Learners in Difficulty:The “Problem” Student

Joseph O. Lopreiato MD, MPHAssociate Dean for Simulation Education

Professor of Pediatrics

Acknowledgment

Drs. Catherine Lucey, Richard Hawkins and

Eric Holmboe

Clerkship Director

Residency Program Director

USU Student

Promotions Committee

Outline

Define the problem

Define the approach as a teacher

Present a strategy to approach to the problem

Definition

• “A trainee who demonstrates a significant enough problem that requires intervention by someone of authority”

ABIM

Learner /School Dilemma

• Conflicts:– Student advocate role– Societal and professional obligations– Institutional loyalty

• Tendencies:– Minimization and temporization• Second chances• Will get better if you work harder• Difficulty in providing negative evaluation (clinical)

USUHS Pre-clinical: Magnitude

Fundamentals:• 98% Pass• 2% Fail or incomplete

Preclerkship CPR module:• 12% Honors• 85% Pass• 2% Fail or Incomplete

USUHS clinical: MagnitudePediatrics:• 16% A• 44% B• 5% C• 3% Fail or incomplete

Internal Medicine:• 25% A• 40% B• 12% C• 4% Fail or incomplete

Approach to evaluation

Symptoms HPI/ PMHx Differential Dx Final Dx

Symptoms: Potential Problem Noted

Low clinical/small group discussion rating

Complaint

Peer incident

Low exam/quiz scores

Poor OSCE performance

Learner self-identified

Symptoms: in Clinical Arena

Direct observation in clinical setting

Critical incident

Poor performance at morning report

Neglecting patient care responsibilities

Yao and Wright, 2000

HPI/PMHx

What happened?

What are the circumstances

Happened before?

Want to talk about it?

Feelings?

Differential Diagnoses

• Study Time/Study Methods/Test taking (OSA)

• Energy (motivation)• Context & Culture (engineer vs. physician)

Organizational Causes:

• Dispersed • Elaborated

Knowledge Causes:

(Bordage)

Differential Diagnoses

• Deprivation (sleep, relationships)• Distraction (family, money)• Depression• Dependence on drugs and alcohol• Disordered personality• Disorders of Learning (ADHD, LD)• Disease

Lucey’s Causes (7Ds):

Lucey Reference ########

Deprivation

Distractions

Depression and Anxiety

Liselotte N. Academic Med 2006;81:354-373

Dependence

Disorders

Disease

Diabetes

Organic brain syndrome

Thyroid disease

Malignancy

Eating Disorders

Post Partum Depression

Etc…

• Deprivation (sleep, relationships)• Distraction (family, money)• Depression• Dependence on drugs and alcohol• Disordered personality• Disorders of Learning (ADHD, LD)• Disease

Lucey’s Causes (7Ds):

• Study Time/Study Methods/Test taking (OSA)

• Energy (motivation)• Context & Culture (engineer vs. physician)

Organizational Causes:

• Dispersed • Elaborated

Knowledge Causes:

(Bordage)

Self-EfficacyArtino & Bandura

◦Choice of activities; effort; persistence

*

Motivation

Rhoads, J of Med Ed 1974

Approach to evaluation

Symptoms HPI/ PMHx Differential Dx

Final DxTreatment Plan

References• Artino, A. R., Jr. (2012). Academic self-efficacy: from educational theory to instructional

practice. Perspect Med Educ, 1(2), 76-85. doi: 10.1007/s40037-012-0012-5• Croen, L. G., Woesner, M., Herman, M., & Reichgott, M. (1997). A longitudinal study of

substance use and abuse in a single class of medical students. [Comparative Study]. Acad Med, 72(5), 376-381.

• Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. [Review]. Acad Med, 81(4), 354-373.

• Ghodasara, S. L., Davidson, M. A., Reich, M. S., Savoie, C. V., & Rodgers, S. M. (2011). Assessing student mental health at the Vanderbilt University School of Medicine. Acad Med, 86(1), 116-121. doi: 10.1097/ACM.0b013e3181ffb056

• Holmboe. (2008). Practical guide to the evaulation of clinical competence. 1st ed. • [edited by] Eric S. Holmboe, Richard E. Hawkins. Mosby/Elsevier in Philadelphia, PA .• Ishak, W., Nikravesh, R., Lederer, S., Perry, R., Ogunyemi, D., & Bernstein, C. (2013). Burnout in

medical students: a systematic review. Clin Teach, 10(4), 242-245. doi: 10.1111/tct.12014• Rhoads, J. M., Gallemore, J. L., Jr., Gianturco, D. T., & Osterhout, S. (1974). Motivation,

medical school admissions, and student performance. [Comparative Study]. J Med Educ, 49(12), 1119-1127.

• Rosebraugh, C. J. (2000). Learning disabilities and medical schools. Med Educ, 34(12), 994-1000.

• Yao, D. C., & Wright, S. M. (2000). National survey of internal medicine residency program directors regarding problem residents. JAMA, 284(9), 1099-1104.

Learners in Difficulty:Therapeutic Considerations

CAPT Barbara Knollmann-RitschelFundamentals Module Co-Directors

Associate Professor for Pathology and Emerging Infectious Diseases

Objectives

• Identify challenges in an ongoing curriculum. • Discuss differences of short and long term

remediation.• Present a strategy for learners with issues in

Professionalism, Science, and Clinical Skills.• Discuss the cost of remediation.

Remediation: Challenges in new Curriculum

• Old Curriculum:• Courses Directors• Long time span with regular contact• Ongoing remediation: course specific help• Failed Course: repeat course/deceleration

New Curriculum: New Challenges

• Modules Directors: organize remediation for multiple courses with Course Directors• Ongoing curriculum- bigger impact when

students are at lower end- need to juggle more courses at the same time• Less time for students with denser curriculum: • The fire hose

Remediation: Challenges in new Curriculum

• Remediation is spaced with ongoing curriculum- – Student fails Fundamentals- final remediation may

not be done until following summer! • Remediation may be 10 months later with ongoing

curriculum

Remediation: Challenges in new Curriculum

• Timing is not ideal- what can we do?– “Pre grade remediation” – what can we do not in

the short term before the end of the module or ongoing remediation

– Balance with in-depth remediation

REMEDIATION OF SCIENCE KNOWLEDGE VS. CLINICAL SKILLS VS. PROFESSIONALISM

Are they the same?

Professionalism

Science Knowledge

Clinical Skills

Creating a Remediation Plan

Review all the data, discuss with CD

Talk with Student

Pre-grade vs. Formal remediation

How does this affect ongoing curriculum?

Written plan to student and OSA

Remediation of Science Knowledge:

• Summary of exam results with strengths and weaknesses• Pre-remediation work summary• Reason for requiring additional work• Grade issued: Incomplete/Fail• Plan:

– What type of remediation is needed and proposed study block.

– A Passing score (above 65%) will be required to pass the Fundamental Module.

Remediation of Clinical Skills

• Review data from direct observations and Simcenter– Where is the Lesion?

• Professionalism• Reporter• Interpreter• Manager• Educator

• Increased time at simulation center- Practice skills – residents FNA– Remediate skills session as close to time of feedback– Focused plan on those skills that are identified as weak

Remediation of Professionalism: Five-Step Approach

• Major concern from AAMC

Tiered Approach: 5 Step Process

Email

Email and Letter

Email, Letter and See me

Email, Letter, See me, See Commandant

Email, Letter, See me, See Commandant, Formal Mentor

Cost

Faculty

Student 1 Student 2

Acknowledgements

USU Student Promotions Committee

Dr. Paul Hemmer

Dr. Janice Hanson