learners in difficulty: the “problem” student joseph o. lopreiato md, mph associate dean for...
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Learners in Difficulty:The “Problem” Student
Joseph O. Lopreiato MD, MPHAssociate Dean for Simulation Education
Professor of Pediatrics
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Acknowledgment
Drs. Catherine Lucey, Richard Hawkins and
Eric Holmboe
Clerkship Director
Residency Program Director
USU Student
Promotions Committee
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Outline
Define the problem
Define the approach as a teacher
Present a strategy to approach to the problem
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Definition
• “A trainee who demonstrates a significant enough problem that requires intervention by someone of authority”
ABIM
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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)
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USUHS Pre-clinical: Magnitude
Fundamentals:• 98% Pass• 2% Fail or incomplete
Preclerkship CPR module:• 12% Honors• 85% Pass• 2% Fail or Incomplete
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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
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Approach to evaluation
Symptoms HPI/ PMHx Differential Dx Final Dx
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Symptoms: Potential Problem Noted
Low clinical/small group discussion rating
Complaint
Peer incident
Low exam/quiz scores
Poor OSCE performance
Learner self-identified
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Symptoms: in Clinical Arena
Direct observation in clinical setting
Critical incident
Poor performance at morning report
Neglecting patient care responsibilities
Yao and Wright, 2000
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HPI/PMHx
What happened?
What are the circumstances
Happened before?
Want to talk about it?
Feelings?
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Differential Diagnoses
• Study Time/Study Methods/Test taking (OSA)
• Energy (motivation)• Context & Culture (engineer vs. physician)
Organizational Causes:
• Dispersed • Elaborated
Knowledge Causes:
(Bordage)
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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 ########
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Deprivation
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Distractions
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Depression and Anxiety
Liselotte N. Academic Med 2006;81:354-373
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Dependence
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Disease
Diabetes
Organic brain syndrome
Thyroid disease
Malignancy
Eating Disorders
Post Partum Depression
Etc…
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• 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)
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Self-EfficacyArtino & Bandura
◦Choice of activities; effort; persistence
*
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Motivation
Rhoads, J of Med Ed 1974
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Approach to evaluation
Symptoms HPI/ PMHx Differential Dx
Final DxTreatment Plan
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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.
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Learners in Difficulty:Therapeutic Considerations
CAPT Barbara Knollmann-RitschelFundamentals Module Co-Directors
Associate Professor for Pathology and Emerging Infectious Diseases
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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.
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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
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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
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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
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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
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REMEDIATION OF SCIENCE KNOWLEDGE VS. CLINICAL SKILLS VS. PROFESSIONALISM
Are they the same?
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Professionalism
Science Knowledge
Clinical Skills
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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
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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.
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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
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Remediation of Professionalism: Five-Step Approach
• Major concern from AAMC
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Tiered Approach: 5 Step Process
Email and Letter
Email, Letter and See me
Email, Letter, See me, See Commandant
Email, Letter, See me, See Commandant, Formal Mentor
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Cost
Faculty
Student 1 Student 2
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Acknowledgements
USU Student Promotions Committee
Dr. Paul Hemmer
Dr. Janice Hanson
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