Session Recorded on July 27, 2021

Welcome to this session of the Teaching Prescription Pad, where we learn the prescription for effective teaching from the best clinical teachers. This session is on remediation of the struggling learner. Our expert is Dr. Steve Craig. Dr. Craig is a general internist in Des Moines, where he's been teaching medical students and residents for over 35 years. I am Jeff Pettit your moderator for this session. Welcome, Dr. Craig.

Thank you, Jeff. It's great to be here.

The first question to start off with is, why is this topic important their interest to you?

Well, it's a great interest to me because in 35 plus years of teaching, it's been a recurring theme that you are going to encounter students or residents as they move along in their training, who are needing help and by remediation mean they need correction of some underlying deficit in one or more areas. The studies show that somewhere between 10 to 15% of both medical students and residents will have a deficit that they definitely need your mediation help with and it took me a long time to figure out how were the best ways to provide that kind of assistance to the learner in need.

How can you identify a struggling learner?

I think one of the things I've learned from experience is they often don't come to our attention until very late in the process and that's one of the challenges, one of the frustrations, is that they often come to us when there's a crisis, like when you investigate the site, why did this happen you figure out where there were several warning signs. They should have been picked up on before it came to this point.

Very often the problem comes when somebody gets upset enough that a patient or patient’s family, nurse or other member of the health care team, or sometimes the supervising resident or faculty say we've got a major problem here that needs to be addressed.

And as I said, in my experience, looking back on it, you often find there were definite clues that that could have been picked up on and acted on earlier to maybe prevent from reaching a point where it either came to a crisis or came to some major event that that brought the need for remediation to everyone's attention.

Could you describe the steps in your process of how you go about working with the remediation student?

I think the first step in the process is I've learned by experience we've got to do a better job of educating our supervising residents and our faculty, and the nurses and other members of the healthcare team to ‘if you see something, say something’ to bring it to the attention if it's the resident to the residency program director. If it's a medical student, bring it to the attention of one of the deans, or the clerkship director for the given clerkship that a student might be operating on because they need to know. Again, it allows the person who's given that information to do some further background investigation to find out what's really going on and whether there's a need for remediation which I said is some correction of some underlying deficit.

So I think that's the first step, early recognition by training the other faculty and staff that you work with, to be on the lookout for her resume struggler particular area, and even it's just your hunch that something's not quite right.

And I think the second step after detection is to say, take your time and trying to find out what the diagnosis is what's the principal deficit what's the principal deficiency that is that a learner has, and it's very often the case that you find they have deficiencies in several areas, but if you spend enough time working on the proper diagnosis you typically will find one area that rises to the top as being the most significant area of deficiency. It's amazing how often we address that particular deficiency and see a lot of the other things that were concerns, start to fall in line as well.

So very often, even though there may be identified problems in several areas, figuring out which one is the biggest area of concern and addressing that at least first, and oftentimes you'll see the other areas fall into place and work better.

I would want to mention Jeff at this point to resources that have been particularly helpful to me. There is a wonderful text that was published, originally in 2013, and a new edition was out in 2018 from a Dr. Jeannette Guerrasio, who is an internal medicine faculty person at the University of Colorado in Denver, and she is head of the remediation efforts for both the internal medicine residency program, and for the medical school, dealing with medical student deficient learners. I really learned a lot when I studied in some depth her two books that described her method for going about making the proper diagnosis of learning deficiencies and then she goes on in the second book to talk about what are the strategies once you've identified the primary of deficiency to try to attack that particular deficiency.

There's also a book published by Springer Publishing called Remediation in Medical Education that was published in 2014 that I think very much in keeping with the same approach recommended but after garage CEO, and I found those two resources to be wonderful and helping me. So, for people listening to this you want to maybe a little deeper dive in a better understanding of this topic I would highly recommend those resources, and I want to assure you I don't get any royalties. I have no particular involvement in the publishing of either one of those works.

All right, great information that will be available afterwards in the transcripts.

What kind of challenges have you come across and going through the remediation process with the learners and what have you been able to do to overcome the challenges?

Well, the first challenge obviously is getting the learner to accept that they need help. And that sounds like it should be easy but as you can imagine there are certainly learners who are in some denial and somewhat argumentative when it comes to pointing out to them concerns that have been raised. And again, it's usually as you do a deeper dive not going to be one isolated incident you usually find there's been a pattern there's been some recurring. You know challenges in a particular area and trying to bring those to their attention and help them to buy into the need for help getting help to correct these underlying deficits is probably the first and most difficult step.

And then as I said already, you really do have to spend some time and really have to do direct observation of learning to figure out where are their deficits and maybe what's the biggest area of deficit and concern. Dr. Guerrasio, who has a wonderful kind of diagnostic strategy talks about the 10 areas that a learner might be deficient in and kind of walks you through how you would recognize a learner whose primary deficiency is in one or more of those areas but I would say the first biggest challenge is getting the learner to accept that they have a problem that they do need to come to grips with and work with you and addressing.

And then the second big challenge is figuring out so like where is their biggest area of concern and as I said you usually get sorted out to one of kind of 10 different areas.

I was going to ask about what the areas were, so she's got them all outlined in her book, so good.

One of the things that I might say a word about Jeff is it's fascinating that some of these things are split into several categories. So for instance, she uses the ACG me general competencies, as the framework for those 10 areas of deficiency. So medical knowledge can be a standalone problem. When we find somebody really has struggled with developing their medical knowledge, usually that one's easier to define and diagnose because you find out they've had a pattern of really poor performance on exams.

Patient Care gets to be the tricky area because in patient care, Dr. Guerrasio identifies three different deficits and you must sort out which one is primary. So, one could be their clinical skills they just have not learned the proper interview techniques they've not learn the proper physical exam, skills, and interpretation of the physical exam findings. It could be in terms of patient care. They're just so disorganized and poor in their time management that that ends up being the primary deficit. And then the third and probably the most difficult to treat is where you find it the clinical reasoning and judgment area of patient care that that is really deficient they they've got a reasonable knowledge base they've got the skills to acquire knowledge they just have a hard time putting things together, and developing their clinical reasoning.

The other area is interpersonal skills. Again, those are usually pretty easy to identify. In terms of people who have problems not just with one or two individuals but with multiple people on the healthcare team and their fellow residents are students, you know, often problems with that area.

Communication where again if you dive into it you can find out what's the difference between an interpersonal conflict versus just having poor communication skills professionalism, which again is that is a very challenging one to address this time times that the learners who are in most denial are the ones where the primary issues are their professionalism, practice based learning and improvement for the student a resident just doesn't see the need to push themselves to get feedback to try to improve to really work hard to identify areas and efficiency that they want to address systems based practice where people who just struggle working in certain types of systems.

We see learners who really do well in the outpatient clinic before they get in the hospital, especially in the ICU they really struggle. So again, kind of getting them to develop their skills and all the areas where they have to be proficient.

And then another big category and one separate from the general competencies was mental wellbeing. And this again can encompass everything from somebody who's got severe psychosocial stressors to somebody who may have an undiagnosed and undertreated psychiatric disease substance with substance abuse, you know, individual substance abuse difficulties or occasionally even as late as you know resident training we find people who have had an unrecognized learning disabilities and have to have those addressed to see them really make the progress that they needed addressing their proficiency.

As you go through your remediation process, do you develop a plan? And in that same regard documentation. How much do you do not do as far as recording everything?

Absolutely. Thank you. That's a great question a great area we should spend a little time talking about and that is, as we said already one of the keys and one of the challenges is getting the learner to recognize and accept that they've got a problem, and they're going to come to grips with it.

Once you've, you know, been able to accomplish that you then set up a remediation program. And oftentimes there's an actual contract that gets developed it says here's what we're going to expect of you in participating in this remediation program, and get them to acknowledge the different things that are going to be required of them.

Before we can say they successfully remediated their problem, we make it clear that if they fail to participate, fail to take this seriously, or just can't show the progress that is needed, then it may affect their ability to continue in medical school, this the medical student during their residency training. If this is the resident, you need to know to have it very clear that this is, you know, serious stuff that really needs their full attention and if it's, they're not able to show the progress that we need to show it could jeopardize their ability to continue on in school and the residency training.

So those are I think some of the initial keys. One of the things that I really liked about both the two references that I cited as they said that one of the things that you really probably need to address is helping the learner to identify a mentor. Someone who will not be doing the critical analysis of whether they're making the necessary progress and isn't the one conducting the remediation. But just someone that can be a sounding board for them to talk with them about what it is that they're struggling with and you know they can feel that they can talk freely with those people because those people are their advocates and are not going to be judging their performance and not conducting the remediation and allow them to have, you know, a say into who they think would be helpful in that regards.

That could be a good advisor and mentor to them that they could meet with on a regular basis and they can express to the mentor. You know how they think it's going and what things are frustrating to them and challenge them and get their help and advice and support and trying to deal with it because frankly, one of the things that you can imagine is sometimes the learner feels like I'm all alone in this struggle, and I don't know how I'm going to ever meet their expectations because they're just making me do things that I don't feel like I'm necessarily capable of doing exactly what's expected of me. It really helps for them to have an ally, and to have a mentor and to have an advisor that they could bounce things off of and get advice and counsel from as they try to meet the requirements and the remediation plan.

So, how do you know if the remediation plan is effective, and along the same lines, do the residents, the learners, seem to be appreciative of someone's sitting down and working them through this process?

In my experience, yes I think they do appreciate that, you know you're not doing this because you're looking for extra things to do and more work you're doing it because you really want to see them make the necessary progress. To be able to continue on in their training. And so, you know, one of the things that I think among the things that I found helpful is the learner has to be self-reflective so you know I oftentimes will counsel to learn, I want you to take a journal, but keep a journal of kind of how you think things are going and what things you see getting better what things still need work.

We're going to have a remediation person who's assigned to you to leave the remediation process. And one of the keys there is deliberate practice with feedback, so you know if it's a clinical reasoning challenge, dealing with, you know some clinical scenarios and let's have you reason through with me how you would approach arriving at the diagnosis and proper treatment of this patient and giving them the feedback about what things they're doing well what things they need to continue working on to do better.

Once we seen that they've been making some progress through this kind of one on one remediation with deliberate practice and feedback, then we're going to say that the next step is going to be as we, you know, move on with your training, we're just going to be very much seeking out feedback from the people that are working with you multi source feedback about how are you doing in the particular area that you've been working on and eating remediation in, and you know there's an age old question that always arises about, is it fair to the learner to feed forward to the people they're working with the challenges they've had.

And I think, if it's reached that point where you said this is make or break we've got to either get this right, or you're potentially not going be able to continue on in your training, and a half to tell people that are going to be assessing the learner that this this particular learner has struggled this particular area. That's all we're going to say, but we're going to be very interested in your feedback and how they're doing in that particular area, so they kind of know what are the, you know, the people are going to be assessing them what is it that they're going to be assessing and asked to give specific feedback about. And again, we try to do that multi source, so they don't have to say well that one individual didn't seem to give me a fair shake you know it's going to be multiple individuals that get a chance to weigh in on how are they doing in this area, they've been working on and trying to remediate the remediation mentor that you mentioned, is this someone who ultimately would add to the evaluation of the person. No, they do so the mentor would strictly be an advisor to the student and a confidant for the student, and we will feed to them what the deliberate practice with feedback is showing what the multi-source feedback evaluations are showing, so they can balance with the learner kind of what the learners telling them about how they think their mediations going and the progress they're making with what's the actual feedback from people who are doing the supervising, And again just to try to help serve as a as an advisor and mentor that student, again, because it's certainly possible that the learner may be telling their mentor Oh It's going great there's no problems I'm making great progress in this area.

And so, if there isn't some right correcting of that information by feeding to the advisor actually we still are really struggling with learning about their clinical reasoning skills and these are the types of things that we're continuing to see as an issue and a problem, then that person can certainly be of help to the remediation team but also great help to the individual learner, with kind of recalibrating for them and saying well you know i think you know your read on this may not be the proper read and we’ve got to keep working, and keeping your focus on trying to do things that will improve in this area is because it sounds like there's still work to be done.

For the mediation mentor, is it necessary for them to be within your own specialty, or no?

That's a really good question and I think you know what the people who are really expert in this field including Dr Roscoe would say is, it's probably important to let the student choose who they're going to feel comfortable with, reminding them that they, you know, want to make sure that person kind of knows a lot about the area they're struggling with so that when information is fed to them or what the challenges are they can be of some assistance and advice to the student. So, I guess I would say, for instance, the problem was clinical reasoning.

And if they were to choose to work with a psychiatrist, they feel comfortable with you just want to remind them that's fine. You get to choose who's going to be your advisor and mentor, you know, maybe the psychiatrists wouldn't be as knowledgeable on the kinds of things we're going to be working on with you, and you might want to consider having somebody who is really involved in and invest in that just as you know, it's a surgical specialty.

Probably helpful if you had a you know a surgical, you know, an advisor mentor that you could work with so that they would better understand what's the nature of the surgical skills that you're needing remediation in. I would say that's the only caveat that I think this learner needs to have a say in who they think they would be most comfortable, helping them and assisting them and advising them and mentoring them. But ideally have that be somebody who also has a pretty good working knowledge of their areas of deficiency.

Alright, thanks. So just before we end this session, are there any other thoughts or suggestions related to remediating and helping the struggling learner?

Yeah, I think the big thing Jeff that I learned is that you know so I serve 15 years his residency program director and I served as the Dean of the branch campus for 16 years. And so I got to see it from two ends of the spectrum the residents who needed help, and the students that needed help, is I learned how important it was to get that word out to faculty and residents that senior supervising residents and to nurses and staff that hey I want to hear if you have concerns about a particular student or residents and sometimes are that hesitate I don't want to get them in trouble. I don't want to raise a concern if nobody else has seen the things that I've seen, but again we can say to them, you've attended confidence share with me any of attended confidence share with me any of your observations and we can then you know do a little more investigating to find out if you know what you're observing is being seen by others and maybe just hasn't been reported and then we can get you know this remediation help started earlier rather than later in the process as you can imagine, if somebody gets all the way into the middle of their Renzi training for me figure out they've got major problems that reasoning skills.

That's going to take a lot longer to remediate and going to potentially interfere with their completing their training on time, way more than if we identify it as a medical student would say let's get you that help early in the process so that when you move on in your training you're not still struggling with those more pounds of basic deficit.

 

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