Fixing the problem

Defining the problem works through the process of making an educational diagnosis. The next step is to develop a plan with the learner to improve performance. Ask the University for help. The unit directors, faculty advisors and program directors should be involved early.

Remember that difficulties are rarely due to knowledge defects alone, so it’s important to ensure that social or health issues are dealt with – by someone else. Don’t become your learner’s physician or therapist. Have them see their family physician or contact appropriate university resources. The PFSP program run by the Alberta Medical Association is another useful option.

www.albertadoctors.org/bcm/ama/ama-website

Helpful strategies

Inadequate clinical knowledge

• Pick two clinical topics seen during the day and encourage the learner to read relevant textbook articles or Clinical Practice Guidelines
• Have the learner give a brief summary next day

Poor clinical reasoning

• Make learners commit to a diagnosis or management plan
• SNAPPS or One minute preceptor may help
• Use higher level questions, such as “What if…?” detailed in Effective Questioning

Issues with communication skills

• Increased observation and feedback
• Role play

Attitude and behaviour issues

• These may be hard to manage
• Make your expectations explicit
  • Don’t assume that learners have the same values about standards of dress, timekeeping or hours of work that you do.
• Model the desired behaviour

Talk to the program director

• Don’t deal with this alone. Most preceptors find it distressing to work with a learner who is struggling, particularly if the learner is reluctant to acknowledge any deficiencies. Feelings of guilt or anger are common, occasionally making it difficult to consider taking on any further teaching responsibilities. Remember it’s not your fault that the learner is struggling.

Fairness, Accuracy, Documentation (FAD)

When rotations are not going well the principles of fairness, accuracy and documentation are particularly important in dealings with the student or resident to protect both the learner and the preceptor and also to ensure that underperforming learners get appropriate remedial assistance.

• Dr Miriam Boillat from McGill University has developed the following guide for working with residents, but the same principles apply with students.

Fairness

• Learner is aware of the objectives for the rotation
• Supervisor is aware of the learner’s level of training
• Evaluation is based on adequate exposure to the learner
• “Consensus” evaluation with input with other sources when appropriate
• Give learner feedback and an opportunity to improve
  • A formal mid-rotation assessment is essential, particularly if there are any concerns about performance
  • Raising the issue only late in the rotation does not allow time for remediation

Accuracy

• Base evaluation on learning objectives for the rotation
• Include specific examples of incidents leading to the unsatisfactory evaluation are included

Documentation

• Document the sequence of events
  • If it isn’t written down, it didn’t happen
• Document the discussion about performance
  • Expectation
  • Consequences, eg, “If your performance does not improve, I will give you an unsatisfactory evaluation or fail for the rotation.
  • Document the intervention
  • Written evaluation coordinated by one individual

Reference:
Modified from Department of Family Medicine, McGill University workshop. The “Problem Learner: Whose Problem is it? June 2006

Working with the struggling learner Develop a remedial plan with program director Avoid becoming the learner's physician or therapist Remember FAD Fairness / Accuracy / Documentation