Occasion d’enseignement | Teaching Moment

Challenging learning situations in medical education

Innovative and structured tools for assessment, educational diagnosis,
and intervention. Part 1: history or data gathering*
Miriam Lacasse MD MSc CCFP Johanne Théorêt MD MA CCFP FCFP Patrick Skalenda MD CCFP Shirley Lee MD MHSc CCFP(EM) FCFP

M
edical school and residency training are the actual underlying behaviour of concern to develop a
demanding programs. Most learners will com- constructive plan to help learners with difficulties.
plete their training without considerable diffi- Many frameworks have been proposed in the edu-
culties. However, up to 1 in 10 learners will experience cational literature and are summarized in the book.1
a problem during their program. During the past 15 Each framework starts with a data-gathering (history)
years, there has been increased attention devoted to the phase followed by a diagnosis and management phase.
“resident in difficulty,” with publications on a variety of However, despite the numerous frameworks available
topics, including classification systems of learners’ diffi- that outline the evaluation and management of learners
culties, assessment frameworks, and intervention plans. facing challenges, most provide only a rather vague
We recently published a book with the goal of sum- “road map” without links to specific tools or comprehen-
marizing the current literature regarding learners facing sive classification models to help facilitate the diagnosis
challenges. The results of the literature review were and management of learners facing challenges.
presented in 3 separate chapters: chapter 1 reviewed Based on a thorough literature review, we propose
the symptoms and signs that indicated potential prob- an integrated approach to assessment, educational diag-
lems; chapter 2 summarized the literature on educa- nosis, and management of challenging learning situa-
tional diagnosis and aimed to help teachers expand their tions derived from the available frameworks but which
“differential” in various challenging learning situations; also adds some specific assessment tools. To provide
and chapter 3 reviewed the management of challenging structure to the assessment of learners facing challen-
learning situations.1 ges, this model is based on the analogy of a medical his-
This article presents the content of chapter 4, which tory and physical examination.
combines the findings of the first 3 chapters in an effort The Educational Consultation Note is an assess-
to develop innovative and structured educational tools ment tool summarizing this approach (available from
and models to aid supervisors and clinical teachers in CFPlus†). This tool is intended to help teachers gather
the diagnosis and management of learners facing chal- data and facilitate their analysis when challenging
lenges. Part 1 details the data-gathering phase. Part 2 learning situations occur.
will discuss objective examination of learners in diffi-
culty, educational diagnosis, and management of chal- Assessment
lenging learning situations. As with clinical assessment, educational assessment
should be focused. The teacher should have particular
Background differential diagnoses in mind when questioning and
Difficulties that arise during training are sometimes observing the learner. Similar to the process of con-
identified by learners themselves, who might individu- ducting a clinical assessment, an educational assess-
ally seek help from their clinical teachers or from other ment might include the following steps:
services. However, in most cases, problems are identi- • identification or personal situation;
fied by the learners’ clinical preceptors who might either • past “educational” history;
note a change from previous performance or identify a • habits;
learner with a lower level of performance compared with • history of the present difficulties;
his or her peers. These often subjective “impressions” • review of systems (environment, teacher, learner);
require further critical assessment to better characterize and
• objective examination.
*This article is adapted from Educational Diagnosis and
Management of Challenging Learning Situations in Medical Chief complaint
Education1 with permission from Université Laval. Similar to a medical encounter, these steps are not
†
The Educational Consultation Note and the Directory of
Symptoms and Signs in Medical Education are available at La traduction en français de cet article se trouve à www.cfp.ca dans
www.cfp.ca. Go to the full text of this article online, then click la table des matières du numéro d’avril 2012 à la page e234.
on CFPlus in the menu at the top right-hand side of the page.

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Teaching Moment

meant to be followed in a strict order, but rather to be workload, overbearing clerical and administrative
used as guidelines to allow flexibility in the approach to responsibilities),
assessing the learner. —inadequate support from allied health professionals,
In medicine, patients usually come to the office owing —exposure to death and human suffering,
to a specific symptom for which they seek assessment, —ethical conflicts, or
diagnosis, and treatment; however, sometimes they are —student abuse; and
asked to come owing to specific observations by their -professional
physicians. In medical education, chief complaints some- —responsibility for patient care,
times come from learners. However, they often arise —difficult patients and challenging health problems,
through observation by clinical teachers because learners —supervision of more-junior residents and students,
might not perceive their own shortcomings, particularly —information overload, and
when related to attitude problems. Too often, teachers —career planning.
will notice a learner having difficulty individually, and will Many teachers do not feel comfortable assessing
either avoid the problem or neglect to share their con- these issues, either because they do not believe this
cerns with the learner early in the course of training, to responsibility is related to their teaching role or they
the detriment of the learner, who is often unaware of the do not feel comfortable delving into the private lives
concerns about their performance. of their students. However, as the patient-centred clin-
Chief complaints retrieved from our literature review ical method improves patient care, many educators
were classified under the 7 CanMEDS–Family Medicine roles believe that the adoption of a learner-centred method
and are summarized in the Directory of Symptoms and will improve teaching and learning. However, “for both
Signs in Medical Education available from CFPlus.† This ethical and training reasons, it is inappropriate for a fac-
tool will help teachers in identifying problematic behav- ulty member to develop a sustained and deeply intimate
iour and will provide them with appropriate terminology to personal or counselling relationship with a resident.”2
describe such behaviour and discuss it with the learner. Therefore, it is important to not become the learner’s
physician or therapist, and to refer the resident to the
Identification or personal situation appropriate professionals if and when a personal prob-
Medical school, particularly residency training, is a time lem is identified.
of personal transitions (geographic relocation for train-
ing, and deferring of important relationships, committed Past educational history
relationships, childbearing, child rearing, etc). Informal A history of educational difficulties and the location of
discussions with learners might serve to raise teachers’ previous training (eg, in the case of international med-
awareness of important elements of learners’ personal ical graduates) might shed light on current learning
lives. Personal, familial, and social issues that might challenges. Difficulty with standardized tests, good ver-
affect training often become apparent before formal bal skills but poor reading comprehension, performance
assessment takes place. Additional relevant information drop under time pressures, difficulty with time manage-
will more likely be uncovered by adopting a nonjudg- ment, or a history of attention deficit disorder might
mental attitude, ensuring confidentiality, and leaving the flag a learning disability.3 International medical gradu-
door open to discussion. ates experience unique circumstances, such as difficul-
Issues that might affect learner functioning include ties with language, differences in medical education
the following. and practice styles, experience since graduation from
• Personal issues: medical school or last clinical experience, different life
-health; stages (eg, family and financial obligations), traumatic
-family (eg, pregnancy, marital problems, death of a experiences (eg, persecuted minorities, refugees, new
family member); immigrants), and cultural differences (eg, approaches
-financial; to and beliefs about communication, authority, gender
-social (eg, isolation [relocation away from family and roles, interpersonal relationships, and the role or status
friends], limited free time to relax or develop new sup- of physicians).4
port systems, dense social agenda); and It is crucial to obtain information about previous
-cultural (eg, minority and cultural issues, which are par- rotations and educational experiences when appropri-
ticularly important for international medical graduates). ate,5 either directly from the learner or from current and
• Training-related issues: past program directors.
-situational
—adjustment to the medical school environment, Habits
—conditions for learning that are less than optimal Substance use and abuse is a recognized problem
(eg, inordinate hours, sleep deprivation, excessive among medical trainees6,7 and clearly should not be

482 Canadian Family Physician • Le Médecin de famille canadien | VOL 58: APRIL • AVRIL 2012
 Teaching Moment

overlooked. For learners with addictions, deterioration effective teaching:

in workplace performance often comes late in the prob- • enthusiasm;
lem evolution, with the familial and social spheres being • role modeling;
affected first.8 • good interpersonal skills;
Study habits should also be assessed. 9 A discus- • good teaching and supervisory skills;
sion with learners regarding their study habits can help • organization and clarity; and
clarify the origin of knowledge deficits or help to under- • clinical knowledge and competence.
stand deficits in their clinical reasoning. Many clinicians are encouraged to become preceptors
for medical students and residents, but specific training
History of the present difficulties and experience in medical education is often lacking. To
This section of the assessment is aimed at validating the identify the elements that need to be worked on, super-
chief complaints with the learner and then further elu- visors might ask for feedback from their trainees. However,
cidating the specific characteristics of the difficulties in many learners will understandably be hesitant to provide
question. constructive feedback to their supervisors out of concern
• What kinds of difficulties are being experienced? What for potentially invoking negative evaluations from these
tends to improve the situation or make it worse? teachers. Inviting and encouraging learners to discuss any
• When did the difficulties start, and what was the teaching concerns with their academic advisor or program
course of their evolution over time? director is often a more effective way to assess this aspect
• Where do the difficulties happen? (Setting, courses, of the learning environment. Another approach is to insti-
rotations) tute a system of regular teacher evaluations coordinated
• Why do these difficulties occur? (Onset) by the program office.
• How severe are the difficulties? (Severity, effects) Because preceptor-related issues can profoundly
To best deal with the problematic situation, a learner- affect the quality of clinical learning, teachers should
centred approach should also include discussion of pos- reflect upon such issues as those listed above and be
sible causes identified by the learner, stress brought on by cognizant of the possibility that personal or professional
the academic difficulties, current or expected effects of the events affect their availability to teach or their percep-
problem, and what the expectations of the learner are. tion of learners’ performance.
Finally, it is important to consider that discussing
the problems identified by the teacher provides a good Learner. Discussion with the trainee, other teachers,
opportunity to appraise and promote self-assessment and staff will help identify other difficulties in competen-
skills in the learner. “Students in difficulty are often not cies under the CanMEDS–Family Medicine roles.
aware of their difficulties. Self reflection is considered an This article provided a detailed overview of how
attribute necessary to practising medicine.”10 Learners to use the first page of the Educational Consultation
are more likely to change their behaviour if they identify Note for data gathering. An overview of how to use the
it themselves and accept feedback. second page will be presented in an upcoming issue,
where strategies for objective examination, educational
Review of systems diagnosis, and management will be summarized.
Environment (also called system). The learner Dr Lacasse is Assistant Professor and Dr Théorêt is Professor and Director
should be asked if the academic environment provides of Faculty Development, both in Département de médecine familiale et de
médecine d’urgence at Université Laval in Quebec, Que. Dr Skalenda is
a high-quality educational experience. Evaluation of Assistant Professor and Dr Lee is Associate Professor, both in the Department
the conditions (or environment) for learning is impor- of Family and Community Medicine at the University of Toronto in Ontario.

tant and includes workload, sleep deprivation, clerical Competing interests

None declared
and administrative responsibilities, information man-
References
agement, and available support. Finally, discussion of 1. Lacasse M. Educational diagnosis and management of challenging learning
patient care issues should be encouraged. Difficult or situations in medical education. Quebec, QC: Université Laval; 2009.
2. Shapiro J, Prislin MD, Larsen KM, Lenahan PM. Working with the resident in
complex patients and problems, exposure to patients difficulty. Fam Med 1987;19(5):368-75.
with serious illness or suffering for the first time, ethical 3. Rosebraugh CJ. Learning disabilities and medical schools. Med Educ
2000;34(12):994-1000.
conflicts, responsibility for patient care, responsibility for 4. Bates J, Andrew R. Untangling the roots of some IMG’s poor academic
supervision of more-junior trainees, biologic hazards of performance. Acad Med 2001;76(1):43-6.
5. Steinert Y. The “problem” junior: whose problem is it? BMJ
the profession, and fear of making mistakes are all com- 2008;336(7636):150-3.
mon difficulties encountered by students and residents 6. Aach RD, Girard DE, Humphrey H, McCue JD, Reuben DB, Smith JW, et al.
Alcohol and other substance abuse and impairment among physicians in
that can impair academic performance. residency training. Ann Intern Med 1992;116(3):245-54.
7. Hughes PH, Conard SE, Baldwin DC Jr, Storr CL, Sheehan DV. Resident
physician substance use in the United States. JAMA 1991;265(16):2069-73.
Teacher. The Educational Consultation Note lists the 8. Winter RO, Birnberg B. Working with impaired residents: trials, tribulations,
following characteristics11,12 as being crucial elements of and successes. Fam Med 2002;34(3):190-6.

VOL 58: APRIL • AVRIL 2012 | Canadian Family Physician • Le Médecin de famille canadien 483
Teaching Moment

9. Hendricson WD, Kleffner JH. Assessing and helping challenging students:

part one, why do some students have difficulty learning? J Dent Educ
2002;66(1):43-61.
10. Cleland J, Arnold R, Chesser A. Failing finals is often a surprise for the stu-
dent but not the teacher: identifying difficulties and supporting students with
academic difficulties. Med Teach 2005;27(6):504-8.
11. Irby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics of effective
clinical teachers of ambulatory care medicine. Acad Med 1991;66(1):54-5.
12. Kilminster S, Cottrell D, Grant J, Jolly B. AMEE guide no. 27: effective educa-
tional and clinical supervision. Med Teach 2007;29(1):2-19.

TEACHING TIPS
• Difficulties that arise during medical school are sometimes
identified by learners themselves, who might individually seek
help from their clinical teachers or other services. However,
in most cases, problems are identified by the learners’ clinical
preceptors.

• Using an analogy of a medical history and physical

examination lends structure to an integrated approach to
assessment, educational diagnosis, and management of
challenging learning situations. Specific assessment tools, such
as the Educational Consultation Note and the Directory of
Symptoms and Signs in Medical Education, can help facilitate
the diagnosis and management of learners in difficulty.

• Many teachers do not feel comfortable assessing issues that

might affect learner functioning, either because they do not
believe this responsibility is related to their teaching role or
they do not feel comfortable delving into the private lives of
their students. However, as the patient-centred clinical method
improves patient care, many educators believe that the
adoption of a learner-centred method will improve teaching
and learning.

Teaching Moment is a quarterly series in Canadian Family Physician,

coordinated by the Section of Teachers of the College of Family
Physicians of Canada. The focus is on practical topics for all teachers
in family medicine, with an emphasis on evidence and best practice.
Please send any ideas, requests, or submissions to Dr Allyn Walsh,
Teaching Moment Coordinator, at [email protected].

484 Canadian Family Physician • Le Médecin de famille canadien | VOL 58: APRIL • AVRIL 2012