The Learner in Difficulty

By Jonathan Sherbino (@sherbino)

This guy (Vilfredo Federico Damaso Pareto) makes my life as a Clinician Educator hard.

An Italian economist from the 19th Century, he derived the 80:20 rule, or in the case of medical education, the 95:5 rule.  The rule is simple.  95% of my headaches as an educator come from 5% of the learners. I’m sure the modified Pareto rule rings true for you.

At times, my base temptation is to ignore this small minority.  But there is a danger in writing off inappropriate behaviour as simply a “bad day.”  A “bad day” is often a signal of underlying problems that have not been explored, nor addressed.   As an example, one study demonstrated an eight-fold increase in the probability of unprofessionalism in future practice if a medical student acted irresponsibly during training.[i]

One definition of a learner in difficulty that I like is this: “A trainee whose competence, health, or behaviour is below expectations such that this is a threat to their professional success.”

So, what to do?

Act.  This is the hardest part.  The rest comes easy.

I often use an approach to the learner in difficulty that parallels my clinical practice of medicine.

Step 1 – Diagnose (the problem)

Step 2 – Design (an intervention)

Step 3 – Develop preventive measures

Step 1 – Diagnose

What are the factors related to the learner?

  • Clinical performance / behaviour
  • Personal issues (I do NOT advocate for CEs to diagnose mental health or addiction problems.  This requires specialized care from a mental health / addictions expert.)

What are the factors related to the teacher?

  • Unspoken expectations / assumptions
  • Lack of experience (as a teacher or clinician) to provide appropriate direction / supervision

What are the factors related to the system?

  • Demanding clinical responsibilities
  • Standards unclear

Confirm the problem

  • Collect data
  • Consult with other faculty / team members
  • Test a hypothesis
  • Engage the learner in the process


Step 2 – Intervention

Occasions for immediate action

  • Patient safety
  • Substance abuse
  • System disruption

Principles of an effective intervention include:

  • Early intervention
  • Clear timeframe / schedule
  • Expectations for behaviour
  • Consequences
  • Iterative feedback
  • Confidentiality
  • Documentation (as appropriate)


Step 3 – Prevention

Certainly not every difficulty a learner experiences can be prevented.  However, a learning environment with clear expectations and a culture of feedback (coaching) can help identify borderline behaviour early.  A system that promotes regular meetings with learners and integrates all feedback from all members of the clinical team can prevent recurrent patterns of problem behaviour.

I’m incredibly fortunate to enjoy a career as a Clinician Educator.  The vast majority of learners that I teach are professional, thoughtful, innovative and engaging.  The learner in difficulty is not intended to be a value judgment.  In many instances, the factors contributing to difficult behaviour arise from circumstances beyond the control of the learner.  However, when this scenario is encountered, I hope that we all would acknowledge that is NOT “just a bad day” and begin the process of supporting the learner in addressing the issue.


[i] Papadakis M et al. Disciplinary action by medical boards and prior behavior in medical school. NEJM 2005;353(25):2673-82