Leadership in Medical Education: Teaching Difficult Learners

By P. Logan Weygandt (@LoganWeygandt) and Michael Gisondi (@MikeGisondi)

Let’s start with a case:

You have the enviable job of residency program director. One of your senior faculty members, an assessment “hawk” by any standard, approaches you in the hallway to discuss Paul. Paul is a second-year resident who has struggled for many months. He is sullen, rarely lighthearted at work, and curt with staff. Your faculty member shares, “We need to talk about your resident, Paul. Something is wrong with him. Every time I try to teach him, he responds, ‘Yeah, I know, thanks,’ while appearing distracted. He never asks questions and he never teaches the medical students. I don’t know how to get through to him, so you need to do something. He is the epitome of a difficult learner.”

Sound familiar?

What makes a learner difficult to teach?

  • Difficult learners share several key characteristics.

Vaughn et al describe three classes of problem learners: cognitive, structural, and interpersonal. Those in the cognitive class have poor foundational knowledge, poor application of knowledge, or poor communication skills. Students in the structural class exhibit poor organizational skills and time management, limiting their efficiency of practice. Finally, those in the interpersonal class may have poor social skills, too much or too little confidence, significant biases against certain patients, or challenges related to substance use. Interpersonal issues are the most common and most challenging to address.

  • Difficult learners cause emotional responses in their teachers.

Emotions run high in educational settings — and emotions drive student learning. Much of the literature concerning emotional regulation focuses on reducing learner anxiety and recognizing the challenging social situations of students. However, the teacher-student dyad is impacted by the emotional responses of the instructor, as well. Humans react emotionally to unexpected situations, and in the clinical learning environment, we expect that our medical students and residents will be smart, professional, eager, and hard-working. Anything less and our amygdalas start to fire. It is common for clinician educators to label a trainee as a difficult learner because of our emotional responses, rather than our expert diagnosis of their learning challenges.

  • Difficult learners have poor learning efficiency.

Learning efficiency is defined as the positive relationship between speed of learning and knowledge retention; fast learners retain more information. Differences in learning efficiency may result from variations in learning strategy, attention control, or prior knowledge. Efficient learners employ effective learning strategies that increase memory, ideally leading to adaptive expertise. Difficult learners often have less attention control, interruptions in learning, and poor retrieval of long-term memory. And importantly, variations in their foundational knowledge result in unpredictable assimilation and application of new knowledge.

7 Evidence-based Recommendations for Teaching Difficult Learners

How do we ensure training success for difficult learners in the health professions?

Should we attempt to change the learners, or instead, should we change our approach to teaching them?

There are evidence-based methods for skill development for both difficult learners and their instructors — but let’s focus on improving our skills as clinician-educators.

  1. Coach for success. Coaching is integral to high-level athletic performance, and it can be equally effective in promoting high-level performance in medicine. Atul Gwande described coaching as an antidote to plateauing of skill proficiency in the operating room. The American Medical Association (AMA) recently published an evidence-based handbook for coaching in medical education. The AMA handbook reviews the process of coaching, relevant literature, and guidance for developing a coaching relationship with learners. One take-home message: establish coaching relationships with trainees early, before difficulties arise.
  1. Normalize critical feedback. Professional athletes train and improve in a coaching culture that provides nearly constant feedback. Performance goals are specific and clear, and critical feedback is expected when performance does not meet explicit goals. We should normalize this critical feedback within medical education. We must lay the groundwork for acceptance of critical feedback before the need to address learner difficulties.
  1. Identify the source of the difficulty. Difficulties can arise from the learner, teacher, or system. We must ask ourselves if the difficulty truly lies with the learner or might stem from our effectiveness as educators? If, after careful consideration, the source of the difficulty appears to arise from the learner, respond accordingly: check-in frequently, offer supportive feedback, and co-design individualized learning plans.
  1. Check-in. Difficulties in professional conduct or performance may stem from personal challenges that have little to do with a student’s cognitive abilities, skills, affect, or behaviors. Learners may be facing personal loss, relationship stressors, mental and/or physical illness, substance use, undisclosed or newly developed disabilities, or simply exhaustion, fatigue, burnout, or fear of failure. Begin the check-in process with a simple question: “Are you OK?”
  1. Diagnose the difficulty. Clinician educators are well-trained to develop a differential diagnosis with a systematic approach. Admittedly, diagnosing the cause of learning difficulties may be new territory for some faculty members. Begin with Vaughn’s method for differentiating learner difficulties as cognitive, structural, or interpersonal. We find this approach to be straightforward and efficient.
  1. Provide actionable feedback. Learners seek meaningful feedback that is actionable, credible, and constructive. It is best to contextualize feedback with specific performance examples based on direct observation. As Ende suggests, “Observations are the currency of feedback, and without them, the process becomes ‘feedback,’ in name only.”
  1. Co-design a plan to address difficulties. Some learner difficulties can be addressed immediately and do not require ongoing remediation. Others mandate significant investment on the part of educators, leadership, and the learner. Many options can be considered, including: direct observation, simulation, case discussion, workload reduction, alternative rotation experiences, mentorship, formal remediation, counseling, and extension of training. It is crucial to work with learners when designing remediation plans, so that they are invested in the process and understand any prescribed interventions.

Summary

As clinician educators, we can expect to encounter difficult learners throughout our careers. Difficult learners may fall behind the performance of their peers due to poor learning efficiency, and we owe them the opportunity and support to overcome their challenges. It is important to establish a coaching culture and to normalize critical feedback. Check-in to ensure the learner is well and prepared to receive actionable feedback. Then use a systematic approach to diagnose the difficult learner and co-design individualized remediation plans.

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About the authors:

P. Logan Weygandt MD, MPH is a medical educator and Assistant Program Director for the Johns Hopkins Emergency Medicine Residency. He is responsible for intern onboarding and remediation. Logan’s research focuses on healthcare disparities and inclusive residency recruitment. Twitter: @LoganWeygandt

Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael currently holds a position as Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. Twitter: @MikeGisondi

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