It’s another challenging day in the life of a program director…
Your faculty members demand that you fire a resident who consistently underperforms. She isn’t progressing, resists feedback, and was placed on academic probation twice. Her structured remediation plan is failing. You haven’t observed any improvement despite devoting countless hours to helping her. She frustrates her clinical supervisors and the residency faculty members assigned to assist her. However, she believes she is deeply engaged in her learning.
Did your remediation fail? Or was it never going to work in the first place?
What do you do next?
The Struggling Learner
A previous post in our Leadership in Medical Education series discussed ‘difficult learners’ framed by Vaughn et al.1, 2 Vaughn classifies difficult learners into one of four groups: affective, structural, interpersonal, and cognitive. Disorders in any one of these domains greatly impacts achievement of training goals. [Note: ‘Difficult’ is not the ideal term for struggling learners yet persists in the literature. These trainees may be difficult or challenging to teach rather than difficult or disagreeable human beings. We use ‘difficult learners’ in this piece for consistency with existing literature.]
- Affective: poorly manages emotional responses to challenges or events
- Structural: poor organizational skills and time management, limiting clinical efficiency
- Interpersonal: problematic behavioral attributes or personality disorders
- Cognitive: poor foundational knowledge and poor application in clinical care
This post provides a brief summary of the cognitive domain of difficult learners and offers management recommendations for program faculty. The primary goal when assisting students with deficits in cognition is to distinguish whether deficiencies involve knowledge acquisition, retention, synthesis, retrieval, communication of knowledge, or some combination of these. Most clinician educators will need to engage a team of experts outside their department to facilitate this evaluation and subsequent interventions.
Learning Disabilities and ‘Failed Remediation’
The assumption that a poorly performing resident is “not working hard enough” is misguided and rarely true. Failed remediation plans may instead be a sign of an undiagnosed learning disability.
Learning disabilities include a group of disorders that affect 10-15% of the general population and 3% of U.S. medical students.3 In medicine, we sometimes fail to identify learning disabilities because our students and trainees are so high functioning. Similarly, students with disordered learning are typically unaware of their disability until their capacity to compensate for their condition becomes inadequate. Residency training uncovers learning disabilities because previously useful compensatory actions fail in the setting of sleep deprivation, pace of training, volume of work, and lack of time.
Recent studies show that 2.7% of medical students disclose disabilities and request accommodations, 4 of which only 10% have disabilities that are apparent to others such as visual, mobility, or auditory disabilities. The majority of disabilities can be concealed by trainees including attentional, learning, psychological, or chronic health disabilities. The prevalence and categorization of disability among residents is unknown. 5
Remediation strategies that do not include a standard assessment for learning disabilities may fail to achieve desired outcomes. Program leaders have finite options to offer these trainees and department resources may deplete quickly. Termination or transfer to another program may be the unfortunate outcome when recommended strategies and program resources are no longer helpful. While we want all of our trainees to succeed, the hard reality is that some learning disabilities are incompatible with residency training and clinical practice.
Finally, psychometric testing may fail to identify the etiology of the presumed disability. Consider whether the clinical learning environment is the actual cause of a failed remediation, not the trainee. Are there structural or systems issues that undermine remediation processes? The learning environment may need attention first, before trainees can be successful.
5 Strategies When Remediation Fails
Consider these 5 strategies to support learners who require more than standard remediation approaches.
1. Psychometric (Neuropsychological) Testing is used to diagnose learning deficits or treatable psychological disorders that impair learning and retention, such as depression, anxiety, or obsessive-compulsive disorder. Neuropsychological evaluations clarify core deficit(s), identify neurocognitive and psychological strengths that might be leveraged, and recommend appropriate accommodations when necessary. 7
We recommend offering neuropsychological testing early in most remediation plans. Some hospitals or GME programs provide psychometric testing to simplify access, referrals, and insurance matters for trainees. Testing may take 1 -2 days and can be expensive. Generally, testing cannot be mandated unless certain criteria are met, usually dictated by the institution. Test results are confidential and treated as any other HIPAA-protected document. Learners may choose to share relevant reports when an accommodation is needed. Remember, the need for testing does not make any attribution about a learner’s IQ.
Where to find a psychometrician:
- Local neuropsychologists who specialize in this testing
- ADHD testing and treatment centers
- Brain Injury rehabilitation centers with neurocognitive specialists
- Universities with cognitive psychology programs
2. Professional Coaching may address affective, structural, and interpersonal challenges that may coexist with and exacerbate cognitive disabilities. Coaching offers learners a different perspective and skills that can augment compensation efforts. For instance, trainees with structural deficiencies often have organizational, time management, and prioritization difficulties that can respond well to coaching.
Coaching is a collaborative, helping relationship. Coach and client (trainee) engage in a systematic process of setting goals and developing solutions with the aims of facilitating goal achievement, self-directed learning, and personal growth. 8, 9 Learners implement action steps required to achieve their goals and coaches keep them on track9.
Never assign a learning coach who would also assess the learner in any formal capacity. Coaching and supervision should be distinct roles. Moreover, professional coaches are specially trained in complementary strategies and techniques that are generally outside the expertise of residency directors and core faculty.
3. Medical Evaluation: Chronic, unidentified, or poorly treated health issues can have a significant impact on trainee performance. Conditions such as thyroid disorder, hearing or visual impairment, substance abuse, and sleep disorder have been identified as contributors to learning disability and poor performance. Some of these disorders manifest as problems with procedural competency, failure to meet a technical standard, or visuospatial learning. 4 Ensuring medical appointments for trainees can have a positive and lasting impact on performance.
4. Involve Collaterals, such as family or friends, who may substantially contribute to the remediation plan and provide support in a more holistic manner. They may have additional insights about the learner. Supportive individuals can guide the trainee to remain focused on their goals and strategies, and they may prove to be a valuable asset in the overall remediation process.
5. Leave of Absence provides time off to address issues identified during a medical or psychological evaluation. Leaves of absence can vary in length and should be long enough to ensure adequate treatment time. Leaves are often at the suggestion and supervision of the practitioner who determines when it is safe and appropriate to return to work. Extended leaves are consequential, including prolonged training time, impact on other members of the team, and a risk to learner privacy.
Take Home Points
- Correctly diagnose the difficult learner.
- Revise remediation plans to address learning disabilities.
- Co-manage with a neuropsychologist to determine appropriate testing and interventions.
- Comprehensive remediation may prevent termination and save a career.
Though well-intentioned, remediation and probation may be viewed as punitive by the trainee. Residents may be resistant, angry, and resentful. In these circumstances, it is wise to acknowledge the possibility of a litigious learner who feels unfairly targeted. Therefore, it is important to follow your institution’s GME policies regarding remediation and probation, and inform your GME office when these processes have failed. Maintain documentation of meetings, suggested strategies, remediation plans, and psychometric test results that were disclosed.
Learning disorders are more prevalent among medical trainees than program leaders realize. The remediation process is not always successful, despite our best efforts and intentions. The challenge lies in correctly identifying the learning challenge to target your interventions. The identification and management processes for learning disabilities may go beyond the scope and expertise of clinician educators responsible for program oversight. Before it becomes necessary to terminate or counsel a resident to another program or specialty, consider less commonly employed tools for remediation and outside resources. These co-managed strategies can serve as invaluable adjuncts to remediation plans the program already has in place.
About the authors:
Merle Carter, MD, is Executive Vice Chair of Emergency Medicine at the Albert Einstein Healthcare Network in Philadelphia, Pennsylvania. She is also responsible for faculty affairs and development for the Department of Emergency Medicine. Merle has previously been the Residency Director for Emergency Medicine, and the DIO/Asst. Vice President of Graduate Medical Education of the Einstein Network. Twitter: @MCEmedMD
Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael is Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. He co-directs the Scholarly Concentration in Medical Education at Stanford School of Medicine. Twitter: @MikeGisondi
- Vaughn LM, Baker RC, Thomas DG. The problem learner. Teach Learn Med. 1998; 10:217-22.
- Weygandt PL, Gisondi, MA. (2020, October 20). Leadership in Medical Education: Teaching Difficult Learners [Blog post]. Retrieved from https://icenet.blog/2020/10/20/leadership-in-medical-education-teaching-difficult-learners/
- Rosenbraugh CJ. Learning disabilities and medical schools. Medical Education. 2000; 34(12): 994-1000.
- Meeks LM, Herzer KR. Prevalence of self-disclosed disability among medical students in US allopathic medical schools. JAMA. 2016; 316:2271-2272.
- Meeks, Lisa M. PhD; Herzer, Kurt MD, PhD, MSc; Jain, Neera R. MS. Removing Barriers and Facilitating Access: Increasing the Number of Physicians with Disabilities. Academic Medicine. 2018; 93(4): 540-543.
- Meeks LM, Case B, Plegue M, Moreland CJ, Jain S, Taylor N. National Prevalence of Disability and Clinical Accommodations in Medical Education. J Med Educ and Curric Devel. 2020; 7: 1-4.
- Prigatano G, Pliskin N (Eds). Clinical Neuropsychology and Cost Outcome Research: A Beginning. East Sussex, UK. Psychology Press, LTD. p. 261.
- Grant A. M., Stober D. “Introduction,” in Evidence Based Coaching: Putting Best Practices to Work for Your Clients, eds Grant A. M., Stober D. (Hoboken, NJ: Wiley) 2006;, 1–14.
- Grant A. M. The efficacy of executive coaching in times of organizational change. J. Change Manage. 2013b; 14 258–280.
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