The medical student in difficulty; how to help them before it becomes a legal matterM. A. Forgie, Associate Dean, UGME,G. Renaud, Academic Advisor, UGME, L. Laramée, Assistant Dean, Student Affairs

Objectives

• Know why students get into difficulty• Be knowledgeable about the resources available

to students in difficulty• Understand the process of student promotion

Workshop outline: Medical student in difficulty

• Context• Evaluation process• Exam process• Appeal process• Resources• Framework for assessment• Case presentations

MD Program Facts and FiguresProvide over 18,000 hours of dedicated teaching per year

Process over 11,000 stipends per year

Students have over 1,620 teachers

Class size 165 (48 francophone)

Fully accredited until 2018

Currently top accredited medical school in Canada

Only bilingual MD Program (dual curriculum)

Aboriginal stream (graduate 100 by 2020)

Over 3500 applicants

Entry cohort 2011 had highest mean GPA in Canada

Highest number of applicants in Canada in 2011 entry cohort

2. Understanding the context...

MD program leadership

MD program operations team

+ 12 hospital coordinators (5 TOH)

Préexternat/Pre-clerkship

Intr

oduc

tion

Unité des fondements de la

médecine /Foundations Unit

Unité II / Unit II

DAC / SCS / PSD

Externat/Clerkship*

Chirurgie / Surgery

Stages à option

obligatoire / Mandatory Selective

Psychiatrie / Psychiatry

Stages au choix/ Electives

OB / GYNPédiatrie /

PaediatricsMédecine familiale /

Family Medicine

Soinsaigus / Acute Care

Medicine

Médecineinterne / Internal

Medicine

Prépara-toire /Link

Stag

e m

éd. i

nter

ne /

Inte

rnal

med

. Se

lect

ive

Unité III / Unit III Unité d’intégration /Integration Unit

ECOS/OSCE

* Il existe une variété d’horaires pour les stages/ There are several different rotation schedules

ECOS/OSCE

Stages au choix / Electives

Module 1 Module 2 Module 3 Module 4

DAC / SCS / PSD 

Stages au choix / Electives

Stages au choix/ Electives

SIM

1

2

3

4

SIM

Retour aux principes essentiels

Back to Basics

Designed by: Anjali Rajani

Sept. Jan. Sept.

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University of Ottawa MD Program

Unité I / Unit I

e e

Stag

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n ch

irurg

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urge

ry

Sele

ctiv

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Stag

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Com

mun

auta

ire/

Com

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Portfolio on Core Competencies

Portfolio on Core Competencies

Portfolio on Core Competencies

Portfolio on Core Competencies

3. Protecting privacy and rights of patients, learners and teachers: can we do all of this at the same time?

Evaluation process

• Exams (written, practical, OSCE, essays)• Small group teaching (CBL, TBL)• Clinical evaluations (PSD, rotations)• Mini-clin Ex• Core competencies (E portfolio)• 360˚

Process of evaluation

Student writes exam

Exam corrected by

UG teamDirector of evaluations

Trouble questions flagged

Promotions Committees

Promotion executive committee

Exam Process

• Marks are approved and finalized by the Promotion Executive Committee.

If a student does not agree: referred to appeal process

Appeal Process

The appeal process is available on-line under: Faculty of Medicine Regulations

www.intermed.med.uottawa.ca/Students/MD/assets/documents/Faculty of Medicine

Regulations_2011_EN.pdf

Appeal of a summative evaluation

1. The student is encouraged first to approach the chairperson of the unit, link period or clinical rotation

2. If concern still persists, the student may submit a written request for review to the Associate Dean, UGME, within 2 weeks of the first official communication of the summative evaluation results.

Appeal of a summative evaluation

Such a request shall identify:

a) The unit or clinical rotation in questionb) The tutor or clinical supervisor whose

evaluation is in questionc) A statement of the grounds for the review

Appeal Process

Student appeal

PEC

Dean’s Review Committee

Faculty Council

Senate (C.A.)

Resources….

Guylaine Renaud Academic Advisor, UGME

grenaud@uottawa.ca613-562-5800 ext. 8427

If a student is in trouble

• Meet with the student• Inform the Rotation Director• Inform the Pre-clerkship or Clerkship Director• Refer to the Academic Advisor• Refer to Student Affairs Office• Refer to UGME Dean

Resources

1) Faculty Wellness Program Dr. Derek Puddester, Directorwww.med.uottawa.ca/Wellness wellness@uottawa.ca613.562.5800 ext. 8507

Resources

2) OMA PHP - Ontario Medical Association Physician Health Programwww.oma.org/Benefits/Pages/PhysicianHealthProgram.aspx

Resources3) SASS – Student Academic Success

Servicewww.sass.uottawa.ca/welcome.php• Student mentoring• Academic Writing Help Centre• Access Services• Counselling and Coaching Service• Office for the Prevention of Harassment

and Discrimination• Aboriginal Resource Centre

Resources

4) UGME Academic Advisor; my role• Academic Concern List• Support for written, practical and OSCE examinations • Clinical Skills Support Program (CSSP) • Mentoring/tutoring services • Clerkship planning throughout the medical education

program • Career strategy (CaRMS) • Accommodations

Student Affairs Office - SAO

Dr. Louise Laramée,Assistant Dean, Student Affairs

louise.laramee@uottawa.ca 613.562.5800 ext. 8136

Student Affairs Office

• Health and Wellness• Manage stress, deadlines, anxiety, resiliency

building • Personal and couples Counselling• Study habits, learning strategies, link with SASS• Financial Aid• Mentoring Program• Advocacy• Accommodation

A Student in difficulty ?….or

a difficult student ?

Sometimes, it’s both

Dyrbye et al, Mayo Clin Proc, December 2005

Why they get in trouble…

How they get in trouble…

Knowledge

Skills

Attitude

COGNITIVE:Knowledge or skills deficitsDifficulties with reasoning

Manifestations:• Incomplete or missing

information• Difficulty organizing

information• Inability to integrate knowledge• Poor problem solving• Poor abstract thinking• Immature critical thinking

Possible contributing factors:• Non-cognitive issues (attitude

or structural)• Mismatch between

teacher/student expectations • Learning disability• Difficulty with concentration

(uncontrolled anxiety, ADD/ADHD)

Modified from Cox (2005)

NON - COGNITIVE:Behavioral / professionalism

or Structural

Behavioral / professionalism• “Disappearing act” : tardiness, frequent

absence, not participating, not answering pages

• Low work rate, “bypass syndrome”• Interpersonal conflicts, inability to work

in a team• Disruptive behavior, outbursts• Rigidity, intolerance to ambiguity• Manipulation, dishonesty• Lack of insight : poor self assessment,

challenges constructive feedback

Non-cognitive (structural)• Poor time management• Poor organizational skills• Difficulty prioritizing• Poor study habits / discipline

Modified from Cox (2005)

NON - COGNITIVE:Behavioral / professionalism

or Structural

• Poor motivation, career choice uncertainty

• Hidden curriculum• Harassment, abuse• Personality traits and disorders• Substance abuse• Stress, fatigue, inability to cope• Financial crisis

• Relationship issues• Life events, grief• Competing responsibilities• Physical health issues• Mental illness• Burnout, loss of empathy,

depersonalization

POSSIBLE CONTRIBUTING FACTORS:

Who can help them?

“Until teachers hold themselves accountable for the professional development of the learner, assessment, feedback and directed remediation regarding professionalism will be postponed and the development of the learner will be suboptimal.”

“..Teachers may inadvertently reinforce problematic behaviors if they do not give timely feedback with specific strategies for improvement.”

P. Hicks et all. Dealing with student difficultiesin the clinical setting. AJOG, 2005.

It’s everyone’s business

Strategies for the teachers and preceptors

in the trenches

Steps in managing underperformance

1. Address underperformance at the time it occurs (not waiting for next assessment). Ensure to Interview in private

2. Be clear in the way that the observed behavior or performance differs from that expected; give factual examples. Don’t assume the student has insight into the situation.

3. Generate a climate of trust, respect, objectivity and low tension4. Explore with the trainee the cause of the problem, including personal,

professional pressures. Offer confidential psychological support or referral where appropriate.

5. Some difficulties are critical and require immediate involvement of relevant academic administration.

6. Invite the learner`s suggestions and input for realistic plan to address the problems

(Modified from Paice & Orton, 2005)

Steps in managing underperformance

7. Agree for a plan for improvement within a reasonable timeframe8. Be knowledgeable regarding available resources and inform the

learner 9. Document the process, discussions, expectations and outcomes;

share these documents with the trainee as you go along10. Always include a scheduled follow-up evaluation with clear

consequences for failure to improve11. If performance has not improved after review, consider other avenues12. Provide supervision, training, mentoring or coaching to assist the

trainee13. Avoid taking on the role of the physician, therapist, buddy, parent

(Modified from Paice & Orton, 2005)

The teacher vs. the student in difficultyPros and Cons of getting involved

The Cons :• May be hard to recognize the occasional

learner in difficulty• May not seem so important yet if there is no

documented issue with patient safety yet• Reluctance to face uncomfortable

conversation• Sense of guilt for not having done a better

job of training• Fearing lack of insight, denial, counterclaim• Hoping the problem will resolve itself• Lack of documentation (factual)• Lack of knowledge of the support structure

and resources to student and teacher at the Faculty

• Unaware of remedial options

The Pros:• Delay only makes matter worse• Harder to challenge behavior that has gone on

tacitly accepted• More effective to be clear from the start about

standards of behavior / performance, feed back constructively and consistently

• Breaches may compromise patient safety• Written comments are more useful than

checklists• Evaluators identify with a sense of

responsibility to fail a trainee to ensure patient safety

• Most evaluators feel confident in their ability to determine if performance is adequate or not

Modified from Dudek (2005), Paice (2009)

S.O.A.P. Framework for assessing underperformance

Subjective: Your impression of the student’s difficulty• Ex. Disorganized, inattentive, rude, withdrawn…

Objective: • document specific examples of the problem, unacceptable behaviors that

are observed, clinical errors• don’t dismiss just the feeling that something is not quite right• triangulate with others, include the learner with this step• contact the pre-clerkship or clerkship director and see if this is a recurring

issue

Modified from Langlois & Thach, (2000)

S.O.A.P. Framework for assessing underperformance

Assessment: Differential diagnosis of the problem1) Is the problem real? (Maybe there is miscommunication or different versions)2) Is the problem important? 3) Is it knowledge, skills or attitude? 4) Could there be other concerns : Cognitive, Health, personal, financial, disability,

Plan: • Gather more data: observe and record, discuss with learner, contact school• Intervene: detailed behavior-specific feedback, specific recommendations for change,

re-evaluation• Get help: not the last resort. Get assistance from Faculty, UGME, SAO• Include the learner in developing the plan• Don`t become the student`s physician or therapist, it is not the duty of the preceptor

to solve all the problems of the learner.

Modified from Langlois & Thach, (2000)

Students with disability

Core principles of the ADA and Ontario Human Rights are :

• Non-discriminatory inclusion and reasonable accommodation

• The ADA placed disability status on the same level as gender, race, and ethnicity in terms of non-discrimination requirements

• It is a moral charge to “take active steps to ensure that our healthcare practitioner community mirrors society’s gender, racial and ethnic mix. Similar to race, gender, and ethnicity, incorporation of people with disabilities is a means to improve access to health care on the part of the underserved—people with disabilities”

Accommodations

• Reasonable accommodations must only be provided for disabilities that have been made known to the school, and for which an accommodation has been requested.

• The evidence necessary to document a disability should include an evaluation by a trained professional, conducted by accepted methods that yield objective and factual data.

• The medical school is responsible for the cost of the reasonable accommodation.

• The definition of essential requirements / functions and reasonable accommodation are evolving

• Accommodations are seen as unreasonable when altering the test would lower academic standards or significantly alter the academic program.

• Extended time for examination is often granted to students with various disabilities.

Accommodation processReasons for accommodation:

Academic:• Learning disability• ADD / ADHD• Mental health• Physical health : permanent or temporary

Non – Academic:• Religious (e.g. time off, space for prayer..)• Physical accessibility• Physical need (e.g. space/time for breastfeeding, )

Student Accommodations Process

1•Student meets with accommodations counsellor at SAO•Fills out request for accommodations form : Academic vs. Non Academic accommodation•Is explained the process and signs the consent

•Student meets with accommodations counsellor at SAO•Fills out request for accommodations form : Academic vs. Non Academic accommodation•Is explained the process and signs the consent

2•Appropriate expert supporting documentation is requested from the student•Psycho educational assessment•Ex. medical certificate: functional limitation, goal of accommodation, suggested recommendations

•Appropriate expert supporting documentation is requested from the student•Psycho educational assessment•Ex. medical certificate: functional limitation, goal of accommodation, suggested recommendations

3•Student meets with Assistant Dean, SAO, to review request, obtain precisions•Request is discussed by Student Accommodations Exec Committee•Student meets with Assistant Dean, SAO, to review request, obtain precisions•Request is discussed by Student Accommodations Exec Committee

4•Presentation of request for accommodations to full SAC•Discussions regarding recommended adaptive measures•Presentation of request for accommodations to full SAC•Discussions regarding recommended adaptive measures

5•Presentation at Promotions Executive Committee •Request and recommendations are either accepted, rejected or modified•Presentation at Promotions Executive Committee •Request and recommendations are either accepted, rejected or modified

6•Granted accommodation is implemented•Student is made aware•SAO team remains available to support the student

•Granted accommodation is implemented•Student is made aware•SAO team remains available to support the student

Now it is your turn….

• 3 Cases

• CBL format

• Use S.O.A.P. framework for assessing underperformance (handout)

Case 1:

You are the pre-clerkship director and have a 1st year student who has the following marks on her exams:

• Foundations Unit: 48%• Unit 1: 54%• What would you do?

Case 2:

You are the CBL tutor and have a student who frequently misses CBL sessions.

• When the student is present, he performs well and is very professional, well prepared for sessions and interacts well with the group.

• What would you do?

Case 3:You have a student with you in clinic who seems to cry easily with constructive feedback and who seems overly stressed and not doing well

• You take her aside and ask her what is wrong and she recounts a story of being mistreated by her previous preceptor who failed her on a rotation

• What would you do?

Review of objectives

• Know why students get into difficulty• Be knowledgeable about the resources

available to students in difficulty• Understand the process of student

promotion

Merci. Thank you.Questions?