CHALLENGING LEARNER
EXAMPLE
1. Give an example of a challenging
learner or a learner in difficulty that you
have worked with.
2. List the difficulties that contributed to
the problem.
Learner in Difficulty:
Strategies for Identification and
Educational Intervention
Northern Constellations 2013
Sudbury
January 19, 2013
James Goertzen MD MClSc CCCP
Associate Professor, NOSM
Medical Director Faculty Development, NOSM
Conflict Disclosure Information:
No financial or industry
relationships to disclose.
Creative Commons Attribution
Noncommercial/No Derivative Works
Canada License
Learning Objectives:
►Review literature on learners in
difficulty.
►Learn strategies for identifying
learners in difficulty, developing
educational diagnosis, and planning
an intervention.
►Reflect on previous experiences
working with learners in difficulty.
►Acquire strategies for supporting
preceptors involved with a learner in
difficulty.
PRECEPTORING
Preceptors who supervise students or
residents on clinical rotations must balance
two essential skills: being a good role model
along with maintaining objectivity to evaluate
learners with a variety of strengths and
weaknesses. This complex mix of role
model and evaluator becomes more
challenging when the preceptor is dealing
with a student or resident in difficulty.
Hunt DD, Tonesk C, Yergan J, Siever M, Loebel JP. Types of problem students
encountered by clinical teachers on clerkships. Medical Education 1989;23:14-18.
PRECEPTORING
Excellent preceptors have burned out and
quit teaching after a challenging or difficult
learning situation.
How can we effectively approach a
challenging learning situation?
Are there strategies that we can use to
prevent a difficult learning situation from
occurring?
LEARNER IN DIFFICULTY
While most students are interested and
capable of learning, a disproportionate
amount of a preceptors time and
energy can be expended in addressing
the needs of a learner in difficulty.
Hicks PJ et al. To the point: Medical education reviews - -Dealing with student difficulties
in the clinical setting. Am J Obstet Gynecol 2005;193:1915-22
CHALLINGING LEARNER
Most medical learners will be quite
successful, but a minority may have
problems ranging from knowledge deficits to
attitudinal and performance deficiencies.
For those with learning difficulties, systems
must be in place for early identification and
design of appropriate educational
interventions.
Hawkins C. The failing resident. Section of Teachers of Family Medicine
Newsletter: Spring, 1997.
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.
LEARNERS IN DIFFICULTY
Learners exhibiting difficulties of any type
can have significant consequences at
multiple levels in their educational system
with impacts on the learner and other
learners, impacts on the preceptor, along
with impacts on the educational institution,
medical profession, and society.
Hicks PJ et al. To the point: Medical education reviews - -Dealing with student
difficulties in the clinical setting. Am J Obstet Gynecol 2005;193:1915-22
PRECEPTOR CHALLENGES
Retaining failing students and failing clinically
unsatisfactory students were identified as the
second and third highest stressors among
female nursing faculty members in Canada.
Failing a student was ranked as the most
problematic responsibility by two thirds of a
group of trained and experienced preceptors
in occupational therapy.
Illot I. To fail or not to fail! A course for fieldwork educators. Am J Occup Ther
1995;49:251-5.
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.
PRECEPTOR CHALLENGES
When assessing the negative behaviors of
a learner, preceptors may feel judgmental or
ill at ease.
Preceptors may feel their role as an educator
is to address the knowledge base of learners
and that addressing behavioral or attitudinal
issues is someone else’s responsibility
Hicks PJ et al. To the point: Medical education reviews - -Dealing with student
difficulties in the clinical setting. Am J Obstet Gynecol 2005;193:1915-22
LEARNER IN DIFFICULTY
A large number of learners who are in
difficulty will eventually perform well if issues
are identified early, an educational
intervention is designed and delivered along
with support systems being put into place for
both the learner and preceptor.
CHALLENGING LEARNER
EXAMPLE
1. Give an example of a challenging
learner or a learner in difficulty that you
have worked with.
2. List the difficulties that contributed to
the problem.
PROBLEM MEDICAL STUDENTS
Objective: Describe the design, implementation, and
evaluation of a remedial program for medical
students with academic difficulties.
Method: Total of 24 British medical students identified in
year 3 & 4.
Results: Causes of academic failure are diverse and often
not academic in nature: deficient study skills,
financial issues along with domestic and emotional
problems. Subjects which students had difficulty all
related to core clinical skills most often involving
communication skills.
Sayer M, Saintonge MCD, Evans D, Wood D. Support for students with academic
difficulties. Med Educ 2002;36:643-50.
PROBLEM MEDICAL STUDENTS
Objective: Identify student problems that most bother
teachers and their relative frequency.
Method: Survey of University of Washington clinical
clerkship coordinators (internal medicine, pediatrics,
psychiatry, obstetrics/gynecology, surgery).
Results: Response rate (466/598) surveys 78%. Frequent:
poor integration skills, disorganized, disinterested,
knowledge deficit, can not priorize, non-assertive, poor
interpersonal skills. Not frequent: hostile, rude,
challenges everything, avoids work, can not be trusted,
substance abuse, manipulative, psychiatric problem.
Hunt DD, Tonesk C, Yergan J, Siever M, Loebel JP. Types of problem students
encountered by clinical teachers on clerkships. Medical Education 1989;23:14-18.
RESIDENTS IN TROUBLE
Objective: Determine prevalence of residents in trouble
over 25 years in one US Family Medicine Residency.
Method: Retrospective record review (summative
transcripts, rotation evaluations, residency director
correspondence, program education committee
minutes) of residents from 1978-2003.
Results: Prevalence of residents in trouble 9.1% (21/226).
Problems included: insufficient knowledge 26.8%,
attitudinal 21.9%, interpersonal conflict 14.6%,
psychiatric illness 12.2%, substance abuse 7.3%,
family stress 7.3%, relationship disruption 4.9%.
Remediation successful in 90% of identified residents.
Reamy BV, Harman JH. Residents in trouble: An in-depth assessment of the 25
year experience of a single family medicine residency. Fam Med 2006;38(4):252-7.
PROBLEM RESIDENTS
Objective: Gain understanding of prevalence,
identification, management, and prevention of problem
residents within internal medicine residencies.
Method: Survey of American Internal Medicine Directors.
Results: Response rate (298/404) surveys 74%. Prevalence
of problem residents 6.9%. Most frequent difficulties:
insufficient knowledge 48%, poor clinical judgment
44%, inefficient use of time 44%. Underlying factors:
stressors 42% and depression 24%.
Yao DC, Wright SM. National survey of internal medicine residency program
directors regarding problem residents. JAMA 2000;284(9):1099-1104.
PROBLEM RESIDENTS
Objective: Determine prevalence/nature of residents in
academic difficulty across postgraduate programs at
University of Toronto.
Method: Cases brought before Postgraduate Board of
Examiners (1994-2000) were reviewed.
Results: 65/7134 (1.5%) residents identified with mean of
2.1 academic problems: affective 31% (depression,
marital problems, low self esteem, illness), cognitive
96% (knowledge deficits, poor written skills), structural
18% (lack of organization/time management skills),
interpersonal 22% (difficult interactions with patients
or faculty), psychomotor 29% , professional
behavior 9%.
Catton P, Hutcheon M, Rothman A. Academic difficult in postgraduate medical
education: results of remedial programs at University of Toronto. Ann R Coll Physicians
Surg Can 2002;35(4):232-7.
PROBLEM RESIDENTS
Objective: Obtain information on the magnitude of the
problem of unacceptable performance by psychiatric
residents.
Method: Survey of American Psychiatric Directors.
Results: Response rate (106/204) surveys 52%. Out of
5,491 residents: 3.3% terminated or resigned,
additional 2.5% involved in deliberations for dismissal.
Reasons for termination: gaps in knowledge 35.8%,
interpersonal problems with staff, residents, or
patients 21.6%, psychological disturbances 17.4%,
irresponsible behavior 16.8%, unethical behavior 4.3%,
illegal behavior 3.8%.
Roback HB, Crowder MK. Psychiatric resident dismissal: A national survey of
training programs. Am J Psychiatry 1989;146:96-8.
PROBLEM RESIDENTS
Objective: Explore prevalence and causes of problem neurology
residents.
Method: Survey of American neurology program directors.
Results: Response rate 75% (95/126). Most prevalent problems
exhibited by residents: 91% - patient care issues (inappropriate
management, poor clinical judgment, poor humanistic
qualities), 74% - professionalism issues (late or absent, being
untrustworthy, moral issues), 62% - interpersonal or
communication issues (inappropriate interactions with staff
and patients), 56% - medical knowledge issues. Most common
underlying causes: stress in resident’s personal lives (48%),
personality disorders (42%), poor preparation for residency in
medical school (25%), cultural differences (22%).
Tabby DS, Majeed MH, Schwartzman R. Problem neurology residents: A national
survey. Neurology 2011;76:2119-23.
PROBLEM PATIENTS
We can extrapolate from familiar principles
used in working with difficult or problem
patients when working with difficult students
or residents. These principles include trying
to better understand learner’s context,
exploring issues within learner/teacher
relationship, and examining our emotional
responses to the situation.
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993; 25: 627-32.
IDENTIFICATION
Although preceptors are able to reliably
identify poor students, they do not handle
them well. What needs to be done is to
document the learner’s weakness and to
make explicit requirements for satisfactory
performance.
Association of American Medical Colleges, clinical evaluation project. The
evaluation of clinical clerks: perceptions of clinical faculty, 1983.
SUSPECTING A PROBLEM
Teachers wonder if they are involved with a
challenging learner:
• Deficit in knowledge base
• Critical clinical incident
• Conversation with another
colleague/preceptor
• Complaints from office staff, nursing, or
patients
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993;25:627-32.
SUSPECTING A PROBLEM
Teachers wonder if they are involved with a
challenging learner:
• Attitudinal or interpersonal relationship
difficulties
• Intuitive sense by preceptor that learner is
not performing at expected level
• Gut feeling there is a problem
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993;25:627-32.
WHAT IS THE CHALLENGE?
Learner problems occur in the areas of knowledge,
skills, or attitudes:
• Knowledge problems can be the result of
deficiencies in the basic or clinical sciences.
• Skill problems include deficits with
interpretation of information, performance of
technical skills, or organization of work.
• Attitudinal problems include difficulties in the
doctor/patient relationship, interpersonal
conflicts, sense of responsibility, or self
assessment.
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993;25:627-32.
PRECEPTOR RESPONSES
Preceptor responses to a challenging or
difficult learner include:
• Denial
• Avoidance
• Desire to rescue or protect
• Anger or frustration
• Helplessness or impotence
• Concern
• Motivation to face the challenge
• Quit preceptor role
LEARNERS’ RESPONSES
Common learner responses when labeled
as a problem include:
• Anger or aggression
• Avoidance
• Anxiety
• Insecurity
• Defensive
• Stressed
• Relief
• Motivation
CONTRIBUTING FACTORS
Learner difficulties are often seen as
residing solely with the resident or student.
Preceptor and systems’ factors should also
be considered to ensure the complete
picture is seen.
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993; 25: 627-32.
PRECEPTOR FACTORS
Preceptors just as learners are human and
have specific expectations, assumptions,
and values. Personal illness, burnout,
loss of a partner or staff member, financial
pressures, family issues, patient
demands, and personality clashes can
have a significant effect on the
teacher/learner relationship.
PRECEPTOR FACTORS
1. Is the presence of a learner preventing
me from doing what needs to be done in
my practice?
2. Are my personal issues seriously
affecting the education of a learner?
Langlois JP, Thach S. Managing the difficult learning situation. Fam Med
2000;32(5): 307-9.
SYSTEM FACTORS
System problems may also be a factor which
impact on the learner, preceptor, or both: too
much work, not enough time, unclear
standards, expectations, or responsibilities;
difficult or demanding patients, little positive
feedback, and lack of administrative support.
Steinert Y, Levitt C. Working with the “problem” resident: Guidelines for definition
and intervention. Fam Med 1993; 25: 627-32.
CLARIFYING A PROBLEM
Process of data gathering and clarification
include:
• Talking to the learner
• Observing the learner in different
situations
• Discussing cases with the learner to clarify
their knowledge base and thought
process
Steinert Y, Nasmith L. The “problem” resident: Who’s problem is it? Conjoint
Conference on Medical Education, Toronto, 1998.
CLARIFYING A PROBLEM
Process of data gathering and clarification
include:
• Talking to colleagues, nurses, and support
staff (confidential and professional
manner)
• Contacting program director early to share
potential concerns and plan an
educational intervention
Steinert Y, Nasmith L. The “problem” resident: Who’s problem is it? Conjoint
Conference on Medical Education, Toronto, 1998.
SOAP APPROACH TO THE
CHALLENGING LEARNER
Subjective: What do you and others think?
Objective: What are the specific concerning
behaviours that are observed?
Assessment: Differential diagnosis of the
challenging learner/preceptor interactions.
Plan: Gather more data, get help, give
feedback, recommend changes, monitor,
and support learner.
Langlois JP, Thach S. Managing the difficult learning situation. Fam Med 2000;
32(5):307-9.
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
DOCUMENTATION
It is common for preceptors to be aware of a
challenging learner, share this information
with each other but make no mention of
these concerns on the evaluation. Failure
to identify and document a problem are fatal
flaws frequently encountered in dealing with
a challenging learner.
McGraw R, Verma S. The trainee in difficulty. CJEM 2001;3(3):205-8.
A colleague approaches you and wants to
discuss Jason, your student on a 3rd year
comprehensive community clerkship.
Your colleague starts: “How did he make it
through this far without something being
done?” His comments include: “notes are
poor”, “examination skills are minimal”,
“functioning at weak 2nd year”. Your
colleague is angry and implies that last
night’s emergency shift was the last straw.
How do you respond to your colleague?
After thanking your colleague for bringing
his concerns to your attention, you ask him
to clarify what happened last night.
“I asked Jason to summarize a patient
visit: he handed me the chart and said
here.” “No, I would like you to tell me
what you found.” “Jason replied” so you
want me to play the game.” “I was so put
off, I saw the patient myself and told Jason
to shadow me for the rest of the shift.”
What would you do next?
JASON:
Subjective: What do you and others think?
Objective: What are the specific concerning
behaviours that are observed?
Assessment: Differential diagnosis of the
challenging learner/preceptor interaction.
Plan: Get more data, get help, give
feedback, recommend changes, monitor,
and support learner.
With support, your colleague elaborates:
Jason’s behavior in the ER has been
frustrating. He sits around with his feet
on the desk using his iphone. Nurses
are angry due to his juvenile comments,
inappropriate humour, rude greetings to
patients, and his helplessness with any
assigned task.
What would you do next?
JASON
List several strategies you can use to gather
more data to develop an educational
diagnosis:
1.
2.
3.
4.
5.
6.
You step back and reflect on the first
month with Jason. His admission notes
are incomplete with physical exam often
left out and a promise to do it later. One
day while seeing a patient, you asked to
borrow his stethoscope. He handed it to
you saying “knock yourself out.” Last
week your feedback on his attempts at
patient humour included a suggestion
that he work on being more empathic.
His response: “This is the way I am; you
live by the sword and die by the sword.”
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
JASON:
Subjective:
Objective:
Assessment: Problem List/Diagnosis
Learner
Preceptor
System
Plan:
UNPROFESIONAL BEHAVIOR
Purpose: Determine if medical students who demonstrate
unprofessional behavior are more likely to have
subsequent licensing board disciplinary action.
Method: Case control study of all California medical school
graduates disciplined by the California Medical Board
from 1990-2000 (68 graduates). Control graduates (196)
were matched by medical school graduation year and
specialty. Variables examined included gender,
undergraduate GPA, MCAT scores, National Board
Examination Part 1 scores, negative excerpts
describing unprofessional behavior in rotation
evaluations, Deans letters for residency placement,
and administrative correspondence. Out come
variable was state board disciplinary action.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in
medical school is associated with subsequent disciplinary action by a state
medical board. Acad Med 2004;79(3):244-9.
UNPROFESIONAL BEHAVIOR
Results: Medical students graduated from 1943-89. 95% of
disciplinary actions were for deficiencies in
professionalism. Prevalence of negative excerpts in
undergraduate evaluations was 38% and 19% in
controls. Logistic regression analysis showed that
disciplined physicians were more likely to have
negative excerpts (Odds ratio 2.15; 95% CI 1.15-4.02;
p = .02).
Conclusion: Problematic behaviour in medical school is
associated with subsequent disciplinary action by a
state medical board. Professionalism is an essential
competency that must be demonstrated for a student
to graduate from medical school.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in
medical school is associated with subsequent disciplinary action by a state
medical board. Acad Med 2004;79(3):244-9.
Learning Objectives:
►Review literature on learners in
difficulty.
►Learn strategies for identifying
learners in difficulty.
►Provide opportunity to reflect on
past experiences when preceptoring
a learner in difficulty.
►Provide strategies for supporting
preceptors involved with a learner in
difficulty.
CHALLENGING LEARNER
A successful intervention with a learner
who is having problems can be one of
the most rewarding experiences
for a preceptor and a critical experience
for the learner.
Kahn NB. Dealing with the problem learner. Fam Med 2001;33(9):655-7.
LEARNER IN DIFFICULTY
Early identification is important
Involve colleagues and program director
Explore preceptor issues
Understand learner’s context
Questions
Comments
Reflections
Exceptional Learners
What challenges to they pose?
Are they stimulated enough?
Can we teach them anything?
How do we give feedback and just not praise?
jgoertzen@tbaytel.net