Learners in Difficulty:
The “Problem” Student
Joseph O. Lopreiato MD, MPH
Associate Dean for Simulation
Education
Professor of Pediatrics
Acknowledgment
Drs. Catherine Lucey,
Richard Hawkins and
Eric Holmboe
USU
Student
Promotions
Committee
Clerkship
Director
Residency Program
Director
Outline
Define the problem
Define the approach as a
teacher
Present a strategy to
approach to the problem
Definition
ABIM
• “A trainee who
demonstrates a
significant enough
problem that requires
intervention by
someone of authority”
Learner /School Dilemma
• Conflicts:
– Student advocate role
– Societal and professional obligations
– Institutional loyalty
• Tendencies:
– Minimization and temporization
• Second chances
• Will get better if you work harder
• Difficulty in providing negative evaluation (clinical)
USUHS Pre-clinical: Magnitude
Fundamentals:
• 98% Pass
• 2% Fail or incomplete
Preclerkship CPR module:
• 12% Honors
• 85% Pass
• 2% Fail or Incomplete
USUHS clinical: Magnitude
Pediatrics:
• 16% A
• 44% B
• 5% C
• 3% Fail or incomplete
Internal Medicine:
• 25% A
• 40% B
• 12% C
• 4% Fail or incomplete
Approach to evaluation
Symptoms
HPI/ PMHx
Differential
Dx
Final Dx
Symptoms: Potential Problem Noted
Low clinical/small group
discussion rating
Complaint
Peer incident
Low exam/quiz scores
Poor OSCE performance
Learner self-identified
Symptoms: in Clinical Arena
Direct observation in clinical setting
Critical incident
Poor performance at morning report
Neglecting patient care responsibilities
Yao and Wright, 2000
HPI/PMHx
What happened?
What are the circumstances
Happened before?
Want to talk about it?
Feelings?
Differential Diagnoses
Organizational
Causes:
Knowledge
Causes:
(Bordage)
• Study Time/Study Methods/Test taking
(OSA)
• Energy (motivation)
• Context & Culture (engineer vs. physician)
• Dispersed
• Elaborated
Differential Diagnoses
Lucey’s
Causes
(7Ds):
• Deprivation (sleep, relationships)
• Distraction (family, money)
• Depression
• Dependence on drugs and alcohol
• Disordered personality
• Disorders of Learning (ADHD, LD)
• Disease
Lucey Reference ########
Depression and Anxiety
Liselotte N. Academic Med 2006;81:354-373
Dependence
Disorders
Disease
Diabetes
Organic brain syndrome
Thyroid disease
Malignancy
Eating Disorders
Post Partum Depression
Etc…
Lucey’s
Causes
(7Ds):
• Deprivation (sleep, relationships)
• Distraction (family, money)
• Depression
• Dependence on drugs and alcohol
• Disordered personality
• Disorders of Learning (ADHD, LD)
• Disease
Organizational
Causes:
Knowledge
Causes:
(Bordage)
• Study Time/Study Methods/Test taking
(OSA)
• Energy (motivation)
• Context & Culture (engineer vs. physician)
• Dispersed
• Elaborated
Self-Efficacy

Artino & Bandura
◦ Choice of activities; effort; persistence
*
Motivation
Rhoads, J of Med Ed 1974
Approach to evaluation
References
• Artino, A. R., Jr. (2012). Academic self-efficacy: from educational theory to instructional
practice. Perspect Med Educ, 1(2), 76-85. doi: 10.1007/s40037-012-0012-5
• Croen, L. G., Woesner, M., Herman, M., & Reichgott, M. (1997). A longitudinal study of
substance use and abuse in a single class of medical students. [Comparative Study]. Acad
Med, 72(5), 376-381.
• Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression,
anxiety, and other indicators of psychological distress among U.S. and Canadian medical
students. [Review]. Acad Med, 81(4), 354-373.
• Ghodasara, S. L., Davidson, M. A., Reich, M. S., Savoie, C. V., & Rodgers, S. M. (2011).
Assessing student mental health at the Vanderbilt University School of Medicine. Acad Med,
86(1), 116-121. doi: 10.1097/ACM.0b013e3181ffb056
• Holmboe. (2008). Practical guide to the evaulation of clinical competence. 1st ed.
• [edited by] Eric S. Holmboe, Richard E. Hawkins. Mosby/Elsevier in Philadelphia, PA .
• Ishak, W., Nikravesh, R., Lederer, S., Perry, R., Ogunyemi, D., & Bernstein, C. (2013). Burnout
in medical students: a systematic review. Clin Teach, 10(4), 242-245. doi: 10.1111/tct.12014
• Rhoads, J. M., Gallemore, J. L., Jr., Gianturco, D. T., & Osterhout, S. (1974). Motivation,
medical school admissions, and student performance. [Comparative Study]. J Med Educ,
49(12), 1119-1127.
• Rosebraugh, C. J. (2000). Learning disabilities and medical schools. Med Educ, 34(12), 9941000.
• Yao, D. C., & Wright, S. M. (2000). National survey of internal medicine residency program
directors regarding problem residents. JAMA, 284(9), 1099-1104.
Learners in Difficulty:
Therapeutic Considerations
CAPT Barbara Knollmann-Ritschel
Fundamentals Module Co-Directors
Associate Professor for Pathology and
Emerging Infectious Diseases
Objectives
• Identify challenges in an ongoing curriculum.
• Discuss differences of short and long term
remediation.
• Present a strategy for learners with issues in
Professionalism, Science, and Clinical Skills.
• Discuss the cost of remediation.
Remediation: Challenges in new
Curriculum
• Old Curriculum:
•
•
•
•
Courses Directors
Long time span with regular contact
Ongoing remediation: course specific help
Failed Course: repeat course/deceleration
New Curriculum: New Challenges
• Modules Directors: organize remediation for
multiple courses with Course Directors
• Ongoing curriculum- bigger impact when
students are at lower end- need to juggle more
courses at the same time
• Less time for students with denser curriculum:
• The fire hose
Remediation: Challenges in new
Curriculum
• Remediation is spaced with ongoing
curriculum– Student fails Fundamentals- final remediation may
not be done until following summer!
• Remediation may be 10 months later with ongoing
curriculum
Remediation: Challenges in new
Curriculum
• Timing is not ideal- what can we do?
– “Pre grade remediation” – what can we do not in
the short term before the end of the module or
ongoing remediation
– Balance with in-depth remediation
REMEDIATION OF SCIENCE
KNOWLEDGE VS. CLINICAL SKILLS VS.
PROFESSIONALISM
Are they the same?
Clinical
Skills
Science
Knowledge
Professionalism
Creating a Remediation Plan
Review all the data, discuss with CD
Talk with Student
Pre-grade vs. Formal remediation
How does this affect ongoing curriculum?
Written plan to student and OSA
Remediation of Science Knowledge:
• Summary of exam results with strengths and
weaknesses
• Pre-remediation work summary
• Reason for requiring additional work
• Grade issued: Incomplete/Fail
• Plan:
– What type of remediation is needed and proposed study
block.
– A Passing score (above 65%) will be required to pass the
Fundamental Module.
Remediation of Clinical Skills
• Review data from direct observations and Simcenter
– Where is the Lesion?
•
•
•
•
•
Professionalism
Reporter
Interpreter
Manager
Educator
• Increased time at simulation center- Practice skills –
residents FNA
– Remediate skills session as close to time of feedback
– Focused plan on those skills that are identified as weak
Remediation of Professionalism:
Five-Step Approach
• Major concern from AAMC
Tiered Approach:
5 Step Process
Email
Email and Letter
Email, Letter and See me
Email, Letter, See me, See Commandant
Email, Letter, See me, See Commandant,
Formal Mentor
Cost
Faculty
Student
1
Student 2
Acknowledgements
USU Student
Promotions
Committee
Dr. Janice
Hanson
Dr. Paul
Hemmer