July 19, 2021

Coping with a challenging learner

Bruce Peyser, MD, FACP
Director of Education and Teaching, Duke Primary and Urgent Care
Physician, Duke Primary Care Pickett Road

Professor of Medicine, Duke University School of Medicine

A few months ago, I realized I was dreading going to work. I wondered who was on my schedule, thought about my work volume, and tried to reflect upon whether I was simply burned out. But upon further reflection, I began to think maybe the problem lay with a particular student who was working with me. He was new and still learning the ropes, but already I was facing difficulties with his clinical skills. I subsequently realized I had a challenging student assigned to me, and he was having a negative effect upon my enjoyment of teaching.
For some additional guidance, I referred to one of my favorite teaching manuals, entitled Community Based Medical Education and edited by Len Kelly, and perused chapter eight, called “The Difficult Learner.” The author defines problem learners as those who “range from a student who needs more teaching and supervision, but who eventually makes good progress, to a resident who has more deep-seated issues who just does not fit into your practice. In this latter scenario, the educational agenda has become derailed, and, try as we might, we cannot get it back on track.” Around this time, my challenging student presented a patient to me, starting with the review of systems and addressing the main problem at the very end of the oral presentation. At that point, I was pretty sure we were en route to this derailment so well described in the book.
Amidst my pause for reflection, I wondered if part of the problem was my own, or whether things were just too chaotic with COVID-19. Maybe all my mask wearing was making me especially grumpier than my normal self. To get an additional opinion about the student, I turned to a colleague who works in our group and asked if she would help me work with this learner. We planned to share this teaching responsibility anyway, and I thought maybe a change of teacher might enable the student to succeed. Perhaps a different approach and a different set of eyes might help me appreciate how I could alter the way I interacted with the student.
But after a day and a half of working together with the student, my colleague cornered me at the end of the day and asked if we could discuss this particular student. She asked what I had observed, and then she shared all that she had seen. It turns out she, too, had witnessed more troubling communication problems that this student had with patients. Additionally, she thought his fund of knowledge was weak and his preparation prior to coming to our clinic was inadequate. This sharing of our notes and observations, which lasted literally for five minutes, was all I needed to confirm my suspicion that we had a very challenging student in our clinic and that we needed help.
The next step in this ordeal was clear. I knew I needed to reach out to the course director for this rotation. The next day, I spoke with this individual at length on the phone, and she asked me about the challenges we had observed. I gave her many examples of the problematic actions and behaviors, and she agreed we needed to come up with some help, because this student’s “learning trajectory” was skewed in the wrong direction. It was most helpful we had many specific examples and observations we could share.
We went ahead a filled out a summative mid-course evaluation even though the rotation was still just several weeks old. We wrote down specific instances of areas where there were gaps and deficiencies. I reviewed this with the student in person, which was not an easy conversation, and I then shared this document with the course director. Not surprisingly, when I sat down to provide feedback to the student, I asked for his self-evaluation, and right off the bat, he knew he was struggling and that his histories were inadequate and presented in a jumbled fashion. I did all this on a Friday afternoon and drove home Friday night thinking this had not been a particularly gratifying or pleasurable week when it came to teaching.
I returned the following Monday and was pleasantly surprised by a student who seemed reenergized. He had spoken to his course director and was going to spend extra time with program staff so he could be re-evaluated and receive more observation and feedback by educators from his program. Within several days, he became laser focused on trying to make some important changes in the office, and he listened to the observations and feedback I gave him throughout the day. I was impressed with the rapid shifts in how he approached patients and how he presented them.  
The presentations were still imperfect, and I had to spend additional time clarifying the history with my patients. But I could sense things were on the upswing, and I shared this with him at the end of the day. He smiled, sighed, and thanked me for taking the time and making the effort to assist him. He could sense that we were on his side, and that we were all working toward the same goal of helping him to become a successful clinician.
Some take-home points from this experience.
  1. Listen to your gut feeling, and if you are not enjoying your teaching or are sensing there are problems, dive into the situation rather than away from it.
  2. Specific observations of actions and behaviors are key. It was helpful to the student that we could cite very detailed items we had observed. He knew we were meticulously watching what he was doing, and we did not write down generic feedback, such as “needs to do more reading.”
  3. Reaching out to course leadership can be really helpful in these kinds of situations. It’s much better to get help early on—and it’s not so helpful to record problems at the end of a rotation.
  4. Once the student knew we were on his side and working toward a mutual and positive outcome, he was ready to dig in, try new things, and make changes. This sense of a team can be very empowering to all involved.