r. brent wright, md, mmm associate dean for rural health innovation university of louisville school...
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R. Brent Wright, MD, MMMAssociate Dean for Rural Health InnovationUniversity of Louisville School of Medicine
Vice-Chair for Rural Health & Associate Professor
Department of Family & Geriatric Medicine05/10/2014
Dealing with Difficult Students
20th annualPreparing health professionals
for the 21st century
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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 :
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Learner Factors
Teacher factors
System factors
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.pdfhttp://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
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/
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Health Related Family
Financial Personal Habits
Social Cultural
Personality Disorders
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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 sufferingethical conflictsstudent abuse
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/05/10/2014
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Training Related Issues Professional
responsibility for patient caredifficult patients and challenging health
problemssupervision of more-junior residents and
studentsinformation overloadcareer 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:
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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Lack of knowledge of what to specifically document
Fear/anticipation of an appeal process
Lack of remediation options
Lack of documentation
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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:
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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AccessibleAccurate, relevant, and consistent Auditable Clear, concise, and complete Legible/readable Timely, contemporaneous, and sequential ReflectiveRetrievable
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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
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Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000 Sep 6;284(9):1099-104.
– Insufficient knowledge (48%)– Poor clinical judgment (44%)– Inefficiency (44%)– Inappropriate interactions (39%)– Provision of poor skills (36%)
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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.
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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)
Medical Knowledge
Patient Care
Organization/Prioritization
Interpersonal Communication
Professionalism
Practice-based Learning & Improvement
Systems based Practice
0 20 40 60 80 100 120 140 160
47.9
53
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41.4
41.2
21.8
13.3
85.8
78.4
71.3
61.9
48.5
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53 RiD with De-ficiencey
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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
Reference : http://www.oucom.ohiou.edu/fd/monographs/difficult.htm
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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.
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Secondary Prevention
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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
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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.05/10/2014
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
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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, PhDPost Doctoral Scholar
UofL/Glasgow Family Medicine Residency Glasgow, KY
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What do we need to discuss further?
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