R. Brent Wright, MD, MMM Associate Dean for Rural Health Innovation

1. Dealing with Difficult Students 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 20th annual Preparing health professionals for the 21st century

2. Three Parts • Learner • Teacher • System

3. Difficult learner in medical education • 9.1% of medical students/young residents are identified as problem or struggling learners • Difficulties might be due to : http://www.stfm.org/fmhub/fm2006/April/Brian252.pdf

4. 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

5. Dealing with difficult learner: • A) Annoying • B) Bothersome • C) Controversy

6. What interferes with learning?

7. Personal Issues http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325462/

8. Personality Disorders • Paranoid Personality Disorder • Anti-social Personality Disorder • Narcissistic Personality Disorder • Borderline Personality Disorder • Schizotypal Personality Disorder • Schizoaffective Disorder

9. 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/

10. 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

11. Learning Disabilities ? • Low motivation • Poor Self-Esteem • Behavioral Concerns • Physical Affects • Self-Critical & Critical of Others

12. Scenario I Personal Challenges • The Softball Game

13. What would you do? • A. Go to the game • B. Talk with the student & miss the game • C. Talk with the student next week

14. 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

15. Preceptor Challenges • Barriers identified by preceptors preventing the reporting of a learner who performed poorly: Dudek NL, Marks MB, Begehr G. Failure to fail: The perspectives of clinical supervisors. Acad Med 2005;80(10 suppl)S84-7.

16. Generational Differences

17. Scenario II: Troubling Arrival • First Day • Worries of Staff • Documentation

18. What would you do? • A. Attribute to Stress & Ignore • B. Monitor for continuance • C. Document and proceed with rotation

19. Documentation

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

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

22. 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.

23. 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

24. The Problem Resident (Continued)

25. Scenario III • The good student, but…

26. What would you do? • Deeper Dive • Talk about concerns • Deny and Ignore • Hope it gets better (on future rotations)

27. 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

28. 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

29. 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

30. Intervention After Problems Emerge

31. A General Approach : SOAP • Subjective: • What do you and others say? Get feedback from other preceptors or staff that have had this student. • Objective: • Document specific incidences or situations with dates. • Assessment: • Based upon your subjective and objective findings coupled with input from others, try to diagnosis the problem. • Devise a Plan: • 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. Langios JP, Thach S. Managing the Difficult Learning Situation. Fam Med 200;32(5):307-309

32. 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

33. Why do we care? • Future Students • Future Residents • Future Fellows • Future Physicians

34. Grow Minds, Not Problems

35. Not Problems

36. Special Thanks MallikarjunSamala, MD, MPH, PhD Post Doctoral Scholar UofL/Glasgow Family Medicine Residency Glasgow, KY

37. What do we need to discuss further?