Dealing with the Difficult Learning Situation

Acknowledgements

This monograph was developed by the MAHEC Office of Regional Primary Care Education, Asheville, North Carolina. It was developed with support from a HRSA Family Medicine Training Grant. The monograph was provided to our Office of Faculty Development with permission to modify and use in our faculty development program.

Introduction

The vast majority of learning encounters proceed smoothly with significant benefit for the learner and often a sense of reward and accomplishment for the preceptor. On occasion, however there is a learning situation where things do not run smoothly. This is usually the result of many different factors involved in the interaction of individuals in a complex medical educational system.

The truth is that the vast majority of times things go just fine. An additional truth is that sometimes they don’t. We hope that this monograph will help prepare you to prevent potential problems and to deal more effectively with problems when they occur.

The goals of this presentation are to:

  1. Help you to develop skill in the early detection of potential problems.
  2. Introduce you to an organized approach to the assessment and initial management of challenging teacher/learner interactions, and
  3. Review a strategy for the prevention of problem interactions.

Dealing with the Difficult Learning Situation: Prevention

The old adage "an ounce of prevention is worth a pound of cure" is as true in clinical teaching as it is in clinical medicine. It is generally much more efficient (and pleasant!) to prevent a problem than to manage the negative impact once it has occurred. Approaches to prevention in teaching can be divided into the categories of primary, secondary and tertiary prevention (Table 1). In medicine, as in education, there are different kinds of prevention. For primary prevention the goal is to totally avoid the problem before it occurs. In secondary prevention the goal is to detect an issue early and act decisively in order to minimize or eliminate the effects. Tertiary prevention is the management of existing problems in order to minimize the negative impact of those problems. Each level of prevention has its own characteristics and strengths.

Primary Prevention

As in medicine, the prevention of problems or issues before they occur is the ideal. Fortunately there are several strategies that can help prevent difficult teacher/learner interactions. Many of these are related to issues of expectations: those that the school or program has for the experience, the learner’s expectations for the rotation and your expectations for the learner’s role and behavior during the time you are working together.

As the preceptor, you should know the specific expectations for the learning experience. At times they may be non-specific and allow the preceptor a large degree of latitude in structuring the experience. At other times the school may be very specific in the learning objectives that they have for the learner. You should know any specific expectations before agreeing to teach the rotation and then review them at the beginning of the rotation with the learner.

Table 1

PREVENTION

PRIMARY: Prevent the problem before it occurs.

  • Know the course expectations.
  • Orient the learner well.
  • Set clear expectations and goals.
  • Determine the learner’s goals and expectations.
  • Reassess mid-course.

SECONDARY: Early Detection

  • Pay attention to your hunches/clues.
  • Don’t wait.
  • Initiate SOAP early.
  • Give specific feedback early and monitor closely.

TERTIARY: Manage a problem to minimize impact.

  • If it ain’t workin’... SEEK HELP.
  • Don’t be a martyr.
  • Do not give a passing grade to a learner who has not earned it.

An important step is a detailed orientation of the learner and a part of this is to make YOUR specific expectations known to him or her. What time does he/she need to arrive? What are the night-call and weekend expectations? What format do you prefer in his/her notes and presentations? What is your dress code? These and many other issues of value to you could vary significantly from site to site and should be specifically addressed with the learner from the beginning. A clear understanding of your expectations and goals can help the learner adapt to your environment and avoid significant problems.

Learners also bring their own expectations to a rotation or learning experience. They may expect a certain level of responsibility or be counting on clinical experiences that are not available in your practice situation. Detecting any mismatches early can allow you to inform them or negotiate options before problems develop. By the same token, knowing the learners’ individual desires goals and expectations will help you to make this a more successful experience for them.

Even if a good orientation and discussion occurs at the beginning of the rotation, new or unanticipated issues can develop for the preceptor and the learner once the rotation is underway. A formal opportunity to sit down together halfway through the rotation creates an opportunity to reassess and refine goals and expectations for both the preceptor and the learner and can set the stage for an even smoother second half of the experience.

Secondary Prevention

If primary prevention has not succeeded then early detection of problems is essential. The parallel with medical practice continues. The clinician wants to detect a clinical problem as soon as possible. Early identification of a clinical issue can make treatment and elimination of that problem much easier. Mammography, Pap smears or blood pressure screening can help identify medical problems early and allow them to be managed more simply and effectively in order to reduce the negative impact on the health of the patient. In some situations early detection allows for a problem to be eradicated. Even if the problem can’t be eliminated early detection can reduce the negative impact of the problem.

Just as early detection is key in the management of medical problems, it is crucial in the effective management of difficult teacher/ learner interactions. Early detection identifies educational problems early and allows for early intervention and a better outcome. Even if an educational problem cannot be eliminated, early detection can help minimize the negative impact on you, your staff, your patients and the student.

The Secondary Prevention is outlined in Table 1 and depends on maintaining an awareness that things can go wrong. Community-based teachers of health professionals are often optimists in dealing with their learners. They have come to expect high quality learners that they are able to interact with in a positive and pleasant way. As a result, early warning signs of difficult interactions are often ignored, down played, or attributed to "A bad day" or other circumstances. It is crucial for the teacher to pay close attention to these "hunches" or feelings that things may not be quite right. Additional "clues" can come from the comments or opinions of staff or partners. For example, when a staff member who has previously interacted well with other learners begins to comment negatively on the current student in the office, this could be an important warning sign. Every "red flag" (or even yellow flag!) should be evaluated, just as attention should be paid to every abnormal Pap smear. Not all will reveal an underlying serious problem, but serious problems could be missed if you are not systematic in looking at these warning signs as a potential indicator of significant issues.

Don’t use "wait and see" as the only way to monitor potential issues. You may want to bide your time and to sit back and observe. "Well, maybe this is a problem but it’s just the first week and we’ve been kind of busy. I’ll just watch for a while." An excuse for one week leads to another and before you know it the problem has grown or it is near the end of the experience and there is no time to intervene. In the community educational setting you must examine and address potential issues as early as possible due to the limited time of the contact. "Wait and see" can be costly and ineffective in a short educational experience.

Plan to institute an organized assessment of a potential problem situation early. Later in the monograph we will introduce a "SOAP" method for assessing educational situations. The earlier you begin looking critically at the situation, the more likely it is to succeed.

Not all situations require an immediate full assessment. When it is a problem appears minor, the preceptor can give specific feedback on the issue to the learner and then to watch carefully to see if that feedback is acted upon. The following example may illustrate this:

A third year medical student is beginning a clerkship in your office. During the first week you have noted that the learner takes a much longer time in evaluating patients than previous students. It is early in the third year and the student has had one clinical experience in the hospital setting only. You arrange a feedback session where you review the learner’s performance with specific examples and give specific suggestions and instruction in time management with patients. You monitor closely the learner’s performance for the next two days in the office.

The above is a "screening test." You have identified a problem behavior and have made a simple intervention to determine if this problem exists. But you have not formally assessed it. The key step is the follow up: monitoring closely for a limited time. If there is no longer a problem, then only continued monitoring is needed. If the problem behavior remains then a very careful assessment needs to be made as soon as possible. Note that this is a very different strategy from "wait and see". A brief active intervention is made and a brief period of observation follows. The chance of problem issues slipping through undetected is minimized. The judicious use of quality feedback and close follow up is invaluable.

Tertiary Prevention

Sometimes in education as in medicine a significant problem can arise despite the best efforts and intentions of the preceptor and the school. Preceptors often see it as a personal defeat or failure if they are having a problem during a rotation. Nothing could be further from the truth. Course directors know that there will be an occasional difficult situation and are prepared and waiting to assist you. Seek help early and discuss your concerns with someone who will understand.

Avoid the temptation to say, "Well, I’ll just stick this out. There are only a couple weeks left." This does nothing to alleviate the negative impact of the problem on you, your staff and patients and does not help the learner. If you have been trying all the tricks and techniques that you know and are still not making any headway, then it is time to get help.

You do not need to be a martyr. Preceptors often feel that they have made a commitment to work with the learner through the entire rotation or experience no matter what. When a situation is having a significant negative impact on your staff, your practice, your patients, or your family, then it is important to recognize that and to seek help in managing it. You are more valuable to the school, your profession and future learners if you seek help early rather than burn out over one bad experience.

It is important not to give a passing grade if you don’t feel the student has earned it. One of the characteristics of a profession and a professional is self-governance. You have a duty to prevent someone who may not be able to serve the profession well from being passed along without important issues or concerns being addressed. Communication of your concerns is important. A call to the course director or other contact person for the program can help you decide an appropriate course of action and will communicate your issues to the educational program. Some grade choices may be available, such as "Low Pass" or "Incomplete", which will require follow up of educational issues or concerns by the program or school. Please give the grade that was earned so that the learner’s performance and abilities are accurately reflected.

Prevention — A Summary

Many potentially difficult situations can be prevented by using sound educational techniques of Setting Expectations and Feedback and thoughtful ongoing Evaluation. Other issues can be detected early by being alert for and paying attention to the hunches and clues that may indicate a subtle or developing issue. At times, despite everyone’s best intentions, a significant problem may occur and careful management is required. The next section will outline a strategy for the assessment and management of the problems you detect.

Dealing with the Difficult Learning Situation: SOAP - An Approach to Problem Interactions

So you have paid attention to early warning signs and despite your best effort at Primary Prevention you think there is a problem… How do you begin? We recommend a SOAP format. This approach, adapted from Quirk (1994), is outlined in Table 2. In a step-by-step fashion it allows you to work from basic data to objective assessments to a differential diagnosis and a plan of action. We will now examine each step in detail.

Table 2: SOAP-An Approach to Problem Interactions

Subjective

What do you/others think and say?

Objective

What are the specific behaviors that are observed?

Assessment

Your Differential Diagnosis of the Problem.

Plan

Gather more data? Intervene? Get help?

SOAP -- Subjective

In assessing a potential difficult preceptor/learner interaction the subjective is usually "chief complaint." What was it that made you consider that there may be a problem with this interaction? Often the first indication that there may be a problem is when a learner is "labeled" by you or someone in your office. When a learner is described as "slow", "uninterested", "angry", "lazy", etc. — this can be an indication of an underlying issue that needs assessment.

Once you have a "chief complaint" then the history should be fleshed out. What do others in the practice think of this learner and his or her performance in the office? When office staff have had experience with several students, they can be insightful assessors of students’ interpersonal skills. Learners will often act differently towards staff or patients than toward the preceptor who will be grading them. As a result your staff’s observations may not completely match your experience. Obtain data from all readily available sources and then determine if a pattern of behavior exists.

Another source of data is the learner. Are they aware that there is a problem or potential problem? A simple question about how they feel things are going may reveal that the learner is aware of an issue, and is working to remedy it. For example, a student who has been 20 minutes late to the office twice in the first week is asked, "How are things going with the rotation? I’ve noticed that you have been late a couple of times to the office this week." The learner apologizes and reports that the clock radio they brought is not working and they plan to go to the store to buy a battery-powered alarm clock after office hours today. Awareness of the issue by the learner is an important step in improving a problem behavior. Lack of awareness of an issue may indicate a more significant issue and/or the need to be more directive.

These labels and impressions should not be considered the "diagnosis" of the problem. Just as "fever" is a symptom of an underlying condition, these impressions or descriptions may just be symptoms of a more specific underlying "diagnosis." In teaching, as in clinical practice, it is important not just to recognize and treat symptoms but to determine and act on an appropriate diagnosis. More specific information will be needed.

SOAP -- Objective

Once information is available on a general pattern of behavior or a general description of a pattern of interaction, it is essential to then identify and list specific instances of behavior to try to document the issues. It is very important to be able to describe specific instances of behavior to the learner. The learner who is unaware that their actions or attitudes were likely to trigger a concern may have difficulty reviewing their performance to determine exactly what behaviors or episodes are responsible. You will need specific information to intervene effectively.

The following are examples of specific behaviors that you might list:

"More than 20 minutes late to the office on Monday, Tuesday and Thursday this week."

"Visit Thursday morning with Joe White: Took forty minutes to assess this patient with a cold."

"Spoke harshly to receptionist when asking her to schedule Mrs. Blackwell’s return visit."

"Unable to recall info on symptoms of UTI on Wednesday AM after we had reviewed it on Tuesday at lunch."

Having a list of specific behaviors and specific instances of behavior (preferably written down) will be extremely important in helping you to make your assessment of the nature the problem and later to decide on and initiate your plan of action.

SOAP -- Assessment

The next challenge is to analyze the information from the Subjective and Objective parts of your assessment and to try to determine what the possible causes are -- to work from the symptoms and manifestations of the problem to determine a diagnosis. Trained clinicians are highly effective at considering a wide range of possible explanations for a medical condition. Unfortunately we are less confident when it comes to assessing learning situations. This comes not from an inherent inability but from the lack of practice and experience. Just as the clinical learners you teach produce short and incomplete differential for clinical problems, we tend to come up short in our assessment of potential sources of learning difficulties. With practice and a little help we can produce an accurate differential of learning issues as well. A guide to potential diagnoses for difficult preceptor/learner interactions is listed in Table 3.

Cognitive

One diagnostic category for learning difficulties is the Cognitive area. Does the learner’s knowledge base or skill base seem less than you expect for a learner at this level? It is possible that it reflects a true deficit in their preparation. It could also be that the learner has not had the same preparation as similar students you have had. Students of different levels of training or from different schools or programs may have markedly different levels of preparation. For example, one medical student in the middle of their clinical clerkships may have had surgery and OB/GYN and another may have had medicine and pediatrics. Their knowledge base and clinical skills may appear very different in the outpatient primary care setting.

Another explanation is that the student may have a learning disability. Dyslexia, spatial perception problems, communication skill deficits and attention deficit disorder have all been diagnosed in for the first time in medical students2. Don’t make assumptions. A student in a demanding professional training program may have a learning disorder that has gone unrecognized. Learners can develop highly effective coping strategies that work in the classroom, only to find that these same strategies do not work in the unique demands of the clinical learning environment.

A student may lack sufficient interest or motivation in your clinical area. A learner oriented toward a primary care career may not be highly motivated to excel in your specialty area. By the same token a learner who is headed toward a career in a specialty area may not fully appreciate the learning opportunities in primary care experience. Lack of motivation may not simply be a diagnosis in itself but could be a symptom of an underlying process. As a result this should be a diagnosis of exclusion and all other reasonable possibilities considered and excluded. Otherwise an important issue may be missed.

Table 3. Assessment- Differential Diagnosis
  • Cognitive Knowledge base/ Clinical skills less than expected?
  • Dyslexia?
  • Spatial Perception Difficulties?
  • Communication difficulties?
  • Lack of effort/interest?
  • Affective Anxiety
  • Depression
  • Anger
  • Fear
  • Valuative Expects a certain level of work
  • Expects a certain grade
  • Does not value the rotation
  • Does not want to be at your site
  • Does not value your teaching
  • Holds principles that conflict with
  • those of you or your patients
  • Environmental Hospital-Care oriented
  • Not used to undifferentiated patient
  • Not time-sensitive
  • Not patient-satisfaction oriented
  • Medical Clinical Depression
  • Anxiety Disorder/ Panic
  • Recovering from Recent Illness
  • Hypothyroidism
  • Pre-existing illness in poor control
  • Psychosis
  • Substance Abuse

Affective

A second category of possible "diagnoses" is Affective or emotion related concerns. New learning situations frequently result in significant initial nervousness and anxiety. Severe anxiety can be a crippling emotion and extreme nervousness can markedly affect performance. It is important to separate normal nervousness from a more significant problem. Does the anxiety manifest itself only in specific situations or is it more generalized? Is the nervousness improving quickly, as the student becomes familiar with your setting? Does it respond to reassurance and encouragement or does it seem to worsen? Is the anxiety having a negative effect on the student’s performance? Persistent or severe anxiety should not be ignored.

Depression can also severely affect performance. The depression may be a normal response to a life situation. A student returning to school after a recent death in the family or a miscarriage may have difficulty in concentration and performance and other feature of depression. Signs or symptoms of depression could also be the result of a major depressive illness that is discussed below.

Anger is an emotion that compromises relationships. The learner may have and display underlying prejudices or biases toward certain ethnic, social or religious groups. They may have and display a superior attitude toward staff and assistants. Anger may be a result of not having been assigned to a preferred training site. It is important to recognize anger and assess underlying causes early or it can have a significant effect on the experience.

Fear is a specific form of anxiety. Prior negative learning experiences may severely impair the ability or willingness of the learner to communicate openly with you. Early students may be intimidated by patient contact–by a fear that they will not be viewed as a professional or intimidated by the prospect of performing physical exam maneuvers on a real patient. Learners (and practicing clinicians) can sometimes be compromised in their work by the fear that they will harm a patient.

One strategy for determining if an affective diagnosis is present is to consider what emotion or affect the learner or learning situation produces in you. Do you feel anxious or nervous when you talk to the learner? Are you sad or depressed after a day of working together? The affect the learner produces in you can be an important clue to the affect of the learner.

Valuative

The Valuative category of diagnoses is among the most common difficulties that arise. They are usually the result of a mismatch between the values and expectation of the student and the preceptor. A learner may anticipate a light workload on an outpatient rotation and may not expect the high volume and long hours that they find. A learner may expect an Honors grade when your assessment to date is that they have been performing at a Pass level. A learner may have a primary interest in a different clinical area and may not perceive your area as valuable to their education. A learner may allow their personal or religious values principles to enter too strongly into their discussion with staff and patients leading to conflict with patients and/or staff. As discussed earlier many of these issues can be detected early or prevented by a thorough orientation, review of expectations or mid-rotation review. It is important to be alert for these common mismatches at all stages of the learning experience.

Environmental

A marked change in the learning environment can affect the learner’s performance. A learner who is used to a hospital care may struggle in the outpatient setting and vice versa. A learner may be used to a well-defined specialty clinic population and may be overwhelmed with the undifferentiated population in the primary care out patient setting. Another may be used to the luxury of having lots of time with patients at an academic center, and may be frustrated by the time pressures of the busy private clinical practice. Patient satisfaction is an important part of modern clinical practice. A new learner may not have fully integrated a strong concern for the patient’s satisfaction in their approach to providing care while learning.

Medical

At times a Medical diagnosis may be at the root of an educational issue. Here the clinicians knowledge of illness and it’s manifestations can be helpful in considering possible medical causes of learning difficulties. Anxiety or Depressive symptoms may be the normal response to a life event or situation as discussed in the Affective section. Sometimes a learner may present with a full-blown Major Depression or Anxiety/Panic disorder. A Recent Illness such as mononucleosis or pneumonia may effect performance, as may a Previously Undiagnosed Illness such as hypothyroidism. A Pre-existing Illness such as diabetes or an eating disorder that is now in poor control can lead to difficulties in the clinical setting. Mental illness, such as schizophrenia, may present with Psychosis in a previously healthy learner. Health professional students are at high risk for Substance Abuse as are health professionals. A healthy suspicion for substance abuse should be maintained when erratic or substandard performance is present.

The Assessment step can seem daunting but there are two important facts to remember. As a health care provider you are trained to make diagnoses and the same skills you use to develop a differential diagnosis on a patient will work with learning difficulties. Also, it is not necessary to have a firm diagnosis in hand to determine a plan and to get the help you need.

SOAP -- Plan

At this point you have determined that a difficult situation exists, you have collected subjective and objective data and developed a working differential diagnosis. Your next step is to decide on a plan (Table 4). Your plan of action must be highly dependent on your differential diagnosis and the impact of the situation on you, your practice and the learner. The following are possible courses of action.

Table 4. Plan

Gather more data?

  • Observe and record
  • Discuss with student
  • Contact School

Intervene?

  • Detailed behavior specific feedback
  • Specific recommendations for change
  • Set interval for reevaluation

Get Help?

  • Get assistance from regional support or School
  • Transfer Student

Gather more data.

For a mild situation where the current negative impact is minimal and further assessment has not uncovered more serious problems, an approach may be to gather more data. You may need more information in the OBJECTIVE area of your SOAP process in order to produce a more accurate differential diagnosis. Observe and record more behavior specific data from direct observation and colleagues can help you decide on a next step. This data will be of value in planning your own intervention or in communicating your concerns to the school or training program.

Consider discussing the issue with the learner. Even at an early stage in your assessment of the situation, this could shed additional light on the issue, including the learner’s awareness of the issue and potential causes.

You may want to contact the school or training program at this point --even for what appears to be a relatively minor concern. They can be a source of excellent advice and guidance as well as moral support. Sometimes information may be available from the learner’s performance on other rotations that may shed light on your concerns. If you do not call and ask for this type of information, you are unlikely to receive it.

Intervene

Difficult learning situations that seem straightforward and are having minimal impact on the practice, the staff and patients may be amenable to intervention in the practice setting. If the problem falls into a category that may be remedied by educational intervention (such as a Valuative or a mild Affective issue), an attempt at intervention may be very appropriate. Detailed specific feedback is the cornerstone of your intervention. The detailed observations you have made will identify your areas of concern for the learner and will allow you to make specific recommendations for change. A set interval for reassessment should be determined so that a discussion of improvements made (or lack of improvement) will occur. Many learners will be able to act upon good feedback and make dramatic improvement. It is important to recognize that if an intervention is not successful, the problem may be a larger one than you had thought and help may be required.

Getting Help

Getting help should not be a last resort. As in clinical practice an important first step is to carefully consider the seriousness of the situation and then decide on an appropriate plan. Just as you would not treat a mild pharyngitis in the hospital or a complicated myocardial infarction at home, you must determine which issues can be appropriately addressed in your setting and when you would need additional resources. It is not the duty of the preceptor to solve all of the problems of the learner. As health care professionals you have strong desire to help others and to solve their problems. Nonetheless, your relationship with the learner is not a provider/patient relationship but a Teacher/learner relationship. There are clearly some diagnoses in our Assessment for which additional resources should be used.

As mentioned earlier, contact with the school can result in additional information or may help you in selecting an appropriate intervention.

The primary responsibility for the well being of the learner rests with the school or program and they have significant resources to help learners in need. In some of these cases it may not be appropriate for the student to remain in your office. Transfer back to the school or program should not be seen as a failure of the preceptor but rather as success for the educational system -- for the learner to get what they most need.

Dealing with the Difficult Learning Situation: Preceptor Issues

To this point we have focused on issues related to the learner. There are times when difficult learner situations can occur due to preceptor related issues (Table 5). Unanticipated events can have a significant effect on a planned teaching experience. Personal illness or an illness in family members may affect your ability to teach effectively. Sudden events such as the loss of a partner or key staff can markedly effect the ability of a practice to serve the needs of a learner. Unexpected financial or schedule-related pressures could upset a previously planned learning/teaching experience. At times an unanticipated personality clash with a learner will make it impossible to establish the necessary close working relationship of the learner and preceptor.

Most clinician teachers do not take their commitment to teach lightly and will often try to work through unexpected difficulties and personal issues. There are two important questions to ask when preceptor issues are present:

1) Is the presence of the learner preventing you from doing what needs to be done?

2) Are your issues seriously affecting the education of the learner?

Often there is a strong tendency to ignore problems and their impact rather than consider declining to take an agreed upon student. The result of this could be a LOSE/LOSE situation for the preceptor and the student.

Table 5. Preceptor Issues that May Affect Teaching
  • Health Issues- Personal, Family
  • Practice Issues- Staffing, Over-scheduling, Financial Issues
  • Relationship Issues — Personality clash with learner.
  • Important Questions:

Is the presence of the learner preventing you from doing what must be done?

Are your issues seriously affecting the education of the learner?

Think for a moment now about what type of personal situation would lead you to cancel a rotation to which you had agreed. If you cannot think of one then you may be prone to putting yourself and the student at risk and may need to reconsider your threshold.

Conclusion

This monograph has focused on the prevention, identification and management of difficult learning situations. It is important again to put things back in perspective and to remember that the vast majority of times learner/teacher interactions go along just fine. It is only rarely that significant problems develop.

The careful application of the prevention techniques discussed in the first part of the monograph can further reduce the occurrence and impact of difficult teacher/ learner interactions. Maintaining a vigilance to help detect issues early and applying the SOAP approach to assessing and intervening early can reduce the impact of the occasional difficulty.

When the rare significant problem occurs it is important that you seek help early and not allow one experience to lead to teacher burn-out. Getting the resources needed for the learner as soon as possible benefits you, the learner and future students that you will be able to teach.

References

Quirk, M. E. (1994). How to Teach and Learn in Medical School.

Springfield, IL: Charles C. Thomas.

 Other Resources

Gordon, G. H., Labby, D., & Levinson, W. (1992). Sex and the teacher-learner relationship in medicine. Journal of General Internal Medicine, 7, 443-447.

Johnston, M. A. (1992). A model program to address insensitive behaviors toward medical students. Academic Medicine, 67, 236-237.

Relevant Preceptor Development Program Topics

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