Teaching undergraduate and postgraduate learners is often a joy. What to do with a student who is not meeting expectations, however, is challenging. Clinical attending physicians must identify, and remediate, students who struggle. This article presents a practical approach to identifying, diagnosing, and managing the learner in difficulty.
Defining At-Risk Students
A learner in difficulty is a student at risk for receiving less than “pass” because of concerns regarding his or her knowledge base, clinical skills, or professionalism.1 Learners in difficulty rarely self-identify for a variety of reasons, including lack of self-awareness or concern that if they acknowledge they are in difficulty, they will be stigmatized.2 However, early identification of such individuals, with appropriate intervention, seems to lead to better outcomes for these learners.3 The responsibility of identifying learners who are not meeting expectations largely rests with their clinical teachers.
The Challenge for Clinical Teachers
Many teachers hesitate to identify and report learners experiencing difficulties for a number of reasons, including inexperience handling such situations, concern they are misjudging the circumstances, lack of documentation, fear of retribution by the student, and the time required to resolve issues.4–6 The current nature of training further compounds this problem. Oversaturated placements, shorter duty hours and academic half days, and concurrent exposure to multiple supervisors reduce student contact with clinical teachers. Problems often go unidentified until a critical incident has occurred.6
Just as we all have an approach to a child who presents with a cough, it is helpful to have a basic approach to a learner who is not meeting expectations. Teachers are good at recognizing a student not doing well but have difficulty deciding what to do next. We propose that the steps should be analogous to those of a physician confronted with a coughing patient: consider a differential diagnosis, take a focused history, observe, and define a management plan.
Julie is a fourth-year medical student working as an acting intern. The supervising resident reports that Julie seems distracted and disorganized, and has a weak knowledge base. The clinical attending has noticed that she appears distracted and disinterested but has not appreciated any knowledge deficits. Julie’s interactions with other members of the health care team have been acceptable.
Recognizing that Julie is not meeting the expectations, the clinical attending needs to develop a differential diagnosis for why Julie is struggling (Table 1). Taking a careful history of a learner such as Julie and gathering focused observations will narrow the differential and help the attending decide on a working diagnosis and therapeutic plan.
Constructing a Differential
The reasons why learners struggle are diverse and are often not academic in origin.7 Moreover, unlike a clinical differential, in which there is usually 1 explanation for the patient’s presentation, the struggling learner may be dealing with several issues. Learning is relational; thus, to determine what may be causing problems for a learner such as Julie, it is important to consider what, if any, interactions a student may be having in the learning context that could be interfering with his or her performance. When constructing a differential diagnosis of a learner in difficulty, the acronym “K-Salts” (knowledge, skills, attitude, learner, teacher, system)2 is useful. This approach allows the attending to think not only of the skills, attitudes, and behaviors of the learner but also to consider the impact of the environment.
Taking the History
When talking to a student who is not meeting expectations, start with open-ended questions to determine his or her level of insight into problems and potential causal factors. As the conversation progresses, some key areas to explore include:
Academic history: to determine how well the student is handling the academic requirements of training (eg, study habits, competing priorities such as research projects, call requirements).
Social circumstances: to determine if any recent or ongoing life stressors are interfering with learning (eg, financial, child care issues, illnesses in the immediate or extended family).
Wellness: to determine if there are any new or previously known physical and/or mental health issues that are contributing to the concerns identified.
Academic relationships: to determine if relationships with other students or attitudes of teachers may be impeding success.
Learning context: to identify if any organizational or systems issues are interfering with learning (eg, inconsistent supervision, poor role modeling, overcrowded learning environments, geographically dispersed teaching sites).
A Conversation With Julie Might Reveal the Following:
Julie is married and has a 2-year-old son who attends day care near her home. Her husband works full-time. She has a 1-hour commute to work and finds it hard to be there on time to pick up her son from day care. Furthermore, her son has been ill, requiring her husband to miss work, and she has been up late at night. She is having difficulty balancing her personal and professional responsibilities and is stressed that she is not doing a good job either at home or at work. Julie feels rushed and tired, and she finds it hard to organize her day. She has never experienced this before and is embarrassed that the team has noticed.
Observing the Student
Although the history is critically important to understanding Julie’s issues, observation enables the attending to better understand the learner’s performance.
Observing Julie admitting an infant with failure to thrive might reveal the following: Julie has a good rapport with the mother but takes a scattered history. She writes her admission note before entering any admission orders, resulting in a delay. Her presentation during rounds is not well organized, and her differential diagnosis for the failure to thrive is rudimentary.
Making the Diagnosis
Julie is having difficulty balancing her home and professional life; in addition, she has problems with organization and prioritization, and has knowledge deficits. Although Julie’s problems are multifactorial, the clinical attending now has a much better understanding of the issues and can offer specific suggestions for improvement.
In addition to offering specific advice, the clinical attending has 2 other critical responsibilities. First, the teacher must document the concerns and what has been done about them, in as much detail as possible (ie, dates, specific circumstances, conversations with other members of the health care team). Second, the clinical teacher should notify a responsible authority in the medical student or residency program. In this way, the teacher can learn if this is an isolated incident or a trend, and greater resources for intervention may be available.
If the learner identifies personal health issues as a contributing factor, guide him or her to the Student Affairs or Wellness office.
Ask for help. The clerkship director, residency program director, education site leader, or associate dean will want to assist you and the learner.
Know your school’s regulations and guidelines about struggling or failing students. Know whom to contact. Know the supports that are available to both you and your students.
You discuss Julie’s situation, and she highlights the multiple issues involved. You suggest that Julie seek advice from the Student Affairs office, and she agrees that this is a good plan. You also suggest some resources to increase her pediatric knowledge. Together, you agree that you will speak to the pediatric Clerkship Director to convey your concerns about the impact of her long commute on her learning. Julie wonders if she could be transferred to the community hospital that is closer to her home; you agree that this would be a good plan.
As clinical teachers, we have an obligation to both our profession and society to identify, and assist, students who struggle to meet the standards expected of them. The good news is that close to 90% of students labeled as “learners in difficulty” succeed after implementation of a structured intervention, especially if they are involved in developing the remediation plan.8
The authors thank Drs Susan Bannister, Robert Dudas, and Christopher Maloney for their thoughtful critique and editing of the manuscript.
- Accepted May 17, 2013.
- Address correspondence to Stacey Bernstein, MD, FRCPC, Department of Pediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- Copyright © 2013 by the American Academy of Pediatrics