#193 LIVE! The Struggling Learner with Dr. Melissa McNeil

February 3, 2020 | By Matthew Watto, MD

What to do when learners struggle. LIVE from UPMC Grand Rounds!

Join us as we discuss how to approach “The Struggling Learner” with Dr. Melissa McNeil (@missydoc0128), Professor Medicine and Associate Chief of General Internal Medicine at the University of Pittsburgh Medical Center (UPMC), recorded LIVE in Pittsburgh, PA!  In this episode, we discuss how to approach the struggling learner, highlighting the 5-Step process discussed in a recent article co-written by Dr. McNeil (Merriam 2019).  This episode is not intended to give educators a roadmap for how to develop and implement a corrective action plan, but was put together to provide a common toolset on how to approach a struggling learner.  As such, the topics discussed can be applied to all kinds of learners that struggle, not just in medicine. However, the techniques discussed involve a common framework routinely taught in medical education (assessment, diagnosis, and referral) and, therefore, is communicated using this shared language.

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Credits

Written and Produced by: Stuart Brigham MD

Infographic: Matthew Watto MD, FACP

Cover Art: Stuart Brigham MD

Hosts:  Matthew Watto MD, FACP; Paul Williams MD, FACP; Stuart Brigham, MD

Editor: Stuart Brigham MD (written materials); Clair Morgan at Nodderly.com

Guest: Melissa McNeil MD, MACP

Special thanks to Dr. William Kelly, FACP, FCCP

Sponsor

ACP’s Medical Knowledge Self Assessment Program, MKSAP 18. MKSAP provides the latest and most comprehensive educational content needed by internists today. It’s THE internal medicine go-to resource for continuous learning and Board preparation. Visit http://www.acponline.org/mksapcurbsiders to place your order!

Practice Diagnosing Struggling Learners:

These were provided Dr. William Kelly from the Uniformed Service University (USU) in Bethesda, MD.  They can be used to help identify common pitfalls encountered by learners and are intended to be discussed in a small group format.  An accompanying paper by Dr. Kelly (Andrews, 2018) and the Self-Regulated Learning (SRL) Technique are discussed during this Grand Rounds presentation.  Dr. Kelly can be contacted at william.kelly@usuhs.edu for any questions on the Self-Regulated Learning Technique (see SRL example images below) and any inquiries about the Uniformed Service University’s teaching seminars.

• “John” https://www.youtube.com/watch?v=lR_zC5QoFLY
• “Paulette” https://www.youtube.com/watch?v=5-QAzP_sgJY
• “Amy” https://www.youtube.com/watch?v=PiEsywpnDCg
• “Matthew” https://www.youtube.com/watch?v=WP0i3bOHCfA
• “Charlie” https://www.youtube.com/watch?v=v_maDtOXE8Y
• “Julie” https://www.youtube.com/watch?v=nGzeO3pzXPg

Time Stamps

• 00:00 Sponsor – ACP’s MKSAP 18!
• 00:15 Intro, disclaimer, guest bio
• 05:50 Guest one-liner, favorite failure
• 10:30 Picks of the Weeks*: Book: Radical Candor; Movie: Clue (1985); Book: Awareness by Anthony De Mello; TV Series:  The Expanse (Season 4) on Amazon Prime
• 13:28 Sponsor – ACP’s MKSAP 18!
• 14:14 Case of a struggling learner; defining terms
• 20:24 Gathering data; Clarifying questions; Timing and feedback
• 28:30 Develop a differential diagnosis; Naming the behavior
• 37:42 SRL tool to evaluate deficits
• 42:55 Case of an overconfident learner
• 48:40 Concern for substance use in a struggling learner
• 52:02 Educational handoffs
• 54:53 Identifying learners who struggle with empathy
• 56:36 Outro

The Struggling Learner Pearls

1. Avoid labeling a learner as a “problem-learner.”  This puts up artificial barriers that shift the blame where it doesn’t belong, causes premature closure, and is counter-productive.
2. Identify the “chief complaint” and name the behavior, being conscious of emotional responses and implicit biases that may drive initial reactions.  Be concrete and specific.
3. Obtain a “history of present illness.”  In medicine, we train our learners to identify the “OPQRST” (onset, provoking factors, quality, radiation, severity, and timing); this is, similarly, instrumental in identifying why a learner struggles.  The history of present illness should include real-time feedback that is sensitive to the situation and competing factors.
4. Generate a differential diagnosis.  The differential diagnosis for struggling learners generally falls into one of four broad categories:
   1. Professionalism
   2. Knowledge/Synthesis
   3. Organization
   4. Communication
5. Correct the problem.  Decide whether it can be handled on your own or needs programmatic resources. Then create a plan, set expectations/timeline and consequences.
6. Faculty development is instrumental.  Using a common framework and modeling behaviors (including how to name a behavior) is a requisite part of any training platform.

Identifying “The Struggling Learner”

“If you don’t care enough about somebody to want to help them get better… that’s what not giving feedback means.  It means I don’t think you can get better and I don’t care enough to help you.”

Dr. Melissa McNeil

“Sometimes hard feedback is what people need to hear.”

Dr. Melissa McNeil

Avoid Labeling the “Problem Learner”

Teaching is difficult, especially in the world of medicine.  Oftentimes, academic physicians find themselves mired by necessities of both providing safe, evidence based patient care while simultaneously teaching others.  These competing factors complicate an already difficult situation when faced with learners who struggle. It can be easy to shrug these learners off as someone who “…just doesn’t get it.”  However, this doesn’t provide any kind of framework to approach these learners and is, frankly, a lazy approach. Think about approaching the struggling learner in the same way we approach patients.  A physician shouldn’t just look at an uncontrolled diabetic as a “…patient who just doesn’t get it.”  This subconsciously labels the patient’s care as “futile,” because it doesn’t highlight the why for the issues they struggle with.

Using Clinical Reasoning with the Struggling Learner

The skills that are developed for clinical reasoning are instrumental in identifying why a learner is struggling.  Just like correctly diagnosing a patient, in order to provide effective feedback to a learner, the underlying issue must first be defined.  This involves knowing the chief complaint and uncovering the history of present illness.  Illness scripts, used commonly in the field of clinical reasoning, are similarly important when identifying the pertinent positives and negatives in learners, not just patients.  These scripts are necessary when developing the learner’s differential diagnosis, which generally include one of four categories:  Professionalism, knowledge/synthesis, organization, and communication.  Just like in clinical reasoning, particular emphasis must be placed on those observed behaviors that either fit or don’t fit the illness script.  The symptoms of these diagnoses, taken from Dr. McNeil’s paper (Merriam 2019) are:

1. Professionalism: Shows up late or leaves early, disrespectful to team members, defensive to feedback, dresses inappropriately
2. Knowledge/synthesis: Less knowledgeable than peers, unable to answer higher-order questions despite having the facts, unable to explain clinical reasoning
3. Organization: Poor time management or study skills, unable to triage to-do list, fails to perform routine tasks (eg, place orders, write notes)
4. Communication: Language barrier, using informal or “slang” language, overly timid or overly contributing, unable to read social cues

Provide Real-Time, Specific Feedback

Feedback should be provided in real time with the learners and specific to the behaviors identified.  It may require pulling the learner to the side after the initial encounter to help ask probing questions to help better flesh out the learner’s diagnosis and name the behavior.  Is this learner having difficulty with knowledge/synthesis? Do they have difficulty organizing their thoughts? Are they having difficulty with communication in general? When providing this feedback, academic physicians must be concrete.  Solely providing positive feedback creates a false sense of confidence in learners and will only serve to perpetuate these behaviors.  

Remediation is Challenging

Providing effective remediation is paramount to correcting behaviors that cause our learners to struggle.  However, remediation that is targeted towards behaviors that are symptoms of a deeper problem is unlikely to correct the underlying problems.  This is akin to giving antipyretics to a patient with pneumonia without administering antibiotics to address the underlying disease.

Learners who lack insight can be dangerous

Learners that are defensive with critical feedback should be a cause for concern.  A learner that refuses to accept concrete, specific feedback can be dangerous to both themselves and their patients.  When this occurs, the academic clinician may allow the learner to “hang themselves” with concrete, specific examples. This may require asking questions to which the learner may not have a response, allowing them to recognize their own deficiencies.

Goal

Listeners will identify practical tools, tips, and techniques using skills developed for patient care and appreciate what they can do when a learner is struggling.

Learning objectives

After listening to this episode listeners will…  

1. Develop an appreciation for how to approach the struggling learner 
2. Recognize how to “diagnose” learners using clinical reasoning skills
3. Appreciate the importance that timely, specific feedback plays in identifying why a learner struggles
4. Identify why lack of insight can make addressing these struggles more difficult

Links*

1. Book: Radical Candor
2. Movie: Clue (1985)
3. Book: Awareness by Anthony De Mello
4. TV Series:  The Expanse (Season 4) on Amazon Prime

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Merriam SB, McNeil MA, Spagnoletti CL. A 5-Step Framework for the Assessment and Remediation of a Struggling Medical Learner in the Clinical Environment. Southern Medical Journal. 2019; Mar; 112(3): 135-136. [https://sma.org/southern-medical-journal/article/a-5-step-framework-for-the-assessment-and-remediation-of-a-struggling-medical-learner-in-the-clinical-environment/]
2. Andrews MA, Kelly WF, DeZee KJ. Why does this learn perform poorly on tests?  Using self-regulated learning theory to diagnose the problem and implement solutions. Academic Medicine. 2018, Apr; 93(4): 612-615. [https://insights.ovid.com/crossref?an=00001888-201804000-00042]

Disclosures

Dr. McNeil reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

McNeil M, Brigham SK, Williams PN, Watto MF. “#193 The Struggling Learner with Dr Melissa McNeil”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. February 3, 2020.

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