Dealing with Difficult
Students
20th annual
Preparing health professionals
for the 21st century
R. Brent Wright, MD, MMM
Associate Dean for Rural Health Innovation
University of Louisville School of Medicine
Vice-Chair for Rural Health & Associate Professor
Department of Family & Geriatric Medicine
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Three Parts

Learner

Teacher

System
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Difficult learner in medical education
• 9.1% of medical students/young residents are identified as
problem or struggling learners
• Difficulties might be due to :
Learner
Factors
Teacher
factors
System
factors
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http://www.stfm.org/fmhub/fm2006/April/Brian252.pdf
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Learner in Difficulty

A trainee who demonstrates a significant challenge or difficulty
within the learning environment that requires intervention by
the preceptor and/or program.
or

A student who is at risk of receiving an unsatisfactory grade
because of problems with knowledge, skills, professionalism,
or a combination of these.
https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf
http://casemed.case.edu/caml/doc/S15328015TLM1004_4.pdf
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
Dealing with difficult learner:
 A) Annoying
 B) Bothersome
 C) Controversy
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What interferes with learning?
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Personal Issues
Health Related
Family
Financial
Personal Habits
Social
Cultural
Personality Disorders
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/
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Personality Disorders
• Paranoid Personality Disorder
• Anti-social Personality Disorder
• Narcissistic Personality Disorder
• Borderline Personality Disorder
• Schizotypal Personality Disorder
• Schizoaffective Disorder
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Training Related Issues

Situational
 adjustment to the medical school environment
 conditions for learning that are less than optimal
 inadequate support from health professionals
 exposure to death and human suffering
 ethical conflicts
 student abuse
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/
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Training Related Issues

Professional
 responsibility for patient care
 difficult patients and challenging health problems
 supervision of more-junior residents and students
 information overload
 career planning
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Learning Disabilities ?





Low motivation
Poor Self-Esteem
Behavioral Concerns
Physical Affects
Self-Critical & Critical of Others
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Scenario I Personal Challenges

The Softball Game
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What would you do?

A. Go to the game

B. Talk with the student & miss the game

C. Talk with the student next week
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Teacher Factors





Inadequate teaching experience
Avoiding ‘making things worse’
Unsure of self
Inadequate observations
Lack of feedback
https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf
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Preceptor Challenges

Barriers identified by preceptors preventing the reporting of a
learner who performed poorly:
Lack of knowledge of what to specifically document
Fear/anticipation of an appeal process
Lack of remediation options
Lack of documentation
Dudek NL, Marks MB, Begehr G. Failure to fail: The perspectives of clinical supervisors. Acad Med 2005;80(10 suppl)S84-7.
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Generational Differences
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Scenario II: Troubling Arrival

First Day

Worries of Staff

Documentation
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What would you do?

A. Attribute to Stress & Ignore

B. Monitor for continuance

C. Document and proceed with rotation
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Documentation
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Documentation

High quality documentation should be:
Accessible
Accurate, relevant, and consistent
Auditable
Clear, concise, and complete
Legible/readable
Timely, contemporaneous, and sequential
Reflective
Retrievable

Poor or absent documentation can prolong the process of dealing with
the difficult student who has become toxic to the learning
environment.
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System Factors




Work overload (both sides)
Inadequate supervision
Poor records
Poor support systems
https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf
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Prevalence of problem in residency

Yao and Wright study (1999 survey)
– 94% of programs with at least one resident in difficulty
(Suspect substantial under-reporting)

Areas of Difficulty
– Insufficient knowledge (48%)
– Poor clinical judgment (44%)
– Inefficiency (44%)
– Inappropriate interactions (39%)
– Provision of poor skills (36%)
Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem
residents. JAMA. 2000 Sep 6;284(9):1099-104.
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The Problem Resident: APDIM Survey 2008
- Survey of IM Program Directors
- 268 programs responded (72% of 372 programs)
 IM residents requiring remediation often have deficiencies in
multiple competencies.
 Deficiencies across competencies; remediation most successful
for Medical Knowledge (86%); least successful for
Professionalism (41.2%).
 Application materials rarely help to identify individuals at risk.
 Performance Deficiencies rarely (5.6%) self-identified by
residents.
Denis M Dupras, Randall S Edson, Andrew J Halvorsen, Robert H Hopkins, Furman S McDonalds. “Problem
Residents”: Prevalence, Problems and Remediation in the Era of Core Competencies. The American
Journal of Medicine. Volume 125, issue 4, pages 421 - 425
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The Problem Resident (Continued)
Systems based Practice 13.3
Practice-based Learning &
Improvement
21.8
Remediation success
56
Professionalism
41.2
Interpersonal
Communication
41.4
Organization/Prioritization
RiD with Deficiencey
53
48.5
61.9
41
71.3
Patient Care
53
78.4
Medical Knowledge
47.9
85.8
0
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100
150
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Scenario III

The good student, but…
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What would you do?
Deeper Dive
 Talk about concerns
 Deny and Ignore
 Hope it gets better (on future rotations)

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Primary Prevention
Know the course expectations.
Communication is the key.
Orient the learner well.
Set clear expectations and goals.
Determine the learner’s goals and
expectations.
Reassess mid-course.
Reference : http://www.oucom.ohiou.edu/fd/monographs/difficult.htm
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Secondary Prevention
Pay attention to your hunches/clues.
Don’t wait.
Initiate SOAP early.
Give specific feedback early and monitor
closely.
http://www.oucom.ohiou.edu/fd/monographs/difficult.htm
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Tertiary Prevention
If nothing has worked…. SEEK HELP.
Do not give a passing grade to a learner who
has not earned it.
Document !!!
http://www.oucom.ohiou.edu/fd/monographs/difficult.htm
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Intervention After Problems
Emerge
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A General Approach : SOAP

Subjective:
 What do you and others say? Get feedback from other preceptors
or staff that have had this student.

Objective:
 Document specific incidences or situations with dates.

Assessment:
 Based upon your subjective and objective findings coupled with
input from others, try to diagnosis the problem.

Devise a Plan:
 Talk with the student about your concerns
 Talk to the college to see if they are aware of previous problems?
 Make sure the student is aware of the consequences if problems
continue.
 Progressions, grade reduction, failing the rotation.
Langios JP, Thach S. Managing the Difficult Learning Situation. Fam Med 200;32(5):307-309
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Developing a Differential Diagnosis

Learner:
○ Cognitive, clinical skills, affective, values, personal,
medical illness, substance abuse

Preceptor:
○ Educational knowledge, teaching skills, affective, values,
personal, medical illness

System:
○ work load, time demands, learner supports, preceptor
supports
http://familymed.uthscsa.edu/ACE/chapter10.htm
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Why do we care?

Future Students

Future Residents

Future Fellows

Future Physicians
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Grow Minds, Not Problems
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Not Problems
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Special Thanks
Mallikarjun Samala, MD, MPH, PhD
Post Doctoral Scholar
UofL/Glasgow Family Medicine Residency
Glasgow, KY
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What do we need to discuss further?
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