Working with the
Difficult Clinical Learner
Luke H. Mortensen, PhD, FAHA
Des Moines University
Why Do You Teach ?
It is possible to store the mind with a million
facts and still be entirely uneducated.
-Alec Bourne
Education is the ability to listen to almost
anything without losing your temper.
-Robert Frost
The whole art of teaching is in awakening the
natural curiosity of a young mind.
-Anatole France
What’s Available at DMU?
• Cutting-edge technology
– METI and Laerdal Human Patient Simulators
• Reevaluation of students and clerkship clinical faculty
– Computer-savvy students and faculty
• Integration of technology into all courses
• Medical Informatics Infrastructure
– Useful, appropriate and effective communication
(electronic and direct) between central campus
and all rotation sites
Medical Informatics
• Introduction to the DMU Portal, e-Library and PDA
Resources
• Access to the DMU Faculty Development Web-site
• Locating and Accessing Full Journal Articles at the
DMU e-Library
• Evidence-Based Practice Resources
• Pub-Med Searching
• Drug Resources
• Disease Resources/References and Full Texts
• PDA Texts, References (ePocrates, etc.), Calculators
and Quick Decision e-Books
• Differential Diagnosis Tools
• Patient Education Resources
www.dmu.edu
DMU Faculty Development Website
Faculty Development at DMU
• What is Available (publicly available, structured
modules, podcasts, RSS feeds, videos, etc.)
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Evaluation of Learners
The Art of Conversation and Conflict Management
Leadership and Negotiation Skills in the Clinical Setting
Career Goals/Management for Medical School Faculty
Understanding a Competency-Based Curriculum
Assessing and Evaluating Competency
Academic Medicine and Medical Education Research
Technology and Teaching Effectiveness
Cultural Competency in the Clinical Setting
Teaching Medical Students Effectively/Providing Feedback
Working with the Difficult Medical Student
The “One Minute Preceptor”:
Time-Efficient Teaching in a
Busy Clinical Practice
Teaching the 5-Microskills
The “One Minute Preceptor”
10 Minutes of Teaching Time
•The average teaching
encounter takes 10 min
3 Minutes
Questioning
1 Minute
Discussion
Presentation
6 Minutes
– 6 min for the learner to
present the case
– 3 min for the preceptor
to ask questions and
clarify information
– 1 min of discussion and
teaching time
•“One Minute Preceptor”
model may take more
than a minute but
provides a structure to
help maximize the
teaching time of the
encounter
The 5-Step Microskills Method
The One Minute Preceptor strategy is based on
five steps that build upon each other:
•
•
•
•
•
Get a Commitment
Probe for Supporting Evidence
Reinforce What Was Done Well
Give Guidance About Errors or Omissions
Teach a General Principle
Step 1 – Get a Commitment
• “What do you think is going on?”
• “What do think the plan should be?”
• “How should this case be followed up?”
• Why?…
– It invests the learner further into the case
– Encourages learner to process beyond their
current comfort level and problem solve
– Allows you to assess their problem-solving skills
Step 2 – Probe for Supporting Evidence
• Explore the basis of the learner’s opinion and
what they have committed to in Step 1
– “What factors support your diagnosis?”
– “Why did you choose that treatment?”
• Why?…
– Was it a lucky guess or was it a well-reasoned
and logical answer?
– Helps you to assess the learner’s…
• knowledge base
• thinking process
• clinical reasoning skills
Step 3 – Reinforce What Was Done Well
• Skills and positive behaviors need repeated
reinforcement to become firmly established
– Provide the learner some positive feedback
– Increase the likelihood that these behaviors will
be incorporated into future clinical encounters
• Describe specific behaviors and likely
outcomes
– “Good job!” is too vague
– Example… “I liked that your differential took into
account the patient’s age, recent exposures and
symptoms…” is reinforcing positive feedback
Step 4 – Guide Errors and Omissions
• Correct the learner’s mistakes avoiding
negative labels such as “bad” or “poor”
– Learner less likely to feel judged
– Learner more likely to see criticism as constructive
• Describe specifically what was wrong, what
the consequence might be, and how to
correct it for the future
– Example… “During the ear exam the patient
seemed uncomfortable. Let’s go over holding the
otoscope.”
Step 5 – Teach a General Principle
• An important and challenging task for any
learner is to take new information from one
encounter and generalize it to others
– Manifestation of symptoms
– Treatment options
– Available resources and references
• Why?… Allows learning to be more easily
transferred to other situations
– Example… “Remember 10-15% people are
carriers of strep, which can lead to false positive
strep tests.”
Conclusion Step
• Wrap up the teaching session with
directions to the learner about what
may be necessary to resolve the case
• Why?...
– Time management is critical
• Signals the end of the interaction so that the
learner may move on to the next encounter
– Directs remainder of the encounter:
• Example…“Let’s go back in the room and I’ll
show you how to get a good throat swab. Tell
me when we have the results, and I’ll watch
you go over the treatment plan.”
Example Teacher-Learner Encounter
The One Minute Preceptor strategy is based on
five steps that build upon each other:
•
•
•
•
•
Get a Commitment
Probe for Supporting Evidence
Reinforce What Was Done Well
Give Guidance About Errors or Omissions
Teach a General Principle
Difficult Learner
“Hard to define…
…but you know one when you see one!”
– a continuum of struggling  failing
– deficiencies in one or more areas
•
•
•
•
•
insufficient knowledge
poor clinical judgment/reasoning skills
poor communication/interpersonal skills
professionalism
inefficient use of time
Objective Structured Educational Experience
• The “OSEE” is a simulation of “the difficult learner”
as a formative experience for clinical teaching
• There exist many useful taxonomies for both the
difficult learner and teaching approaches – in this
exercise, we will focus on the interactive features of
the student-preceptor encounter
• As such, this isn’t about doing teaching wrongly or
rightly, but to help us reflect on what we are doing
as educator-clinicians and teaching efficacy
The Scenario
• The agenda for today is to start with a
volunteer from the audience who will
‘precept’ our “difficult learner.”
• The student:
– A fourth-year undergraduate medical student
– Has just had a 15-minute patient encounter
• The volunteer:
– Will act as the attending in a clinical environment
in which students or residents are seeing patients
– Will debrief the student-patient encounter
Observation
• Following the encounter, we will open the
discussion to these areas:
– The Encounter
• The teaching-learning interaction
– Formative Assessment
• Feedback for the preceptor
– Appreciative Inquiry
• Objective is NOT to correct but to explore
reasons for choices made
Observation of
The Teacher-Learner Encounter
Debriefing the Encounter…
• What did we just see?
• Discuss a key point in the interaction that
you felt was remarkable.
• How would you characterize the learner?
• How would you describe the teacher?
• How did the preceptor teach this learner?
Debriefing the Encounter…
• Did the preceptor fall into the learner’s trap
by providing answers to all questions asked?
• Did the preceptor placate the learner?
• What kind of teacher does this learner need?
– What do you think the student learned?
• What does this learner need from this
teacher?
– How much time did they take?
– How much time do they need?
Formative Assessment
• Debriefing the faculty member
– Feedback for the teacher
– DMU resources available for clinical educators
• Appreciative Inquiry
– What was this encounter like for the preceptor?
– Why did they make the choices they made?
– Would they change anything?
• What would follow-up with this learner
include?
– What were your expectations?
– How do you formally evaluate this learner?
– How is the learner remediated?
Bibliography
• An Innovative Program to Augment Community Preceptors' Practice and
Teaching Skills. Wilkes, Michael S.; Hoffman, Jerome R.; Usatine, Richard;
Academic Medicine, Vol 81(4), Apr 2006. pp. 332-341.
• Reliability and Validity of Checklists and Global Ratings by Standardized
Students, Trained Raters, and Faculty Raters in an Objective Structured Teaching
Exercise (OSTE). Quirk, Mark; Mazor, Kathleen; Haley, Heather-Lyn; Teaching
and Learning in Medicine, Vol 17(3), Sum 2005. pp. 202-209.
• Giving effective feedback to medical students: a workshop for faculty and house
staff. By: Brukner, Halina; Altkorn, Diane L.; Cook, Sandy; Quinn, Michael T.;
Mcnabb, Wylie L.
• Initial experience with a multi-station objective structured teaching skills
evaluation. Prislin, Michael D.; Fitzpatrick, Camille; Giglio, Mark; Academic
Medicine, Vol 73(10), Oct 1998. pp. 1116-1118.
• Using "Standardized Students" to Teach a Learner-Centered Approach to
Ambulatory Precepting.. By: Lesky, Linda G.; Wilkerson, Luann. Academic
Medicine, v69 n12 p955-57 Dec 1994.
• Enhancing the Effectiveness of One-Minute Preceptor Faculty Development
Workshops. By: Bowen, Judith L.; Eckstrom, Elizabeth; Muller, Melinda; Haney,
Elizabeth. Teaching & Learning in Medicine, Winter2006, Vol. 18 Issue 1, p35-41
• Microteaching and standardized students support faculty development for clinical
teaching. By: Gelula MH. Acad Med2002 Sep ;77(9):941
Remediation References
•
Cohen GS , Blumberg, P. Investigating whether teachers should be given assessments of students made
by previous teachers. Academic Medicine 1991;66:288-89. The authors describe a discussion from
problem-solving sessions at the Generalists in Medical Education meetings. They recommend a written
institutional policy allowing faculty to communicate about problem students.
•
Hemmer PA, et al. Internal medicine clerkship directors’ use of and opinions about clerkship
examinations. Teach Learn Med 2002;14:229-35. Reports findings of the CDIM survey about exams. 83%
use NBME exam. Exam typically counted towards 25% of grade. Retest usually offered once without
remediation; remediation required after second failure.
•
Hemmer PA, Pangaro LN. Natural history of knowledge deficits following clerkships. Acad Med
2002;77:350-53. The authors describe the “prognosis” of failing medicine clerkship exam. 48 students
(6%) failing the exam had acceptable clinical evaluations. 8 of 48 students who failed the exam failed on
retaking the exam. All 8 students passed on retake after completing the fourth year medicine rotation.
Four of the 48 students failed USMLE Step 2.
•
Kovach RA et al, “Peer assessment of professionalism: A four year experience in the clerkship.”
Presentation at CDIM, Nashville, TN, October, 2004. The author describes a well-received program of
peer evaluation regarding professionalism at Southern Illinois University.
•
Lavin B, Pangaro P. Internship ratings as a validity outcome measure for an evaluation system to identify
inadequate clerkship performance. Acad Med 1998;73:998-1002. Retrospective cohort analysis showing
some correlation between interns with poor evaluations and those who required remediation during
medical school.
•
Lin C, et al. Personal remedial intensive training of one medical student in communication and interview
skills. Teach Learn Med 2001;13:232-9. The author describes an extensive, personalized, successful
tutorial for a student who required intensive remediation of communication skills between the second and
third years of medical school.
•
Magarian GJ, Campbell SM. A tutorial for students demonstrating adequate skills but inadequate
knowledge after completing a medicine clerkship at the Oregon Health Sciences University. Acad Med
1992;67:277-8. The authors describe a detailed, multi-prong approach to remediating students with
inadequate knowledge.
Remediation References (cont.)
•
Noel GL. A system for evaluating and counseling marginal students during clinical clerkships. J. Med Ed
1987;62:353-55. The author describes the USUHS process of all clerkship directors meeting to discuss
struggling students and identify remediation plans for those who need them.
•
Papadakis MA, et al. Early detection and evaluation of professionalism deficiencies in medical students:
One school's approach. Acad Med 2001;76:1100-06. The author describes University of California-San
Francisco’s well-developed program of identifying lapses in professionalism lapses.
•
Parenti, CM. A process for identifying marginal performers among students in a clerkship. Acad Med
1993;68:575-77. The author describes University of Minnesota’s review process where Medicine Clerkship
Committee reviewed all student evaluations with one or more “below expectations” or “unacceptable”
mark in any category. Students could be given a passing grade or referred to the Scholastic Standing
Committee (SSC). This review increased the number of students referred to the SSC and remediated.
•
Peng R, et al. Personality and performance of preclinical medical students. Medical Education
1995;29:283-88. A description of personality traits and medical school performance in Malaysia.
•
Phelan S, et al. Evaluation of the noncognitive traits of medical students.” Acad Med 1993;68: 799-803.
The author describes University of New Mexico’s evaluation of seven professionalism traits: reliability and
responsibility, maturity, critique, communication skills, honesty and integrity, respect for patients, and
chemical dependency or mood disorder.
•
Segal SS, et al. The academic support program at the University of Michigan School of Medicine. Acad
Med 1999;74:383-85. The authors describe a program striving to identify students at risk of academic
difficulty early in medical school and help them access resources.
•
Wear D, et al. Medical students' experience of academic review and promotions committees. Teach Learn
Med 2004;16:226-32. A qualitative description of students’ experiences by promotions committees.