1. IDENTIFICATION, DIAGNOSIS & REMEDIATION OF THE STRUGGLING LEARNER Jeannette Guerrasio, MD University of Colorado, SOM Chris Knight, MD University of Washington, SOM Dominique Cosco, MD Emory University, SOM SGIM 2016 Annual Meeting

2. DISCLOSURE INFORMATION  The presenters have no disclosures.

3. OBJECTIVES  Describe the impact of struggling medical learners  Diagnose area(s) of learner difficulty  Choose and implement a remediation strategy appropriate to the identified areas of difficulty

4. TIMELINE  Welcome and introduction5 min  Identification and Diagnosis of 20 min Learner Challenges  Large group discussion  Remediation of Specific Deficiencies40 min  Small group discussion  Successes, failures and frustrations10 min  Large group discussion  Brief Summary5 min

5. MAGNITUDE  Medical Students  Up to 15% struggle during their MSIII medicine clerkship  Up to 11% struggle as MSIVs  Residents  Point prevalence in need of remediation 7-15% Paul G, Teaching and Learning in Medicine. 2009: 21(3):254-60. Yao DC and Wright SM. JAMA 2000; 284;1099-104.

6. IMPORTANCE 1. Time 1. Morale 1. Reputation 2. Patient Safety. Lavin, B et al. Acad Med 1998;73(9):998-1002.

7. IN THE LITERATURE  Limitations:  Rare published evidence to guide best practices in remediation 7 Hauer KE. Acad Med 2009; 84(12):1822-1832.

8. 8

9. Adapted from Hauer KE. Acad Med 2009; 84: 1822 -1832. 9

10. IDENTIFIERS  Formal written evaluations of competencies  Peer assessments  Examinations  Written  Clinical performance 10

11. IDENTIFIERS  Verbal comments  Reporting system for concerns  Mid-rotation performance evaluations 11

12. Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832. 12

13. COMPETENCIES:  Medical Knowledge  Patient Care  Interpersonal Skills and Communication  Professionalism  Practice-Based Learning and Improvement  Systems-Based Practice 13 The Outcomes Project. Accreditation Council for Graduate Medical Education. 1999.

14. COMPETENCIES “PLUS”:  Medical Knowledge  Patient Care  Clinical Skills  Clinical Reasoning  Organization & Time Management  Interpersonal Skills and Communication  Professionalism  Practice-Based Learning and Improvement  Systems-Based Practice 14

15. COMPETENCIES “PLUS”:  Medical Knowledge  Patient Care  Clinical Skills  Clinical Reasoning  Organization & Time Management  Interpersonal Skills and Communication  Professionalism  Practice-Based Learning and Improvement  Systems-Based Practice  Mental Well-being 15

16. % of Learners with Deficit

17. CASES #1 17

18. IDENTIFY THE DEFICIT… 1. Medical Knowledge 2. Clinical Skills 3. Clinical Reasoning and Judgment 4. Time Management and Organization 5. Interpersonal Skills and Communication 6. Professionalism 7. Practice-Based Learning and Improvement 8. Systems-Based Practice 9. Mental Well-Being 18

19. ADDITIONAL INFORMATION  Direct Observation  Presentations/Rounds  Interview the Learner  Other Sources 19

20. CASE #2 20

21. IDENTIFY THE DEFICIT… 1. Medical Knowledge 2. Clinical Skills 3. Clinical Reasoning and Judgment 4. Time Management and Organization 5. Interpersonal Skills and Communication 6. Professionalism 7. Practice-Based Learning and Improvement 8. Systems-Based Practice 9. Mental Well-Being 21

22. CASE #3 22

23. IDENTIFY THE DEFICIT… 1. Medical Knowledge 2. Clinical Skills 3. Clinical Reasoning and Judgment 4. Time Management and Organization 5. Interpersonal Skills and Communication 6. Professionalism 7. Practice-Based Learning and Improvement 8. Systems-Based Practice 9. Mental Well-Being 23

24. WHO NEEDS TO KNOW?

25. Make sure the learner receives the feedback as soon as possible 25 Z-Score Assessment Relative to Standard Level of Resident By Expert Assessment Hodges B Acad Med 2001;76(10 S):S87-9.

26. WHO NEEDS TO KNOW? Make sure the learner receives the feedback as soon as possible 26 Z-Score Assessment Relative to Standard Level of Resident By Expert Assessment Hodges B Acad Med 2001;76(10 S):S87-9.

27. WHO ELSE NEEDS TO KNOW?  Medical Student  Clerkship Director  Office of Student Affairs at the SOM  Remediation Team  Resident or Fellow  Program Director  Dean of Graduate Medical Education  Remediation Team 27

28. REMEDIATION TEAM APPROACH  Review the learner’s academic record  Review examples of deficit(s) and confirm deficit(s)  Look for trends and severity 28

29. Adapted from Hauer KE et al. Acad Med 2009; 84:1822- 1832. 29

30. REMEDIATION STRATEGY  The goal of remediation is to target and fix: the greatest deficit! 30

31. Adapted from Hauer KE et al. Acad Med 2009; 84:1822- 1832. 31

32. 32

33. 33

34. SMALL GROUPS  Create a remediation strategy for learner with a given deficit that includes:  Deliberate Practice  Feedback  Reflection 34

36. Unprofessional behavior in medical school Subsequent disciplinary action by the state medical board THE DATA Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.

37. Unprofessional behavior in medical school Subsequent disciplinary action by the state medical board THE DATA Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.

38. Faculty Time in Hours 38

39. Adapted from Hauer KE et al. Acad Med 2009; 84:1822- 1832. 39

40.  Define Success: 1. Has the individual caught up to his or her level of training in the previously deficient competency? 2. Is the improvement sustainable? MEASURING SUCCESS

41. REASSESSMENT  Repeat clerkships/rotations  Standardized patient encounters & simulation  Directly observed encounters in clinical environment  Written or web-based assessments  Chart reviews & Chart-stimulated recall  Multi-source evaluations  Arrival and Departure Times  Attendance  Attire  Responses to self-assessment Patient and procedure logs 41

42. VALUE OF FACULTY TIME?  the odds of probation by 3.1% per hour (95% CI, 0.09-.0.63)  negative outcomes by 2.6% per hour (95% CI, 0.96-0.99) 42

43. 43 Guerrasio J et al. Acad Med. 2014;89(2)352-358.

45. Successes, failures, frustrations, questions?

46. SUMMARY  Challenge of struggling medical learners exist in all programs  IDENTIFY  DIAGNOSE  REMEDIATE with  DELIBERATE PRACTICE  FEEDBACK  REFLECTION IN ACTION  Success for teacher, learner and patients! 46

47. ACKNOWLEDGEMENTS Our Mentors:  Eva Aagaard, MD  Maureen Garrity, PhD  Carol Rumack, MD  Contact:  Jeannette.Guerrasio@ucdenver.edu Jeannette.Guerrasio@ucdenver.edu  www.clinicalremediation.com www.clinicalremediation.com 47

48. 48