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CHALLENGING LEARNER EXAMPLE

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

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CHALLENGING LEARNER EXAMPLE

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  1. 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.

  2. 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

  3. Conflict Disclosure Information: No financial or industry relationships to disclose. Creative Commons Attribution Noncommercial/No Derivative Works Canada License

  4. 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.

  5. 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.

  6. 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?

  7. 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

  8. 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.

  9. 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.

  10. 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

  11. 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.

  12. 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.

  13. 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

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  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.

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  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.

  24. 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.

  25. 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.

  26. 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.

  27. 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.

  28. 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

  29. LEARNERS’ RESPONSES Common learner responses when labeled as a problem include: • Anger or aggression • Avoidance • Anxiety • Insecurity • Defensive • Stressed • Relief • Motivation

  30. 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.

  31. 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.

  32. 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.

  33. 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.

  34. 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.

  35. 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.

  36. 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.

  37. 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

  38. 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.

  39. 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?

  40. 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?

  41. 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.

  42. 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?

  43. JASON List several strategies you can use to gather more data to develop an educational diagnosis: 1. 2. 3. 4. 5. 6.

  44. 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.”

  45. 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

  46. JASON: Subjective: Objective: Assessment: Problem List/Diagnosis Learner Preceptor System Plan:

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