Tuesday, June 23, 2009


Teaching is pretty easy when we have bright, motivated students and residents who share our values and “hang on our every word”. But that is not always the case.

I was facilitating a group of faculty at a conference this spring where the topic was “the problem student/resident.” One member of the group was describing the terrible time she was having with a certain resident and how she “had to come down hard on him” and how she didn’t see much hope of him improving his clinical performance as he had a “rotten attitude” and a “poor work ethic”. She was quick to let our group know that she never had any trouble with “good residents”.

As our group tried to help her explore her main issues, it struck me that I had heard that many times before – “I never have trouble with the good student or good resident”. Well the truth is, NOBODY DOES. Those students and residents would learn no matter what we did. They make us feel like good teachers and so we become better!

Our real challenge as teachers comes when the student or resident 1) is working at top mental capacity and just barely making it, 2) does not share our values or social mores, and/or 3) does not share our expectations for work productivity. At some point, we identify students or residents who need some “special action” on our part. That “special action” is often called remediation. Remediation can be a simple learning plan designed by the resident or student and monitored by a faculty member, or it can be a formal learning plan that is designed by the faculty, approved by a committee and monitored closely with specific consequences attached to not meeting benchmarks.

The issue for discussion for June/July is REMEDIATION ACTIVITIES. What has been your experience? What works? What doesn’t work? Are their specific types of student or resident issues that are more amenable to change through a specific type of remediation? Should we try, as a community, to formalize a series of “remediation steps” that all programs within an institution would follow depending on the severity of the problem? I’ve posed lots of questions,… Now let’s hear what you think.


Anonymous said...

I sure wish there were some guidelines to follow. I sometimes feel that the behavior of a "problem student" is scrutinized so much more than the "good student" that the identification process is self fullfilling. I know it can't be black and white, but having guidelines that say, "this is unacceptable" and "this is the consequences" for everybody would be welcome. I have only been teaching for a short time and maybe I'll feel better prepared to handle problem situations on a case-by-case basis at some point, but right now... GIVE ME A STEP-BY-STEP HEURISTIC

Moises Auron said...

Essentially, remediation is a very strong effort being taken by the teacher to help the difficult learner achieve the goals and objectives of the subject/course/program, etc. A challenge that may arise is when the student is unaware of this and don't even understand why such measures are being taken.

It can be psychologically difficult and challenging for both teacher and learner. But in Medicine, the stakes are high and the priority number one is patient's safety.

My first thought is that you need to assess what is the student's perspective of the situation (Ask-Tell-Ask). Then provide an objective assessment of the real picture. Tell what are the desired goals to be achieved - and where is the student standing now.
I would then establish a deadline - this will establish a timeframe for the student to improve.
The next thing is to prioritize the things that need to be achieved first in order to move up and save the subject, etc.
It depends on what are you trying to improve - is it just merely knowledge base - then providing with easier to read material; perhaps audiovisual material (now we have plenty)- this is important as you try to target the learners' best learning process. - then I would do weekly knowledge assessments - examinations, both written and oral. I would give constant feedback about the performance in the exam and set goals for improvement.

If it is a clinical rotation failure - then too many stakes are involved here - interpersonal relationship with patients, medical personnel, nurses, etc. Is this a problem with documentation? it is a problem with interpersonal relationships?, it is a problem with the level of trust? (eg. a resident that lies about the patient's work-up or vital signs), etc. I think that in the clinical setting, the remediation becomes more complex and many people need to be involved to help the student achieve success...need for intense supervision; verification of what he/she says; 360 degrees evaluations from all medical and non-medical personnel, as well as patients; constant evaluation of the quality of his/her notes....and set timeframe goals for evaluation - every week, every two weeks - with constant feedback.

An important part can be the psychological aspect, that somehow needs to be involved. Perhaps, having a counselor meet initially with the student may help figure out unfound things that may jeopardize their learning and help to solve them out.

At the end of the remediation deadline, you have a summative feedback, and see if there is a trend toward correction and improvement. The final decision can be made from that.

Anonymous said...

I find that remediation to be done right needs a lot of time, effort and planning. While it is important to know the steps required for this, more often than not we do not do a very good job at this as we are not given sufficient time to do this right

Steve said...

The last comment is so important. All the plans in the world are useless unless there is follow-up. Students and residents will get the wrong idea if plans are made and no one monitors progress to reinforce or correct. I strongly suggest making remediation guidelines that are manageable possible to follow.

Askar said...

Medhat Askar
I think that designing and implementing an effective remediation process that targets specific patterns of performance problems is contingent upon the educator’s ability to diagnose the nature of the performance issues as early as possible. This ability can probably be developed by experience but for startup educators, I agree with previous comments, guidelines are indispensible.

Christine said...

Remediation has never seemed like the right word for what we try to do to get learners back on the right track. If they have the requisite mental and physical capacity to be successful, then what they need from us is a new way to approach the problem or content or task. I wonder if we would listen more than "prescribe" if we and they would be more successful.

Alta Chavez said...

Christine: I think your point is a good one and raises the challenge in "prescribing" a remediation process: the solution to the problem may need to be more individualized. I would expect that this does take time and listening since it then is the teacher's task to understand why the student doesn't "get it"..

Anonymous said...

I've "diagnosed" some obvious things- when I asked a resident why she didn't read the material on glycemic management (about 3 papers- all brief), she said she really only learned by listening- was unable to sit and read. I didn't think this was a problem resolvable by me but I did urge her to question her attendings more about clinical management issues.
I have had several residents not be able to record history data properly due to difficulty with epicare - one agreed to take additional training.
Another resident was habitually late- and I handled that by addressing it with the chief resident.
But frankly the more subtle and sometimes passive-aggressive problems are harder to diagnose and solve- why some residents see 1 patient in a half-day and some see many- why some obtain a full history and others only the skeleton- Am open to your suggestions as well!