IRLS:
The learner in difficulty
Ming-Ka Chan, Wade Watson
Date: October 25, 2014
Disclosure
• MingKa Chan
– Clinician Educator, CanMEDS & Faculty
Development Royal College of Physicians and
Development,
Surgeons of Canada
• Wade Watson
– CanMEDS Academy, Royal College of
Physicians and Surgeons of Canada
– CME, Mead Johnson, Pfizer
Acknowledgement
• Based on a workshop developed by
– Wade Watson
– Ming-Ka
Ming Ka Chan
– Joanne Hamilton
Is this familiar?
• a learner has been on service for 2 weeks
– appears disorganized on rounds
– writes inadequate notes
– does not have an understanding of patient
problems
Google search
• “medical
medical trainee in academic difficulty
difficulty”
Why don’t
don t we address problems?
• perceived lack of skills in addressing the
issue
• don
don’tt like upsetting people
• fear of reprisals
• feel that there is little time to deal with
the issue
• “not my problem”
Why should we address problems?
• obligation to the learner
• obligation to the profession
• easier
i to correct problems
bl
b
before
f
they
h
are ingrained
• problem learners become problem
physicians*
• “it is our problem”
An interesting result!
• national licensing examination (LMCC Part
2) scores
– patient-physician communication
– clinical decision making
• correlated
l t d with
ith complaints
l i t tto medical
di l
regulatory authorities
Tamblin et al, JAMA. 2007
Objectives
• Identify the learner in difficulty
• Classify the difficulties learners may
have
• Review and practice a framework for
planning
l
i h
help
l
• Discuss the failure, remediation and
probation process
“ stitch
“A
i h iin time
i
saves
nine
nine”
“The
The learner in difficulty
difficulty”
Working definition:
“A learner
l
with
i h academic
d i performance
f
that
h
is significantly below that expected
b
because
off an affective,
ff ti
cognitive,
iti
structural, or interpersonal difficulty.”
(Quirk, 1994)
Scope of the problem
• 25% show signs of burnout
• 25% show signs of mild depression
• 12.6%
12 6% misusing
i i alcohol
l h l
• 3-7% are “difficult” or a “problem”
Lake and Ryan, MJA 2005
Factors contributing to poor performance
• learner
– stress
– medical/psychiatric
factors
– substance
b t
abuse
b
– cultural differences
– poor communication
– lack of clinical
knowledge
• supervisor/system
– no feedback
– no support
– responsibilities >
l
level
l off competence
t
– interpersonal
– overwork
– exposure to serious
illness/death
Lake and Ryan, MJA 2005
Classification of academic difficulties
•
•
•
•
•
•
affective
cognitive
structurall
interpersonal
psychomotor
professional
Affective
• problems with adjustment
– illness, death, marital problems
– poor grades with subsequent failure to
perform
– low aspirations,
aspirations low self esteem
– withdrawal, feeling overwhelmed, depressed
Cognitive
• written
– reading skills, unable to complete assignments
• spatial
p
– perceptual problems
• oral communication skills
– poor interviewing
• integration
– difficulty with conceptual/abstract thinking
• knowledge base
Structural
• unable to structure experience in
environment
– poor time management
– lack of organizational skills
– poor study habits
Interpersonal
• difficulty interacting with others
– shy or non-assertive
– poor social skills
– manipulative
– aggressive
Psychomotor
• difficulty in technical skills
Professional
• deficits in behaviors
– honesty
– integrity
– reliability
Supervisor/system factors
• appropriate environment for learning?
• appropriate supervision?
Prevention?
• being a good supervisor
– supervision is considered inadequate by many
learners
– lack of supervision one of the greatest
stressors in learners
Paice et al, Med Educ 2002
Qualities of a good supervisor
• clear about respective roles ansd
responsibilities
• informs learners how supervision will
occur
• provides
id clear
l
ffeedback
db k
• makes time to get to know the learner
• direct observation
• recognizes the power differential
Lake and Ryan, MJA 2006
Framework for analyzing learner problems
Knowledge
gaps
Teacher
perceptions
expectations
Attitude
Skill
motivation
ti ti
insight
self assessment
doctor-patient
p
relationships
iinterpretation
t
t ti
technical
Learner
life history
personal problems
learning disabilities
psychiatric
hi t i ill
illness
learner expectations
System
unclear standards
overwhelming
workload
l k off supervision
lack
i i
lack of feedback
Steinert, BMJ 2008
Categorizing problems using CanMEDS:
•
•
•
•
•
•
•
medical expert
p
communicator
collaborator
manager
health advocate
scholar
professional
It is a good format for documentation too!
http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf
Nature of academic problems
1. Medical expert (85%)
2. Professional (51%)
3 Communicator (49%)
3.
4. Manager (43%)
5 Collaborator
5.
C ll b t (20%)
• average of 2.6 problems/resident
• all had medical expert or professional
issues or both
Zbieranowski et al, Academic Medicine 2013
Role of the resident leader
• Needs to be explicit
– support
– immediate supervisor
– part of remediation committee
– resident mentor
– mediator
– teacher
– assessor
– advisor
27
Successful remediation
• early identification of difficulties
• open/ongoing dialogue with learners
• systematic review/monitoring of
remediation
• learner centeredness
• individualized
– may need more than one strategy
• appropriate resources/full academic support
Approach in clinical medicine
S
O
A
P
An approach to academic problems
S
T
O
P
An approach to academic problems
Specify the problem
T
Target
/ goals
l
Options
Plan and procedures
Specify the problem
• gather and document information
– how does the learner fall short?
• perception vs.
vs reality
• consider the learner, preceptor and the
llearning environment
• be aware of confidentiality
• use a team approach
document document,
document document
• document,
Set Target / Goals
•
•
•
•
•
discussion with learner
goal setting
l
learner
d
driven,
i
program di
directed
d
ongoing feedback
document everything
possible Options
• further/different
assessment
• more time on rotation
g
• schedule change
• increased observation
and feedback
peer support
g
counseling
leave of absence
medical
treatment
• formal
•
•
•
•
– remediation
– probation
Plans and procedures
• develop a plan
• plan follow up
• learning
l
i contract??
Time to practice STOP
• Divide into groups of three. There
are two scenarios presented (or provide
yyour own from p
personal experience)
p
)
• Try to specify the problem, set a
g g , investigate
g
options
p
and
target/goal,
develop a plan
• Be p
prepared
p
p
present a summaryy and yyour
observations to the group
• You have 10 minutes
Scenario
• A learner has been to the program
administrators (PA) office with many minor
requests which has increased the workload in
the office. He/she has been condescending.
Analysis
Knowledge
not aware of the
program
p
g
assistant
responsibilities
Teacher
Program director may
not have been explicit
about PA roles
Attitude
insight
interpersonal
p
difficulties
Learner
unrealistic
expectations
Skill
N/A
System
inadequate orientation
Steinert, BMJ 2008
Specify the problem
Target/Goals
g
Options
Plan
Specify the problem
inappropriate requests to program assistant
lack of respect
Target/Goals
g
treat PA appropriately
pp p
y
Options
inform learner of issues, give specific examples
get feedback from the learner
explain the role of the PA
discuss options of improving the interactions
with the PA
consider orientation of all trainees to PA roles
Pl
Plan
develop
d
l plan
l based
b d on information
i f
ti
follow up with PA to ensure the behavior does
not continue
positivelyy reinforce appropriate
p
pp p
learner
behavior
Scenario
• learner has been on service for 2
weeks
– does not appear to have an
understanding of patient problems
– difficulty in focusing
– don
don'tt answer their pages so you cannot
locate them
– disheveled appearance, unpleasant
odour, stained clothing
Analysis
Knowledge
understanding of
professional dress and
p
hygiene
Teacher
Ni clear orientation of
expectations
Attitude
insight
Skill
N/A
Learner
personal difficulties
(social, psychiatric)
? substance abuse
System
no clear orientation
Steinert, BMJ 2008
Specify the problem
lack of organization
lack of professionalism
problems
bl
with
i h time
i
management
problems with communication
Target/Goals
define clear expectations and organization
similar to peers: access
access, dress
dress, hygeine
Options
confirm with others
inform learner of specific issues
explore reasons for difficulties
clearly define expectations
develop a standard orientation to set
expectations
i f
inform
faculty/other
f
lt / th systems
t
off reporting
ti
Plan
regular follow up
positively reinforce appropriate trainee
behavior
written feedback
Question
• What other tools have you seen that may
help learners in difficulty?
Examples of other tools
•
•
•
•
learning contract
learning prescription pad
written/other
i
/ h media
di orientation
i
i
standardized orientation checklist
46
Successful remediation strategies
• early identification
• open/ongoing dialogue with the learner
• systematic
i review/monitoring
i /
i i off
remediation process
• learner-centeredness
• individualized
• appropriate resources/faculty support
Szumacher et al, Ann Acad Med Singapore, 2007
When a problem is not resolved…
•
•
•
•
rotation failure
remediation
probation
b i
removal from the program
Failing a learner
• a mid
mid-rotation
rotation evaluation must be given,
given
in person and in writing stating deficits,
plans and desired outcomes
plans,
• end of rotation evaluation process is the
same
• documentation should be both general
and
d specific
ifi
• a failed rotation results in remediation
Remediation
• a formal process of extra specified
training to enhance and further evaluate
a learner
learner’ss skills,
skills knowledge and
attitudes, that have been assessed to
have significant deficits or concerns
• outcome could be return to regular
rotations further remediation,
rotations,
remediation or
probation
Probation
• defined period of time
• structured to address identified area of
weakness
• outcome is either reinstatement or
di i l
dismissal
Remediation/probation principles
• fairness
• accuracy
• documentation
d
i
Fairness
• learner knows the rules
• supervisor and learner are aware of the
objectives
• adequate exposure for evaluation
• previous evaluations kept confidential
• mid-rotation feedback is given
• evaluations
l ti
can be
b appealed
l d
• the learner must have a mentor/advisor
Accuracy
• uniform standards apply which are
determined at the supervisory level
• evaluations are based on learning
objectives
• specific
ifi examples
l are given
i
iin evaluations
l ti
Documentation
•
•
•
•
of problems – sequential
of evaluations – sequential
off interventions
i
i
– sequential
i l
of quantitative and qualitative
evaluations
Remediation Contract
•
•
•
•
Written document
Formalized process
E
Everyone
knows
k
the
h expectations/rules
i / l
Outlines responsibility
– Learner
– Supervisor
p
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11
11.
12.
Smith CS, Stevens NG, Servis M. A general framework for approaching residents in difficulty.
; ( )
Fam Med. 2007;39(5):331-6.
McGraw R, Verma S. The trainee in difficulty. CJEM 2001;3:205-8.
Stubbe D, Heyneman E, Stock S. A stitch in time saves nine: intervention strategies for the
remediation of competency. Child Adolesc Psychiatr Clin N Am. 2007;16:249-64.
Sayer M, Chaput De Saintonge M, Evans D, Wood D. Support for students with academic
;
difficulties. Med Educ. 2002;36:643-50.
Steinert Y. The "problem" junior: whose problem is it? BMJ 2008; 336:150-3.
Steinert Y, Levitt C. Working with the "problem" resident: guidelines for definition and
intervention. Fam Med. 1993;25:627-32.
Lake FR and Ryan G. Teaching on the run tips 11: the junior doctor in difficulty. MJA 2005
183:475-6.
Yao DC, Wright SM. The challenge of problem residents. J Gen Intern Med 2001;16:486-92.
Trainee in difficulty, South Australian Institute of Medical Education and Training,
www.saimet.org.au
Helping a Trainees in Difficulty, www.oxforddeanerycdu.org.uk
Lake FR and Ryan G
G. Teaching on the run tips 13: being a good supervisor-preventing
supervisor preventing
problems. MJA 2006 184:414-5.
Zbieranowski I, Takahashi SG, Verma S, Spadafora SM. Remediation of residents in difficulty:
a retrospective 10-year review of the experience of a postgraduate board of examiners. Acad
Med 2013;88(1):111-6.