EXERCISE 11.1: Challenging Training Situations

Purpose: For each of the cases listed, please consider various ways that you might respond as a trainer. These exercises are meant to build your skill and adaptability to difficult clinical, behavioral, ethical, and clinic flow issues in training.  

  1. A somewhat new trainee continues to dilate beyond appropriate size, appears overconfident, and demonstrates little “sixth sense” when things don’t feel right. In this moment the trainee suddenly has a look of discomfort, and mentions, “I felt some obstruction and a tearing feeling.”
    • You need to assess what the trainee has done, making the transition as smooth as possible to preserve safety, and not to alarm the patient.
    • Subtly communicate the need to switch places.
    • Help reassure the patient if there is a change in her procedure.
    • Have a low threshold to use ultrasound guidance if available.
    • Consider the following preventative steps:
      • Practice with simulation models like the papaya, an IUD model, or even a trainer’s fisted hand as a pretend cervix if no other model is available.
      • Consider requiring comfort with a model BEFORE a real patient, to set a learner up for success during an actual procedure.
      • Introduce the trainee gradually to the procedure.
      • Prepare the trainee for “moments of caution” including the first dilation.
      • Work very closely next to a trainee, assisting with your hands, until you gradually gain confidence in his/her skill level.
    • Give feedback after the case, starting with the opportunity for self-assessment.
    • Recognize the trainee for having asked for help when feeling resistance, which contributed to the patient’s safety.
    • Give ideas for improvement, and steps to take to either prevent or manage this challenge if it arises again.
  2. A trainee is lacking in enthusiasm, often anxious to leave, and is more interested in gaining procedural skills than providing options counseling or empathic care. They tend to sit back and avoid saying much, making assessment of skill difficult.
    • Engage the trainee with values clarification work and counseling exercises.
    • Ask the trainee for specific contributions or actions.
    • Ask for their assistance in making this a meaningful experience. “How can I make this training more useful for you?”
    • Consider asking other trainers if they have had a similar experience with this learner.
    • If the behavior continues, ask the trainee about her apparent lack of enthusiasm, and focus on basic expectations of the rotation.
    • Evaluate the trainee honestly.
  3. You start off with the values clarification exercises with a trainee who is shy but friendly. After a brief introduction, they tell you that they are struggling over whether or not to provide abortions. They feel it is hard to “help someone commit a sin.” They would feel better if only they could spend a lot of time with each patient to make sure that they thought abortion was the right decision for that patient. They especially wanted to avoid doing abortions for those patients who use it as birth control. The trainee states, “Clearly some women make bad decisions for themselves, so I can not trust that they are making the right decision about this.”
    • Consider asking more about how they perceive sin and forgiveness, and how they weigh the relative difficulty of decisions in this realm.
    • Consider asking if they believe in broader platform such as the importance of respecting patient autonomy, reduction of stigma, or a clinician’s duty to ensure a patient receives care.
    • “Broaden” the approach to explore other scenarios that might evoke physician bias in relation to childbearing or not (e.g. alcoholism, drug-use, HIV, refusal of blood transfusion, or refusal of a C-section).
    • Do values clarification, some counseling observations, and then reassess.
    • It’s important to give them the space to work it through in a way that doesn’t adversely affect the care of your patients.
    • We recommend evaluating trainees on their ability to render non-judgmental care. When trainees are unable to do so, we need to give an honest evaluation and let the residency faculty know what areas still need work.
  4. A trainee shows confidence with the procedural aspects of aspiration abortion, but tends to be very formal with clients, using extensive medical jargon, and speaking in a tone you feel is not very empowering to the patients.
    • Do counseling exercises and role-play early. Ask the trainee to play the patient at times, and see which tone they prefer as a patient.
    • Review alternative ways to say things.
    • Ask the trainee to do the procedure while you talk to the patient and see if they can glean from your word-choice.
    • Give feedback after every case.
    • Reinforce the benefits gained by the things they tried.
    • Reinforce their strong procedural skills, and potential to provide support.
  5. The last couple days in your training clinic, you’ve noticed the clinic flow seems less than optimal, with longer patient waiting times, and your staff becoming mildly inpatient with training. How might you approach this?
    • Acknowledge that training can slow down the clinic, and remind the staff of the long-term benefits. Enlist their support in its success.
    • ‘Bookmark’ topics to finish reviewing at the end of the clinic day.
    • Use a debriefing session after clinic to ask staff to share their perspectives and brainstorm strategies for improvement. See Clinic flow strategies.
    • Help keep the case moving by helping with that or the next step (for example, if the trainee is struggling to put adequate pressure on the dilator, add the additional pressure on their hands, so they appreciate the appropriate pressure needed).
    • Agree ahead of time with trainee/team on a time limit after which the trainer intervenes (for example, if the case is going on longer than 10 minutes). This can helpful depersonalize things when the trainer intervenes if a case is taking too long, and it also ensures that concerns about flow are addressed in an ongoing way.
    • Consider having one trainer whose focus is the learner, and another practitioner whose focus is flow and keeping waiting times minimized,
    • Consider other options that may work in your own practice setting.
  6. You are assisting a trainee in a procedure on a patient with a very low pain threshold. During the dilation, the patient starts fidgeting and becomes noisier. The patient then becomes more active on the table, withdrawing from each cervical dilation by the trainee, and starts crying loudly in the middle of the dilation. How do you proceed?
    • Have the trainee pause during the procedure so you can assess the situation clinically and check in with the patient.
    • If you feel the procedure is safe, help reinforce the techniques of relaxation including breath, stabilizing her hips into the table, visualization, and talking her through the procedure. Assess whether more local, oral or IV medication might be helpful.
    • Ask for a medical assistant to be more active or step into the doula role yourself. Making eye contact with the patient, holding the patient’s hands, walking through a guided meditation as distraction, and breathing with the patient can all make a huge difference.
    • Sometimes, just getting the case done as quickly as possible, though, is necessary, and you will have to complete the procedure. Make this transition using a subtle signal so the patient doesn’t become alarmed.
    • Discuss the case after you finish, giving the trainee the first opportunity to assess and problem-solve, and explain why it was important if you needed to take over the case. Offer positive and then constructive feedback.


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