Residents as Teachers Loyola University Medical Center Stritch School of Medicine Graduate Medical Education Session 3A

Dealing with the Difficult Learner

Intended Learning Outcomes Understand the various types of challenging learners Identify opportunities to optimize your guidance and teaching of difficult learners Create a plan for your own difficult learner interactions

Background The literature suggests up to 15% of medical students are identified as “struggling.” Disagreement exists on the definition Identification is important Courage is required These students are often passed along because some teachers don’t have the courage to address issues Identifying and addressing early is key It is our duty: unprofessional student behavior correlates with future disciplinary action

Contributors to the Issue Student-centered problems Where most of us feel the most problems lie System problems Educator issues Ronan-Bentle et al. International Journal of Emergency Medicine :39.

Student-Centered Problems Cognitive Unprepared for one or more aspects of the clerkship Patient care, academic work, assignments Due to poor preparation for clerkship, underdeveloped critical thinking skills, insufficient attention, learning disability May show gaps in basic clinical knowledge Perform poorly in the clinical environment or on exams Easiest to identify and remediate

Student-Centered Problems Non-Cognitive/Personal ACGME: learners should demonstrate basic aspects of professionalism: Integrity Respect for others Responsiveness and sensitivity to patients Accountability May be due to personal stressors, substance abuse, differing belief systems, lack of awareness, conflicting expectations of the objectives of the rotation More difficult to identify Many educators are uncomfortable with addressing

System Problems The structure of the learning environment may be contributing May be different than previous rotation experiences: Different role or unclear role on team More or less autonomy Mandatory rotation that they do not plan to pursue as a specialty May be interpreted as lack of enthusiasm or committment

Educator Issues Rotators may encounter a wide variety of academic and clinical staff Supervisors may not be formally trained in teaching, evaluation, and feedback methods Varying degrees of comfort handling learners with different needs and styles Busy clinicians may see students as a hindrance rather than an asset Residents are often stressed and may identify a student as difficult their own training opportunities are challenged

Identifying the Difficult Learner Often the issue is multifactorial Student-Centered System Problems Educator Issues Pinpointing the source is critical Strategies for addressing the issue will depend on the source We will now focus on addressing student- centered problems

Actions Needed Make expectations and rotation objectives clear Orientation, beginning of interaction Make sure you put yourself in a place to observe the behavior May need direct observation of patient interaction Give specific feedback in the moment! More on this later Engage the learner in the plan to improve Give the opportunity to show improvement Document

Barriers to Action Defensive student Student has frequently received generic, often positive verbal feedback Lack of direct observation or student performance Poor understanding of resources to assist Fear of negative consequences for the evaluator and student Poor documentation of behavior prior to this interaction

Giving Feedback to the Difficult Learner Do this in private Make sure that the learner understands your goal to improve their performance, not only to criticize Be specific about the behavior Being specific can help you consider the etiology as well as the learner understand how to improve Give examples of the behavior

Giving Feedback to the Difficult Learner Explain your assessment of the problem Perception vs. Reality: “When you are consistently tardy to rounds, it is perceived that you do not consider your role on the team as important.” Allow the learner to express their thoughts about the behavior; their view may be very different Give examples of how changing this perception will have wider implications than just succeeding on the rotation (get buy-in) Teacher and learner develop strategies together for management the behavior and for follow up

Documenting the Issue Using the SOAP format can be helpful S: Describe the behavior “Student is repeatedly late.” “Student cannot provide appropriate ddx on presentations.” O: Specific instances of behavior “On 4/15, student arrived 45 minutes late for their shift.” “After interviewing a patient with altered mental status, their only diagnosis was intoxication.” Langlois JP, Thach S: Managing the difficult learning situation. Fam Med (5):

Documenting the Issue A: Differential diagnosis of the difficulty Lateness = professionalism, attitudinal Inadequate knowledge base = cognitive P: Detailed course of action, with learner input “Student will arrive 10 minutes early to each shift and must have shift card signed upon arrival.” “Student will read core chapters on selected topics and be able to list differential diagnoses for several basic patient presentations.”

Consider Your Responsibility Our duty is to create capable and competent physicians We owe it to patients to address concerns and not let worrisome behaviors go undocumented This duty outweighs any potential negative concerns you should have for: The student’s reputation Your own evaluations

Facilitating Remediation Once an improvement plan has been identified Close supervision, providing deliberate practice, immediate feedback (formative), and reflection Strategies Cognitive: will require educational tools  Focused reading or discussion  Simulation Non-cognitive: depends on behavior pattern  Coaching, role-playing  May require bringing in additional expertise Consider involving the student’s advisor or mentor Reassessment and certification of competence Hauer KE, Parish SJ, Reichgott MJ: A model for educational feedback based on clinical communication skills strategies: beyond the “feedback sandwich”. Teach Learn Med 2006, 18 (1),

Student Example: “Taylor Swift” Taylor is a third year medical student doing her pediatrics rotation. Her presentations are extremely long and focus on irrelevant details. She often misses key facts in the history and her physical exams are superficial. Her clinical reasoning is poor, she seems to get easily side- tracked by irrelevant details. On her evaluation, you give her a pass (not high pass, not honors). She comes to you when she receives the grade and is upset. She says she has never received lower than a high pass on the 4 rotations she has already completed. No one has ever told her there was a problem.

Apply SOAP S: Describe Taylor’s problem O: List the specific behaviors A: Assessment Who, me??

Potential Sources Student-Centered Clinical skills deficit NO INSIGHT System None Educator Ineffective feedback

Plan: Improving Insight Guided self-assessments Examples to help Taylor: Review of annotated H&P’s Annotate own H&P (explain why you did; how it could be better) Watch video of herself performing a task, using a checklist, then compare to an video demonstration by an expert Ambrose SA et al. How Learning Works, 2010

Plan: Improving Insight Teach heuristics for self-correction (How to know if you’re off track?) Examples to help Taylor: How many items are reasonable in a differential diagnosis Oral presentations no longer than 5 minutes Require Reflection What part of working up chest pain did you get better at? What part of working up chest pain to you want to learn/practice now? How have your skills evolved over the last 3 rotations?

Potential Sources Student-Centered Clinical skills deficit No insight System None Educator INEFFECTIVE FEEDBACK

Plan: Improving Ineffective Feedback Same team! Common goal Not a reflection of your personal worth Invited feedback works better, should always be expected Give feedback based on what YOU observed, descriptive, neutral, specific Don’t interpret/assume intent of what you saw Limit feedback to what’s fixable Subjective data is ok if labeled as such

Student Example: “Starbucks” Trevor is a Sub-I on a busy cardiology consult service. He often arrives late, frequently “disappears” during the day, when he reappears he’s always carrying a cup of coffee. He does not consistently return your pages. His H &P’s and clinical reasoning seem fine for his level of training. Twice, he failed to write a progress note on a follow up patient after you asked him to do so.

Apply SOAP S: Describe Trevor’s problem O: List the specific behaviors A: Assessment

Potential Sources Student-Centered Mental health Substance abuse Learning disability External stressor Unmotivated Unprofessional System Fatigue Isolation from support network High stakes work Educator Didn’t make expectations clear Didn’t provide feedback

Plan: What to do about Motivation 3 variables Environment: supportive or not? Learner self-efficacy: high or low? Learner values the work and goals: yes or no?

Motivation Don’t See Value RejectingEvading Do See Value HopelessDefiant Don’t See Value RejectingEvading Do See Value FragileMotivated Environment NOT SupportiveEnvironment Supportive Self Efficacy LOW Self Efficacy HIGH Ambrose SA et al, How Learning Works, 2010

Plan: Strategies to Demonstrate Value Connect material to students’ interests “As a cardiologist, you will need to know this” Provide authentic, real world tasks- helps the learner concretely see the relevance Case-based, bedside teaching Show relevance to students’ current academic lives “This will be on the boards” Demonstrate the relevance of skills taught to future professional lives “In my current job I see this frequently” Identify and reward what you value Some services give an award for best H&P Show your own passion and enthusiasm for the discipline Provide flexibility and control: give them choices about what they want to learn ““We can talk about these 3 topics today. Which interests you the most?” Give students an opportunity to reflect “What did you learn?”

Plan: Strategies to Increase Self Efficacy Articulate expectations Learning objectives, orientation Provide rubrics Evaluation forms, milestones Identify an appropriate level of challenge Ask learners what they need to work on, formal needs assessment Ensure alignment of objectives, assessments, and instructional strategies Provide early success opportunities Start with small, easy tasks Be fair

Recap Clear expectations and learning objectives must be provided Identify the behavior with concrete examples Engage learner in the solution Give opportunity to remediate Success depends on early and frequent assessments of the behavior DOCUMENT! If the problem is recurrent or deemed to large to address during the clerkship, the appropriate medical school support should be involved