1. Marian University Faculty Development Trish Sexton, DHEd, FNAOME October 2014

2.  http://www.ahme.org/site_content/Remediation%20Book/Reme diation%20of%20the%20Struggling%20Medical%20Learner.pdf

4. At the close of our work together, successful participants will:  Diagnose learner deficits and identify the biggest student issue  Recognize the four steps of remediation  Describe a stepwise remediation process for at least three major learner deficits

5.  Up to 15% of third year students struggle during clerkships; 11% of fourth years  Will these numbers increase with increasing numbers of schools and larger class sizes?  ABIM reports 8 – 15% of IM residents have learner difficulty.  Other specialty college’s numbers are similar

6.  The number of students and residents who struggle are essentially the same.  Could this mean that deficiencies do not resolve without intervention?

7.  Struggling learners take time  Ignoring the issue affects morale  Deficiencies don’t resolve spontaneously  Can impact patient care / patient safety  Our obligation is to educate all learners

8. “Hard to define…but you know it when you see it” A continuum of struggling  failing

9. “Hard to define…but you know it when you see it” A continuum of struggling  failing Deficiencies in one or more areas O Insufficient knowledge O Poor clinical judgment/reasoning skills O Inefficient use of time O Poor communication/interpersonal skills O Professionalism issues Yao and Wright 2000. JAMA 284; 1099 –104.

13. If you have a stick, can you change the outcome?

14.  The act or process of correcting a fault or deficiency  It is done in as organized and objective fashion as possible

15.  Medical Knowledge  Patient Care  Interpersonal Communication  Practice-based Learning and Improvement  Systems-based Practice  Professionalism  Mental Wellbeing

16.  Direct Observation  Exam scores  Ability to take a history, perform a physical exam, etc.  Efficiency  Prioritization of tasks  Responsiveness to faculty, administration  Ownership of education

17.  Presentations / Labs / Small Groups  Formulation of DDx, Assessment and Plan  Formulation of questions  Ability to interact appropriately and provide valuable input  Interview the learner!  Review reading materials / test scores  Explore social stressors / mental health  Substance abuse / use  Get their perspective

18.  Other  timeliness  360 evals  Exam scores  OSCEs  Logs

20.  NG is a 1 st year student who is having a hard time keeping up and performing at the most basic level. He previously had moderate difficulties in college school and barely passes exams, which he attributes to stress.  He feels overwhelmed and wants to do the “right thing”, but is often not sure what that is.  He feels the professors are unreasonable in demanding he finish attend labs and other learning activities.  He is trying to keep up with his reading schedule but barely has time to get to it.

21. 1. Medical Knowledge 2. Patient Care 3. Interpersonal Communication 4. Practice-based Learning and Improvement 5. Systems-based Practice 6. Professionalism 7. Mental Wellbeing

22.  Presents as:  Poor exam scores  Inability to answer questions  Apparent lack of familiarity with the literature

23. Competency Assessment / Diagnosis of deficiency Development of Individualized Learning Plan Remediation Activities with Deliberate Practice Feedback Reflection Focused Re-Assessment Coaching and Mentoring KE Hauer, et al. Acad Med. 2009 84:1822 - 32

24.  Create a “success team”: faculty, learning resources, learner, other (counseling?)?  Identify gaps (review study habits / skills; knowledge deficiencies, skill deficiencies, etc,):  If learner has done well in the past, probably needs to put in more time  If the learner has always struggled, set a new study method

25.  Create a study plan  Assign reading: review material rather than primary articles  Focus on symptom-based resources rather than diseases  Provide practice questions (written or oral)  Encourage compare and contrast  Link reading to patient cases when possible  Encourage student reflection: keep an ongoing list of questions that require answers  Give feedback  Assess whether your corrective action plan has been successful; modify with future students

26.  BA is a fourth year student with excellent test scores, rotation evals up to now, and seems to do well with patients.  Staff and fellow students have recently reported that he is treating them rudely and is occasionally inappropriate with female staff / colleagues. He often calls in “sick” on Mondays and Friday but has told other students of his “awesome weekends” when he returned to work.  When confronted with his current behavior, he states he knows how to take care of patients and didn’t do anything wrong. He’ll be graduating soon anyway!

27. 1. Medical Knowledge 2. Patient Care 3. Interpersonal Communication 4. Practice-based Learning and Improvement 5. Systems-based Practice 6. Professionalism 7. Mental Wellbeing

28.  Presents as:  Inappropriate dress  Showing up late / leaving early  Rude or poor interpersonal communication  Unreliable  Dishonest  Passing off work  Unethical actions that may be brought to your attention

29. Competency Assessment / Diagnosis of deficiency Development of Individualized Learning Plan Remediation Activities with Deliberate Practice Feedback Reflection Focused Re-Assessment Coaching and Mentoring KE Hauer, et al. Acad Med. 2009 84:1822 - 32

30.  *Does it interfere with learning and / or patient care?  Create a Success Team:  Faculty member / course director  Learner  Student Affairs if appropriate  Academic Affairs if appropriate  Ask the learner for insight: write about his/her own level of professionalism  Provides you insight, provides the learner a chance to process and provides documentation  Review the importance of professionalism – lack prevents competence

31.  Identify what you expect the learner to accomplish in a given time frame  BE EXPLICIT! – high accountability; state (in writing) what is unacceptable behavior  State consequences including an official letter of warning in the student’s file #  # Have the learner identify a role model (one that you agree on)  Consider mental health referral if anger or substance abuse is the issue Will likely need an extended time of increased supervision to watch for relapses.

32.  EW us a 2 nd year student who has been seeking multiple excused absences due to recent family emergencies.  She has been having difficulty keeping up with classes and her exam scores have been substandard.  She complains of not sleeping well and having no appetite and is contemplating quitting medicine because it is too hard.  She does not feel her husband is supportive of her future career choice and she feels like she abandons her daughter when she drops her off at daycare.  She admits to taking xanax to relax and drinks 3 – 4 glasses of wine each night.  Other students have not noticed any significant problems.

33. 1. Medical Knowledge 2. Patient Care 3. Interpersonal Communication 4. Practice-based Learning and Improvement 5. Systems-based Practice 6. Professionalism 7. Mental Wellbeing

34.  Presents as:  Anything!  Inconsistency  “6 Ds”  Depression  Distraction  Deprivation  Drugs  Disability  Disordered personality  Note: the 6 Ds help explain – they do not excuse behavior!

35. Competency Assessment / Diagnosis of deficiency Development of Individualized Learning Plan Remediation Activities with Deliberate Practice Feedback Reflection Focused Re-Assessment Coaching and Mentoring KE Hauer, et al. Acad Med. 2009 84:1822 - 32

36.  Who to involve?  Faculty mentor / coach  Learner  Mental / behavioral health  Ask the student to explore his/her concerns and yours  Is this a new problem?  Are their specific limitations affecting performance?  Have they ever been told they have a learning disability?  Do they use addictive substances regularly? Have they used illicit drugs or non-prescribed pharma since starting med school?

37.  Trust your instincts!  Know that when a student struggles with substance abuse or mental health issues, personal life is affected first (and work / school last)  If either are affecting work – the situation may be CRITICAL  Ask directly about:  Psychosocial stressors  Depression  Anxiety  Learning disabilities  Substance abuse  Seek services: Student health; disability office, counseling, etc.

38.  All learners with deficits will need a supportive environment  Remediation must be customized to the situation  Establish specific remediation strategy:  Addressing the underlying cause  Discussing stress reduction techniques  Establishing tools / management skills to overcome deficits while the direct cause is addressed

39.  Mandate evaluations  Careers are at stake!  Emphasize wellbeing – not punitive action  Watch for relapses

41.  The task of the modern educator is not to cut down jungles, but to irrigate deserts. C. S. Lewis

42.  Jeannette Guerrasio, MD Association for Hospital Medical Education, 2013