Dealing with Difficult Students

20 th annual Preparing health professionals for the 21 st century

05/10/2014

R. Brent Wright, MD, MMM

Associate Dean for Rural Health Innovation University of Louisville School of Medicine Vice-Chair for Rural Health & Associate Professor Department of Family & Geriatric Medicine 1

Three Parts

 Learner  Teacher  System 05/10/2014 2

Difficult learner in medical education

• • 9.1% of medical students/young residents are identified as problem or struggling learners Difficulties might be due to : Learner Factors Teacher factors System factors 05/10/2014 http://www.stfm.org/fmhub/fm2006/April/Brian252.pdf

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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.

or  A student who is at risk of receiving an unsatisfactory grade because of problems with knowledge, skills, professionalism, or a combination of these.

https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf

http://casemed.case.edu/caml/doc/S15328015TLM1004_4.pdf

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 Dealing with difficult learner:  A) Annoying  B) Bothersome  C) Controversy 05/10/2014 5

What interferes with learning?

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Personal Issues

Health Related Financial Social Personality Disorders Family Personal Habits Cultural http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/ 05/10/2014 7

Personality Disorders

• Paranoid Personality Disorder • Anti-social Personality Disorder • Narcissistic Personality Disorder • Borderline Personality Disorder • Schizotypal Personality Disorder • Schizoaffective Disorder 05/10/2014 8

Training Related Issues

 Situational       adjustment to the medical school environment conditions for learning that are less than optimal inadequate support from health professionals exposure to death and human suffering ethical conflicts student abuse http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/ 05/10/2014 9

Training Related Issues

 Professional      responsibility for patient care difficult patients and challenging health problems supervision of more-junior residents and students information overload career planning 05/10/2014 10

Learning Disabilities ?

     Low motivation Poor Self-Esteem Behavioral Concerns Physical Affects Self-Critical & Critical of Others 05/10/2014 11

Scenario I Personal Challenges

 The Softball Game 05/10/2014 12

What would you do?

 A. Go to the game  B. Talk with the student & miss the game  C. Talk with the student next week 05/10/2014 13

Teacher Factors

     Inadequate teaching experience Avoiding ‘making things worse’ Unsure of self Inadequate observations Lack of feedback https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf

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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.

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Generational Differences

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Scenario II: Troubling Arrival

 First Day  Worries of Staff  Documentation 05/10/2014 17

What would you do?

 A. Attribute to Stress & Ignore  B. Monitor for continuance  C. Document and proceed with rotation 05/10/2014 18

Documentation

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Documentation

 High quality documentation should be: Accessible Accurate, relevant, and consistent Auditable Clear, concise, and complete Legible/readable Timely, contemporaneous, and sequential Reflective Retrievable  Poor or absent documentation can prolong the process of dealing with the difficult student who has become toxic to the learning environment.

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System Factors

    Work overload (both sides) Inadequate supervision Poor records Poor support systems https://www.ucalgary.ca/ofd/system/files/Learner%20in%20difficulty.pdf

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Prevalence of problem in residency

 Yao and Wright study (1999 survey) – 94% of programs with at least one resident in difficulty (Suspect substantial under-reporting)  Areas of Difficulty – Insufficient knowledge (48%) – Poor clinical judgment (44%) – Inefficiency (44%) – Inappropriate interactions (39%) – Provision of poor skills (36%) Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000 Sep 6;284(9):1099-104.

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The Problem Resident: APDIM Survey 2008     Survey of IM Program Directors 268 programs responded (72% of 372 programs) IM residents requiring remediation often have deficiencies in multiple competencies.

Deficiencies across competencies; remediation most successful for Medical Knowledge (86%); least successful for Professionalism (41.2%).

Application materials rarely help to identify individuals at risk.

Performance Deficiencies rarely (5.6%) self-identified by residents.

Denis M Dupras, Randall S Edson, Andrew J Halvorsen , Robert H Hopkins, Furman S McDonalds. “Problem Residents”: Prevalence, Problems and Remediation in the Era of Core Competencies. The American Journal of Medicine. Volume 125, issue 4, pages 421 - 425 05/10/2014 23

The Problem Resident (Continued)

Systems based Practice 13,3 Practice-based Learning & Improvement Professionalism Interpersonal Communication Organization/Prioritization 21,8 41,2 41,4 41 53 56 48,5 61,9 71,3 Patient Care Medical Knowledge 53 47,9 0 50 78,4 85,8 100 RiD with Deficiencey Remediation success 150 05/10/2014 24

Scenario III

 The good student, but… 05/10/2014 25

What would you do?

  Deeper Dive Talk about concerns  Deny and Ignore  Hope it gets better (on future rotations) 05/10/2014 26

Primary Prevention

Know the course expectations.

Communication is the key.

Orient the learner well.

Set clear expectations and goals.

Determine the learner’s goals and expectations.

Reassess mid-course.

Reference : http://www.oucom.ohiou.edu/fd/monographs/difficult.htm

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Secondary Prevention

Pay attention to your hunches/clues.

Don’t wait.

Initiate SOAP early.

Give specific feedback early and monitor closely.

http://www.oucom.ohiou.edu/fd/monographs/difficult.htm

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Tertiary Prevention

If nothing has worked…. SEEK HELP.

Do not give a passing grade to a learner who has not earned it.

Document !!!

http://www.oucom.ohiou.edu/fd/monographs/difficult.htm

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Intervention After Problems Emerge

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   

A General Approach : SOAP

S ubjective:  What do you and others say? Get feedback from other preceptors or staff that have had this student. O bjective:  Document specific incidences or situations with dates. A ssessment:  Based upon your subjective and objective findings coupled with input from others, try to diagnosis the problem. Devise a P lan:  Talk with the student about your concerns    Talk to the college to see if they are aware of previous problems? Make sure the student is aware of the consequences if problems continue. Progressions, grade reduction, failing the rotation.

05/10/2014 Langios JP, Thach S. Managing the Difficult Learning Situation. Fam Med 200;32(5):307-309 31

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 http://familymed.uthscsa.edu/ACE/chapter10.htm

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Why do we care?

 Future Students  Future Residents  Future Fellows  Future Physicians 05/10/2014 33

Grow Minds, Not Problems

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Not Problems

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Special Thanks

Mallikarjun Samala, MD, MPH, PhD Post Doctoral Scholar UofL/Glasgow Family Medicine Residency Glasgow, KY 36

05/10/2014 What do we need to discuss further?

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