines, and supervise her examination skills at the bedside. Her analytical skills were sharpened by use of simple methods like one-minute preceptor model [25]. Considering the hard-working nature of Dr. Y, she had an excellent performance at the end of 3 months and then was rotated back to the casualty team. She was tagged to a senior shadow peer for next two months before she was assigned independent duties.

Fictitious Dr K had a major problem in attitude that led to a negative and unprofessional workplace environment (Box 2). He was called for a meeting with the program director and all faculty members. Problems encountered were enlisted, and justification for the same was sought. A verbal warning was given, failing which a written memorandum was issued. His parents were informed of the minutes of the meeting. His responsibilities during clinical postings were delineated, and he was not allowed to switch on his mobile phone during work hours. His interactions with patients, peers and nurses were video recorded. He became conscious of his actions being recorded. These video records were reviewed in a subsequent meeting with the resident, and corrective measures were suggested to him. A timeline was provided for correction of his actions, failing which he was warned of possible termination of his candidature for the program. He was tagged to a role model teacher and peer with whom he worked for next three months. His behavior improved dramatically. He was more polite, respectful and considerate in his actions at the workplace. He would finish all his work before leaving the ward.

Teaching medical professionalism is challenging, but essential part of medical training. One of the most effective ways to teach professionalism to residents is to foster faculty role modeling [23]. Residents often look up to a positive role model to imitate his/her professionalism. Majority of problem residents improve with appropriate and timely remedial measures. Remedial measures must define the deficiency, provide a pathway for its rectification, set minimal benchmark goals or expectations in an acceptable timeline, and evaluation based on set goals [13].

Broad identification of problem into cognitive, behavioral or a combination of both is essential to design specific cures. Majority of attitudinal problems require extensive close monitoring and feedback, and, in some situations, require psychological help. The structured reading session can be planned for those with the poor knowledge base (Table I). The Problem Resident needs to be involved in identifying the problems and designing their remedies, based on his/her priorities.

Table I Remedial Measures for Problem Residents

Three golden rules for correction include "act early, maintain confidentiality, and document everything" [7,22]. The plan should be individualized. Set up achievable goals and devise a timeline for each of the desired goals. It is essential to identify the red flag signs that require psychiatric consultation, including suicidal tendency, harm to patient, and substance- or alcohol- abuse. Finally, ensure that a problem resident graduates out of the department sans his/her problems.

Can we predict at the outset that a resident will be problem resident? Robust educational system ideally should have rigorous screening mechanism for recruiting residents for the teaching program. A problem resident is often recognized within the first year of residency, or more often they come to attention when a resident has poor performance in the ongoing assessments. Periodic assessment of residents should ideally include core medical knowledge, interpersonal skills and communication, practice-based learning, and professionalism [23].

Few problems come to attention following a complaint about the resident in some adverse event like fights with colleagues or patient or when there is gross mismanagement for any patient. Indian system recruits medical postgraduates through common written entrance examination that often lacks personality assessment [26]. Moreover, with the advent of online admission sessions, while allotting postgraduate seats, institutions have no control over the recruitment of students. Even resident with adverse remarks on the conduct certificate during graduation years can safely land in prestigious institutions solely based on cognitive abilities [27]. The selection procedure for residency should not only look for core medical knowledge, but also the past performance during the undergraduate course, the opinion of teachers and peers. Screening for personality traits, motivation, character, affective domains and communication skills need to be incorporated in the selection process [28].

Once a resident is inducted into the system, an orientation plan should be in place. It should include orientation to the clinical postings and their expectations from residents. Importance of socialization should be emphasized. They should go to movies, go to dine outside, and have regular birthday parties even at the workplace – during the lunch hours. Mentoring a resident is an essential aspect of medical training [29]. It shapes the personal and professional development of the resident. Effective incorporation of mentorship program during residency could avert emergence of problem resident. Mentors selected by free choice have been shown to be better than assigned mentors [30]. A broad approach to handling a problem resident has been summarized in Fig. 1.

Fig. 1 Approach to a problem resident.

Conclusion

Resident doctors face a variety of professional and personal problems, including deficits in knowledge, skills or problems with attitude. Faculty members and institutional heads must be sensitized to handle these problems. Remedial measures need to be individualized and must be framed with the involvement of affected resident. One-to-one faculty mentorship, peer support, psychological consultation, rotating the resident out of difficult workplace, stringent monitoring of their behavior, and providing effective feedback are some of the remedial measures to handle a problem resident. Providing enjoyable learning experiences should be the goal of every residency program.

Contributors: PG, JSK: conceptualized the idea; JSK, KR: drafted the manuscript; TS, PG: provided intellectual inputs. All authors approved the final version of the manuscript.

Funding: None; Competing Interest: None stated.