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Dealing with Difficult Learners
Caroline Harada, MD Division of Gerontology, Geriatrics, and
Palliative Care
The plan
Description of problem
Approach: SOAP Differential diagnosis
3 Cases: Taylor Swift Tangent to talk about Metacognition
Starbucks Tangent to talk about Motivation
Angry guy Remediation plans
What is a “difficult learner?”
Cognitive vs. Non-cognitive issues
Labeling issue- once a difficult learner does not make a person forever difficult
Why do we care about it?
Learner likely in need of help
If unaddressed, learner may go on to have difficulties in their professional life
If unaddressed, patients may get hurt
It takes up a lot of educators’ time and energy
It’s not rare 15% of medical students on an IM clerkship
“Starbucks”
Trevor is an IM intern on a busy cardiology consult service. He often arrives late, frequently “disappears” during the day, when he reappears he’s always carrying a cup of coffee. He does not consistently return your pages.
His H &P’s and clinical reasoning seem fine for his level of training. Twice, he failed to write a progress note on a follow up patient after you asked him to do so.
“Angry Guy”
Jose is a PGY-2 resident in emergency medicine. He frequently gets in arguments with nurses and is openly hostile and disrespectful toward his attendings.
His knowledge and skills are on par with his peers, and his clinical judgment seems good. He seems to genuinely want to provide good care to his patients.
When confronted about his interpersonal communication and professionalism issues, he blames the nurses for being rude and disrespectful, and the attendings for being stupid and unreasonable.
“Taylor Swift”
Emily is a third year medical student doing her pediatrics rotation. Her presentations are extremely long and focus on irrelevant details. She often misses key facts in the history and her physical exams are superficial. Her clinical reasoning is poor, she seems to get easily side-tracked by irrelevant details.
On her evaluation, you give her a pass (not high pass, not honors).
She comes to you when she receives the grade and is upset. She says she has never received lower than a high pass on the 4 rotations she has already completed. No one has ever told her there was a problem.
An Approach to Difficult Learners: SOAP
S- Name the problem, what do people say/think about it?
O- List the specific behaviors observed
A- Formulate a differential diagnosis
P- Make a plan with the learner
Langlois JP, Thach S. Fam Med 2000
A-Differential Diagnosis
Cognitive Learning disability Poor fund of knowledge Poor procedural or clinical
reasoning skills Poor metacognitive skills
Behavioral/professionalism Mama didn’t teach him/her
right Mental health Depression, anxiety, other ADHD Personality disorders
Substance abuse Other medical problems Not handling stressors well Difficulty handling work-
related stress External stressors: Family
issues, financial stress, marital issues
“Taylor Swift”
Taylor is a third year medical student doing her pediatrics rotation. Her presentations are extremely long and focus on irrelevant details. She often misses key facts in the history and her physical exams are superficial. Her clinical reasoning is poor, she seems to get easily side-tracked by irrelevant details.
On her evaluation, you give her a pass (not high pass, not honors).
She comes to you when she receives the grade and is upset. She says she has never received lower than a high pass on the 4 rotations she has already completed. No one has ever told her there was a problem.
Apply SOAP
S- Describe Taylor Swift’s problem
O- list the specific behaviors
A- assessment
Potential Sources of Problems
Learner • Clinical skills deficit • No insight
Educator • Didn’t give feedback
System • Limited time • Patient care • Definition of roles • Limited training for
faculty • Little training in
metacognition
Metacognition
The process of reflecting on and directing one’s own thinking
Ambrose SA et al. How Learning Works, 2010
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
Cycle of Self-
Directed Learning
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
STRATEGIES
Assess the task
Explain what you want VERY explicitly
Explain what you don’t want
Check learner’s understanding of the task Ask them to describe what they need to do to accomplish the
task
Provide assessment criteria (rubric)
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
STRATEGIES
Evaluate Strengths and Weaknesses
Give early performance-based assessments Pre-tests Feedback after each new patient is presented
Provide opportunities for self assessment Do the admission note (including assessment and plan)
independently, then compare to the resident’s A&P
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
STRATEGIES
Plan the Approach
Give the learner a plan for how to accomplish the task
Later, require learner to make their own plan for how they will accomplish the task Process mapping Scripts
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
STRATEGIES
Apply Strategies, Monitor Performance
Teach heuristics for self-correction (How to know if it’s wrong?) If efficiency is the challenge, set time limits (no more than 15
minutes perusing old records) If interpersonal skills are the challenge, identify signs for how to
know the interaction didn’t go well
Guided self-assessments If write ups the problem, provide examples of annotated notes If interpersonal skills: learner watches video of himself in an
interaction and evaluates using criteria you provide
Annotate own work Explain why you wrote what you did for each component of H&P
Peer review
Assess the task
Evaluate strengths and weaknesses
Plan
Apply strategies, monitor
performance
Reflect, adjust prn
STRATEGIES
Reflect, Adjust as needed
Require reflection on performance “What did you learn from this patient?” “What do you want to practice now?” “How have your skills evolved over the last 3 rotations?”
Prompt students to analyze the effectiveness of their study skills Exam wrapper- when get the exam back, respond to guided
analysis of their performance, and relate that to how learner studied
Assignments focusing on strategy instead of implementation Discuss pros and cons of several strategies for completing a task
Potential Sources of Problems
Learner • Clinical skills deficit • No insight
Educator • Didn’t give feedback
System • Limited time • Patient care • Definition of roles • Limited training for
faculty • Little training in
metacognition
Feedback
Data that is input back into system to permit correction and improvement
Ende, J JAMA 1983
Feedback Pearls
Same team! Common goal
Not a reflection of your personal worth
Invited feedback works better, should always be expected
Based on what YOU observed, descriptive, neutral, specific
Don’t interpret/assume intent of what you saw
Limit feedback to what’s fixable
Subjective data is ok if labeled as such
Ende, J JAMA 1983
“Starbucks”
Trevor is an IM intern on a busy cardiology consult service. He often arrives late, frequently “disappears” during the day, when he reappears he’s always carrying a Starbucks cup. He does not consistently return your pages.
His H &P’s and clinical reasoning seem fine for his level of training. Twice, he failed to write a progress note on a follow up patient after you asked him to do so.
Apply SOAP
S- name the problem
O- list specific behaviors
A- assessment
Potential Sources of Problems
Learner • Mental health • Substance abuse • Learning disability • External stressor • Unmotivated • Unprofessional
Educator • Didn’t make
expectations clear • Didn’t provide
feedback
System • Fatigue • Isolation from
support network • High stakes work
What to do about motivation?
3 variables Environment: supportive or not? Learner self-efficacy: high or low? Learner values the work/goals set: yes or no?
Environment supportive
Environment NOT supportive
Motivation
Rejecting
Evading Motivated
Fragile Rejecting
Evading Defiant
Hopeless Self efficacy
LOW
Self efficacy HIGH
DON’T see value
DO see value
DO see value
DON’T see value
Ambrose SA et al. How Learning Works, 2010
Strategies to Demonstrate Value
Connect the material to students’ interests Example: “as a cardiologist you will need to know this”
Provide authentic, real world tasks- helps the learner concretely see the relevance Examples: “case-based”, bedside teaching, real patients
Show relevance to students’ current academic lives Example: “this will be on the boards”
Demonstrate the relevance of skills taught to future professional lives Example: “in my current job I process map once a year”
Identify and reward what you value Example: VA IM service gives a prize each month for the best H&P
Show your own passion and enthusiasm for the discipline
Provide flexibility and control- give them choices about what they want to learn Example: “we can talk about these 3 topics today- which interests you the most?”
Give students an opportunity to reflect Example: ask “what did you learn?” “how did you prepare for this assignment?”
Strategies to Increase Self Efficacy
Articulate expectations
Example: learning objectives, orientation sessions
Provide rubrics
Example: evaluation forms, Milestones
Identify an appropriate level of challenge
Example: ask learners what they need to work on, administer a formal needs assessment
Ensure alignment of objectives, assessments, and instructional strategies
Example: You want to teach residents how to have a DNR conversation- your learning objective shouldn’t be for them to be able to communicate effectively (too broad), the assessment shouldn’t be a written test, and the instructional strategy shouldn’t be a Power Point presentation
Provide early success opportunities
Example: Start with small, easy tasks
Provide targeted feedback- timely, constructive, guidance about effective strategies going forward
Be fair
Educate students about the ways we make attributions about success and failure
Provide flexibility and control- give them choices about what they want to learn Example: “we can talk about these 3 topics today- which
interests you the most?”
Give students an opportunity to reflect Example: ask “what did you learn?” “how did you prepare for
this assignment?”
“Angry Guy”
Jose is a PGY-2 resident in emergency medicine. He frequently gets in arguments with nurses and is openly hostile and disrespectful toward his attendings.
His knowledge and skills are on par with his peers, and his clinical judgment seems good. He seems to genuinely want to provide good care to his patients.
When confronted about this, he blames the nurses for being rude and disrespectful, and the attendings for being stupid and unreasonable.
Apply SOAP
S- name the problem
O- list specific behaviors
A- assessment
Potential Sources of Problems
Learner • Mental health • Substance abuse • External stressor • Unprofessional
Educator
System • Patient volume • Fatigue • Isolation from
support network • High stakes work
An Approach to Difficult Learners: SOAP
S- Name the problem, what do people say/think about it?
O- List the specific behaviors observed
A- Formulate a differential diagnosis
P- Make a plan with the learner Set expectations and timeline Frequent follow up meetings Involve experts- clerkship director, program director/chief
residents, clinical experts (psychiatrist? counseling?)
Langlois JP, Thach S. Fam Med 2000
Remediation Plan
Provide appropriate treatment
Provide instruction with deliberate practice, feedback, reflection. Use specialists if needed.
Reassessment and certification of competence
Document entire process
Ronan-Bentle SE et al. Int J Emerg Med, 2011
Metacognitive Summary
Description of problem
Approach: SOAP Differential diagnosis
3 Cases: Poor insight (Taylor Swift) Tangent to talk about Metacognition
Unmotivated (Starbucks) Tangent to talk about Motivation
Angry (Angry guy) Remediation plans
Key Learning Points
An ounce of prevention is worth a pound of pain Good teaching practices are good because they work Enhancing metacognition can help avoid problems later
Enhancing motivation can be done
SOAP approach can help Remember to think about diagnosis Your plan should involve other people
