Anna Chang, MD Andrea Marmor, MD, MSEdAssociate Professor, Geriatric Medicine Associate Professor, Pediatrics

University of California, San Francisco

Introductions Defining the problem:

Who is a “difficult” learner? How can we help them?

Description of the SOAP approachWork on cases in small groupsLarge group review and wrap-up

What departments are we from?Who do we teach?Key words: What types of difficult

learners do we encounter? E.g., late, rude, deferential, slacking off

1. Adherence to ethical practice principles

2. Effective interactions with patients and those important to patients

3. Effective interactions with people working in health care system

4. Reliability5. Commitment to autonomous

maintenance/improvement in oneself, others and systems

Wilkinson 2009

Unprofessional students/residents more likely to subsequently be disciplined by Board Papadakis: 2005, 2008

Other reasons?

Hickson, 2007

Pre-Clerkship Clerkship/Residency

Formal • Orientation week• TLCS • OSCE• Critical reflections• Patient interviews• FPC curriculum

• Intersession• Supervisor

evaluations• Case reviews/M and M• USMLE step 2 CS• Structured clinical obs• Specialty boards

•Faculty mentors•Peer/faculty evaluations•Attendance and participation policy•Remediation

Informal

• White coat ceremony• Small Group dynamics

• Graduation (oath, etc)• Team dynamics• Bedside teaching

•Role modeling (peers, teachers)•Personal reflection

Pre-Clerkship Clerkship/Residency

Formal • Orientation week• TLCS • OSCE• Critical reflections• Patient interviews• FPC curriculum

• Intersession• Supervisor

evaluations• Case reviews/M and M• USMLE step 2 CS• Structured clinical obs• Specialty boards

•Faculty mentors•Peer/faculty evaluations•Attendance and participation policy•Remediation

Informal

• White coat ceremony• Small Group dynamics

• Graduation (oath, etc)• Team dynamics• Bedside teaching

•Role modeling (peers, teachers)•Personal reflection

Hidden •Unintended role modeling•Normative culture

1. Recognize broad categories of professionalism problems in learners

2. Become familiar through practice with several approaches to recognizing and helping difficult learners

3. Know what resources are available to help with dealing with professionalism problems in learners.

1. Recognize broad categories of professionalism problems in learners

2. Become familiar through practice with several approaches to recognizing and helping difficult learners

3. Know what resources are available to help with dealing with professionalism problems in learners.

1. Recognize broad categories of professionalism problems in learners

2. Become familiar through practice with several approaches to recognizing and helping difficult learners

3. Know what resources are available to help with dealing with professionalism problems in learners.

Application of a clinical framework to an educational problem Learner-centered, instead of patient-

centeredTakes us from our impressions

(subjective) to a plan for action and reassessment

The judgment/sense that there is a problem “Current Complaint”

Should drive initial hypotheses (“differential diagnoses”) but not assessment

Consider: Personal reactions Alternate explanations for behavior

Collection of information to support/refute hypotheses (“differential diagnosis”)

Consider: Multiple sources of information Scope of problem

▪ 5 domains of professionalism▪ Settings affected▪ Isolated vs. pattern

Classroom Faculty evaluations Peer evaluations Paper or SP Exams

Clinical Training Faculty/resident/

student evaluations Critical incidents Observation of

clinical encounters

Practice-Based Patient satisfaction Self-administered

rating scales 360 degree

evaluations

Reflectiveness Advocacy Lifelong learning Dealing with uncertainty Balancing availability to others with

care of self Seeking and responding to results of

an audit

Wilkinson 2009

Your “working diagnosis”, after collection of objective data

Consider the differential: Are there other possibilities? How will you distinguish between them?

1 Address learner directly• Focus on behavior, not personality• Assess their self-awareness

2 Remediate• Individualized intervention • Target to specific goals

3 Reassess• When?• How?

Clinical and classroom vignettes Represent different challenging learners Your task: 30 minutes

Use the discussion guide to apply the SOAP method to these learners

May modify the specifics to suit your setting Large group discussion:

Be prepared to present on your hypothesis-generation, assessment and initial plan

Each group will present your SOAP approach to your case

Focus on hypotheses (S), information-gathering (O) and initial assessment (A)

Larger group: brainstorm on Plan

Senior resident on inpatient serviceReputation for academic strengthRecently has acted

disinterested/burnt-out Interns/students intimidatedBackground:

First in family to attend college, leader in medical school

3rd year med student with PhDLate to clinic session, poor job on H

and P and presentation However, good knowledge of

pathophysiologyDoes not respond to feedback on

these issuesThinks he performed well, feels others

are uncomfortable with his intelligence

4th year student on nephrology elective Expresses enthusiasm about learning,

and gets her work done Looking at/typing in smart phone on

rounds, in patient rooms and during teaching

Others have noticed, but aren’t sure how to handle it

Unclear if she is using phone for learning or personal

Senior resident on ward, cheerful and enthusiastic

Allegra talks over others, humor is a little off

Gifted in psychosocial assessments, but misses some important clinical details

Background: community advocate, academic difficulty, “learning disability”

Hickson, 2007

Remediation successful in cognitive domains Easier to measure Review by Hauer, et al 2001

What about professionalism? We’re just starting to learn about this….

We need to be leaders in this area

Use real incidents as examples Critical reflection

Clear expectations Use frameworks (Wilkinson, SOAP, etc) Individualized improvement plan

Instruction with practice, feedback and reflection Explicit faculty mentorship Reassessment and certification of

competence Use existing infrastructure

Attributed to Gandhi

Small group covers clinical and personal issues

Steve rarely contributes verbally Will scribe for group, performs well on

written assignments3 other group members are very

talkativeToday he started to speak but very

quietly, then withdrew

First year student, lecture series that includes patient interviews

Tara sits in the front, plays games/checks news on laptop

Regularly comments during lecture Occasionally disrespectful to lecturers Always warm and engaging with families

SOM core curriculum small group setting

RT comes late, pulls out computer Usually disengaged, occasionally

dominatesFacial expressions show

boredom/disrespect for you and other students