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Understanding and Assisting the Faltering or Failing Clinical Learner Developed by: Wayne Weston MD & Michael Rieder MD.

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Presentation on theme: "Understanding and Assisting the Faltering or Failing Clinical Learner Developed by: Wayne Weston MD & Michael Rieder MD."— Presentation transcript:

1 Understanding and Assisting the Faltering or Failing Clinical Learner Developed by: Wayne Weston MD & Michael Rieder MD

2 Developed for The Faculty, Staff, & Community Development Office The Schulich School of Medicine & Dentistry The University of Western Ontario Supported by a faculty development grant from the Royal College of Physicians and Surgeons of Canada

3 Goals  The purpose of this presentation is to demonstrate, with two short video clips, how to inform students: First, that they are at risk of failure And, second that they have failed  In addition, the PowerPoint presentation provides some ideas to consider when “working up” the student to determine their learning needs in order to prevent failure  We provide some practical tips regarding due process  Finally, we provide several references for anyone who wishes to learn more.

4 Overview 1. Video demonstration of a faltering clerk and how the teacher presented the warning 2. Presentation: why students falter and fail 3. Due process – the steps that teachers must take to provide a failing grade 4. Video demonstration of a failed clerk – how to present the “bad news” Note that these are simulated interviews

5 Demonstration of Feedback to a Faltering Student  The student is a clinical clerk near the end of clerkship.  He is presenting the case of a patient with a 3 mo. history of chest pain as well as poorly controlled type II diabetes and GERD.  The patient had been booked for an assessment of his chest pain and diabetes and the student had spent 30 min. assessing him. His supervisor had asked him to do a thorough assessment of these two problems.  (He is not having chest pain today and is stable.)

6 What to Watch For…  Is the history detailed enough to make a diagnosis of his chest pain?  Did the student collect all the information needed to decide on investigation and management?  Is the differential diagnosis adequate?  Did he do a thorough assessment of the patient’s diabetes?

7 To see this 8 minute edited interaction, click this button: The video will open in a separate window. To return here, close the window with the video.

8 Using the Tape  These clips are not meant to be perfect – discussions with faltering or failing students are uncomfortable and challenging for teachers. But they do illustrate how these conversations might be conducted and some of the issues teachers need to be prepared to address.

9 Key Points  The case presentation is brief and to the point and the student has a clear plan for investigation and management.  But…on questioning him about more details, it becomes clear that there are large gaps in his data base & his answers are vague  The differential included PE which was quite unlikely and ignored GERD which was much more likely to explain the patient’s chest pain  In the 30 minutes he had to work up the patient he should have been more thorough

10 Key Points, cont’d.  The student is making a number of common errors: He failed to review the chart before seeing the patient – co-morbid conditions & medication history are essential aspects of the workup of the patient He has focused too quickly on cardiac & chest conditions as the source of the pain & does not have a broad enough differential He has not collected enough detail about the diabetes to guide his management decisions

11 Key Points, cont’d.  The teacher made it very clear that the student was at risk of failing – she used the “F” word so that the student would be quite clear he has a serious problem  The teacher indicated the nature of the deficiency and offered additional teaching to help the student to remedy his weaknesses  There are several weeks left in the rotation to improve

12 Key Questions The “Best & Brightest” If we take such bright students how come anyone fails? Can we prevent it? If they should fail (i.e. do not meet the expected standards), how do we do it correctly? And how do we help them with remediation?

13 Why Learners Fail  Academic reasons  Personal reasons  Poor teaching

14 Why? 1. Academic Reasons  Doesn’t know (or understand) the expectations  Poor learning strategies – what worked in the first two years doesn’t work in clerkship  Not interested (i.e. interested in something else)  Learning disability  Did not learn the basics e.g. illness in 1 st two years

15 No Life…  “When my Mom calls and asks about the weather I tell her, ‘I don’t know; I don’t go outside’.” - Second year medical student.

16 Why? 2. Personal Reasons  Stress  Having second thoughts about medicine  Interpersonal problems  Sickness e.g. depression, physical illness, substance abuse  Developmental issues especially around identity formation & intimacy  Unprofessional behaviour  Ethno-cultural issues e.g. IMGs may have special learning needs related to cultural differences or background

17 Why? 3. Poor Teaching  Unclear about objectives, expectations  No orientation or needs assessment  No feedback (until too late)  Not enough opportunities to learn e.g. Pap smears  Ignored early cues of problems  Did not provide extra assistance when problems were identified  Punishment vs. additional support especially around professionalism issues

18 Adjusting to the Clerkship  Focus of learning changes from isolated basic science facts  clinically relevant principles  Approach to learning changes from deep  superficial  Cognitive style – taking charge of their learning  Personal development – identity formation  intimacy  Professionalization – developing a sense of self as a physician with mature responsibilities  “Boundary maintenance” – finding an appropriate & flexible balance between life and work

19 “The third year is mainly a feeling of walking around not knowing what you’re doing.” – Third-year medical student Trying to cope…

20 The Failing Student  Not common (1 - 4 per year)  But…common enough!  Causes tremendous angst for students & faculty  Consumes inordinate amount of resources – take up as much time as all the other students in the class combined

21 UWO Form – a 5-point scale Does Not Meet Expectations Meets Expectations Exceeds Expectations This means fail! Students may not realize that “Does Not Meet Expectations” means that they have failed.

22 Assessment Policy  Assessments must be given at the end of each block (i.e. not weeks or months later)  There should be a formal structure for mid- term evaluation – schedule it early to make sure it happens

23 Policy, cont’d.  Students in trouble need to know when they are in trouble and how to try to get out of it – beware of mixed messages e.g. “You are doing pretty well but you have some areas that you need to work on.”  Unless they are told by the mid-point that they might fail, given clear instructions about what must improve & adequate opportunities for learning, a failure is likely to be overturned by an appeal  This feedback should be shared in a supportive and sensitive fashion

24 The Failing Student  Early identification is key  “Diagnose” the learner – why is he/she faltering or failing & what can we do about it?  Early feedback with careful attention to areas in which performance in inadequate is important – must warn the student of the possibility of failure – use the “f” word!  Document, document, document!  Consult and get advice early – talk to your undergraduate coordinator

25 Consequences of Not Meeting Expectations  If a student does not Meet Expectations on ALL blocks then they fail the clerkship  Another option is to give the student an “Incomplete”. This would apply to a student who missed a lot of time because of illness  Supplemental Remedial Privileges (SRPs) may be awarded by the Clerkship & Electives Committee based on the recommendation of the block coordinator  SRPs are a privilege not a right

26 Supplemental Remedial Privileges  A structured 4 week period of remedial work  Must be structured and evaluated  Usual practice is to have this completed PRIOR to electives, i. e. as first block of 4 th year  Appears on their transcript as SRP (Supplemental Remedial Privileges)

27 The Failed Student, cont’d.  The student should have the reasons for a failing evaluation explained in detail and should have the opportunity to ask questions  The student must have their options explained (i.e. Appeal) – this should be in writing with copies to the Clerkship & Electives Committee (CEC) and decanal office  The student must be provided with a description of the process (which includes approval of the evaluation by the CEC)

28 The Failed Student, cont’d.  Communication with the decanal office and clerkship committee must occur as soon as possible  All relevant documentation should be maintained in a central file with copies provided to the decanal office and clerkship committee as necessary

29 The Failed Student, cont’d.  The decision by the clerkship committee with respect to whether or not to grant Supplemental Remedial Privileges (SRP) is largely based on the input from the block coordinator and their team  Decisions about SRP should include considerations of what would constitute appropriate remedial work and how to evaluate it  The decision NOT to recommend SRP must be carefully justified  In rare circumstances a student may be granted the opportunity to repeat the year

30 Demonstration of “Breaking Bad News” to a Failed Student  This student had received a warning at the mid-point of the medicine rotation but did not improve  Assessments have been forwarded to the coordinator of the rotation  The clerk and coordinator are meeting in private to discuss the student’s final grade on the rotation

31 To see this 10 minute edited interaction, click this button: The video will open in a separate window. To return here, close the window with the video.

32 Key Points  Be prepared: Have the evidence at hand Talk to all the people providing assessment information so that you have first hand examples & not just vague comments on paper Be ready for a strong defence by the student Note the arguments from the student that the assessment was wrong – the judgment that a student has failed is not up for negotiation Don’t get side tracked – the fact that the student passed all other rotations is not relevant to the failure on this rotation

33 Key Points, cont’d.  Although inevitably subjective, a failing grade is based on the best judgment of expert clinical teachers & would not be overturned by an appeal  The only grounds for an appeal relate to the fairness of the process – was the student clearly informed about their deficiencies soon enough to remedy them?  Usually this means that the student is informed of their deficiencies at the mid-rotation feedback session. However, with professsionalism issues such as cheating, misrepresentation or not following through on responsibilities, the student may be failed even if they were not apparent at the mid-point feedback session.

34 Appeals Process  Students have the right to appeal their assessment  Appeals should be on the basis of the fairness of the process, not simply a disagreement about the assessment itself  The appeal should be submitted in writing  Students are STRONGLY advised to get advice on writing their appeal

35 Common Teacher Errors  Not orienting the clerk/resident and establishing clear expectations  Not observing the learner with patients  Not listening to your “gut” – usually you have an inkling that a student is in trouble quite early on  Procrastinating “Maybe they are just having a bad day” “No time today, I’ll discuss it later” “I’ll give them the benefit of the doubt” “It’s too late now” – no time for remediation  Not checking with other team members or discussing with clerkship coordinator or program director

36 Preventing Failure DDo a realistic needs assessment early in the rotation EEstablish clear expectations – two-way (what the student expects of us and what we expect of the student) OObserve and provide feedback early & often DDon’t save up a litany of complaints PPay attention to your intuition CConfront additional learning needs quickly EEstablish a comfortable relationship with the learner as a “coach” rather than a “parent”

37 Professionalism Issues  Often, failing students have problems with professional behaviour e.g. frequent lateness, not following through on responsibilities etc.  These behaviours often annoy teachers who tend to avoid confronting them head on because of discomfort  As a result, the student may not realize the gravity of their deficiencies and may not change  It is important that these behaviours be addressed clearly, non-judgmentally and as soon as possible

38 Examples of Feedback re Unprofessional Behaviour  “I noticed that you have been late for rounds twice this week. We expect students to be on time. This is important for your own learning and for the functioning of the team. Is there some problem with this that I should know about?”  “I am disappointed in the effort you are putting into your learning over the past week. I wonder if you are aware of our expectations in this regard.”  These comments indicate the supervisors concerns and open the door to a discussion about the expectations and the possibility of legitimate personal difficulties in meeting them.

39 When the Learner is Failing Needs assessment - get more information from: Direct observation of the learner with patients Discussion with the learner Discussion with other team members Feedback from patients More discussion of cases & chart review Beware focusing too much on gathering more information (“building the case”) vs. discussing how to improve

40 Referral  For primarily academic problems – to someone who can help improve learning skills – that could be you  Personal problems &/or illness – to a personal physician  For problems related to professionalism – to the program director or undergraduate coordinator. Also contact the Dean’s office

41 Resource Issues – Questions to Ponder  Do we have enough faculty with enough time to be effective teachers for faltering students?  Do we need a “special operations unit” of exemplary clinical teachers with dedicated time for concentrated and remedial teaching?  Could this be a role for some of our best teachers around retirement (pre & post)?

42 Summary  Orient each clerk & provide clear expectations  Observe early & provide specific feedback  Early formative assessment – at 1 week in 6-week rotations and 2 weeks in 12-week rotations  Pay attention to your hunches  Don’t wait  Gather more information  Speak to other members of the team and patients

43 Summary, cont’d.  Speak to the learner ASAP  Formulate an educational “diagnosis”  Form a plan for remediation and follow up in collaboration with the student  Deal with any blocks to learning  If it ain’t working…SEEK HELP!  Document!  Never give a passing grade to a learner who has not earned it

44 References  For more information about the UWO clerkship:  UWO Charter on professionalism: ism.shtml ism.shtml  A physician charter:  Project Professionalism:  An additional list of references is available from the main menu

45 Credits  Actors: Clinical supervisors: Cynthia Kenyon, MD (scenes I & II); Jim Silcox, MD (scene III) Student: George Kim, MD  Production: Wayne Weston, MD  Co-ordination: Catherine Blake, Manager Educational Research and Development  Recording: Rodd Rossoni, Media Specialist, Educational Technology

46 Feedback  We welcome your comments about this presentation – what you liked and suggestions for improvement  We also welcome your questions  Please contact Wayne Weston at

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