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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)S84-7.05/10/2014 15

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

41

41.4

41.2

21.8

13.3

85.8

78.4

71.3

61.9

48.5

56

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.htm05/10/2014

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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