IDENTIFICATION, DIAGNOSIS & REMEDIATION
OF THE STRUGGLING LEARNER
Jeannette Guerrasio, MD University of Colorado, SOM Eva Aagaard, MD University of Colorado, SOM
Kerri Palamara, MD Massachusetts General Hospital, SOM Abby Spencer, MD, MS Temple University, SOM
SGIM 2014 Annual Meeting
DISCLOSURE INFORMATION
The presenters have no disclosures.
OBJECTIVES
Describe the impact of struggling medical learners Diagnose area(s) of learner difficulty Choose and implement a remediation strategy appropriate to the identified areas of difficulty
TIMELINE
Welcome and introduction 5 min Identification and Diagnosis of 20 min
Learner Challenges Large group discussion
Remediation of Specific Deficiencies 40 min Small group discussion
Successes, failures and frustrations 10 min Large group discussion
Brief Summary 5 min
MAGNITUDE
Medical Students Up to 15% struggle during their MSIII
medicine clerkship Up to 11% struggle as MSIVs
Residents Point prevalence in need of
remediation 7-15%
Paul G, Teaching and Learning in Medicine. 2009: 21(3):254-60. Yao DC and Wright SM. JAMA 2000; 284;1099-104.
IMPORTANCE
1. Time
1. Morale
1. Reputation
2. Patient Safety
.
Lavin, B et al. Acad Med 1998;73(9):998-1002.
IN THE LITERATURE
Limitations: Rare published evidence to guide best practices in
remediation
Advantages: Wealth of knowledge on this topic
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Hauer KE. Acad Med 2009; 84(12):1822-1832.
8
Adapted from Hauer KE. Acad Med 2009; 84:1822-1832.
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IDENTIFIERS
Formal written evaluations of competencies Peer assessments Examinations Written Clinical performance
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IDENTIFIERS Verbal comments Reporting system for concerns Mid-rotation performance evaluations
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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-1832.
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COMPETENCIES:
Medical Knowledge Patient Care Interpersonal Skills and Communication Professionalism Practice-Based Learning and Improvement Systems-Based Practice
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The Outcomes Project. Accreditation Council for Graduate Medical Education. 1999.
COMPETENCIES “PLUS”: Medical Knowledge Patient Care Clinical Skills Clinical Reasoning Organization & Time Management
Interpersonal Skills and Communication Professionalism Practice-Based Learning and Improvement Systems-Based Practice
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COMPETENCIES “PLUS”: Medical Knowledge Patient Care Clinical Skills Clinical Reasoning Organization & Time Management
Interpersonal Skills and Communication Professionalism Practice-Based Learning and Improvement Systems-Based Practice Mental Well-being
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% of Learners with Deficit
0 5 10 15 20 25 30 35 40 45
Medical Knowledge
Clinical Skills
Clinical Reasoning
Time Management & Organization
Interpersonal Skills
Communication
Professionalism
Mental Well-Being
Fellow/Attending
Resident
Student
CASES #1
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IDENTIFY THE DEFICIT… 1. Medical Knowledge 2. Clinical Skills 3. Clinical Reasoning and Judgment 4. Time Management and Organization 5. Interpersonal Skills and Communication 6. Professionalism 7. Practice-Based Learning and Improvement 8. Systems-Based Practice 9. Mental Well-Being
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MEDICAL KNOWLEDGE
Presentation A history of poor exam scores Unable to answer fact based questions
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CLINICAL REASONING Presentation During Presentations Extraneous information Unable to focus Too many tests Difficulty differential diagnosis analyzing diagnoses individualizing protocols/practice guidelines
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ADDITIONAL INFORMATION
Direct Observation Presentations/Rounds
Interview the Learner
Other Sources
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CASE #2
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CASE #2
Your resident is disheveled and left his white coat at home again. He shuffles through multiple papers of various shapes and sizes as he presents the following case:
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IDENTIFY THE DEFICIT… 1. Medical Knowledge 2. Clinical Skills 3. Clinical Reasoning and Judgment 4. Time Management and Organization 5. Interpersonal Skills and Communication 6. Professionalism 7. Practice-Based Learning and Improvement 8. Systems-Based Practice 9. Mental Well-Being
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TIME MANAGEMENT & ORGANIZATION Presentation Unprepared for deadlines Disorganized in appearance Presentations and notes missing sections and out of
order Arrival and departure times
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PROFESSIONALISM
Presentation Inappropriately dressed Frequently late or absent, unreliable Dishonest Try to pass off work Poor patient - doctor relationships Specific unethical actions may be brought to your
attention
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WHO NEEDS TO KNOW?
WHO NEEDS TO KNOW?
Make sure the learner receives the feedback as soon as possible
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-2
-1.5
-1
-0.5
0
0.5
1
Bottom Third Middle Third Top Third
Actual
Z-Sc
ore
Asse
ssm
ent
Rel
ativ
e to
Sta
ndar
d
Level of Resident By Expert Assessment
Hodges B Acad Med 2001;76(10 S):S87-9.
WHO NEEDS TO KNOW?
Make sure the learner receives the feedback as soon as possible
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-2
-1.5
-1
-0.5
0
0.5
1
Bottom Third Middle Third Top Third
Actual Perceived
Z-Sc
ore
Asse
ssm
ent
Rel
ativ
e to
Sta
ndar
d
Level of Resident By Expert Assessment
Hodges B Acad Med 2001;76(10 S):S87-9.
WHO ELSE NEEDS TO KNOW? Medical Student Clerkship Director Office of Student Affairs at the SOM Remediation Team
Resident or Fellow Program Director Dean of Graduate Medical Education Remediation Team
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REMEDIATION TEAM APPROACH
Review the learner’s academic record Review examples of deficit(s) and confirm deficit(s) Look for trends and severity
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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-
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REMEDIATION STRATEGY
The goal of remediation is to target and fix:
the greatest deficit!
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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-
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35
CLINICAL REASONING
Deliberate Practice Framework for creating a ddx Create ddx: age, gender, race/ethnicity, & cc
Feedback Re-enforce the use of resources for feedback
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CLINICAL REASONING
Reflection Update list of differential diagnoses What was missing? What was more or less prevalent?
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CLINICAL REASONING
Deliberate Practice Continued Compare and contrast diagnoses
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Presenting Symptom: Chest Pain
Symptoms and historical info.
Signs Diagnostic Work-up
Treatment
GERD Subacute, epigastric, burning, supine, relief with antacids
Tenderness to palpation of the epigastrium
History alone, Abnormal EGD
Raise head of bed, change diet, avoid tobacco and alcohol, weight loss, H2 blocker, PPI
Stable Angina
Male, advanced age, pressure with radiation to arm or jaw, exertional, +/-SOB, nausea, DM, HTN, HLD, tobacco,+ FmHx
May have murmur, lateral PMI, gallop, paradox split S2, or normal
Abnormal EKG, Dynamic EKG, Stress test, Cath
Modify risk factors such as… weight reduction, DM control, HTN control, smoking cessation ASA, statin, +/-ACE-I B-blocker, NTG
Etc.
Blankenburg R. et al.. PAS May 2011.
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CLINICAL REASONING
Receiving Feedback Re-enforce the use of resources and seniors or
consultants for feedback
Reflection Reflect on identifying differences between diagnoses What questions would be pertinent while taking a
history?
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SMALL GROUPS
Create a remediation strategy for learner with a given deficit that includes: Deliberate Practice Feedback Reflection
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Unprofessional behavior in medical school
Subsequent disciplinary action by the state medical board
THE DATA
Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.
Unprofessional behavior in medical school
Subsequent disciplinary action by the state medical board
THE DATA
Papadakis MA, et al. N Engl J Med 2005; 353:2673-82. Kern DE, et al. Curriculum Development for Medical Education. 2009; p 67.
Facu
lty T
ime
in H
ours
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Adapted from Hauer KE et al. Acad Med 2009; 84:1822-
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Define Success: 1. Has the individual caught up to his or her level of
training in the previously deficient competency? 2. Is the improvement sustainable?
MEASURING SUCCESS
REASSESSMENT Repeat clerkships/rotations Standardized patient encounters & simulation Directly observed encounters in clinical environment Written or web-based assessments Chart reviews & Chart-stimulated recall Multi-source evaluations Arrival and Departure Times Attendance Attire Responses to self-assessment Patient and procedure logs
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VALUE OF FACULTY TIME? the odds of probation by 3.1% per hour (95% CI, 0.09-.0.63)
negative outcomes by 2.6% per hour (95% CI, 0.96-0.99)
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Medical Student Resident Post-Residency
Withdrew
Transferred but Did NotGraduate
Probation/RestrictedPractice
Transferred and Graduated
Good Standing
Graduated
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Guerrasio J et al. Acad Med. 2014;89(2)352-358.
Successes, failures, frustrations, questions?
SUMMARY Challenge of struggling medical learners exist in all
programs IDENTIFY DIAGNOSE REMEDIATE with
DELIBERATE PRACTICE FEEDBACK REFLECTION IN ACTION
Success for teacher, learner and patients!
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ACKNOWLEDGEMENTS
My Mentors at the University of Colorado Eva Aagaard, MD Maureen Garrity, PhD Carol Rumack, MD
Contact: [email protected] www.clinicalremediation.com
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