The Struggle Is Real: Breaking Barriers that Limit Student Success

The Fall 2022 Webcast Audio Seminar Series of the International Association of Medical Science Educators (IAMSE) entitled, “The Struggle is Real: Breaking Barriers that Limit Student Success,” highlighted strategies for supporting students to be successful across the trajectory of their health professions education. These strategies underscored the impact of institutional, psychosocial, and economic determinants of learning on student performance while exploring options for creating a supportive learning environment to ensure student success. Leading experts presented each of the five webinars and each webinar was broadcast live, weekly from September 1st, 2022, through September 29th, 2022, to an international audience.

“This Trainee Is Terrible:” How to Help the Struggling Learner

Presenter: Calvin Chou, MD, PhD, Professor of Medicine, University of California San Francisco.

Dr. Calvin Chou introduced the series by conceptualizing remediation as educators “kicking the can’t down the road.” He defined remediation as a correction for trainees who started out on the road toward becoming an excellent health professional but have moved off course [1]. He noted remediation oftentimes becomes a parallel curriculum, making the remediation process isolating for both learners and faculty. Dr. Chou identified the following four zones for student performance and their corresponding levels of corrective action: Zone 1—performance above expected level with no corrective action, Zone 2—performance below expected level with corrective action, Zone 3—performance below acceptable level with remediation, and Zone 4—performance below unacceptable level prompting exclusion. Dr. Chou noted that the learner’s trajectory in each of these zones is not wholly linear. He also remarked that failing learners is a multi-tiered process, and that “failing to fail” learners is an ongoing issue across the health professions that directly impacts the social duty and responsibility of health professions educators [2].

Dr. Chou then outlined the following five steps for structuring a remediation plan: Step 1 Identification: This step includes setting clear expectations, decreasing the cognitive load, creating fair assessments, and engaging in early identification of potential learning issues. Step 2 Clarification: This step includes identifying learner-specific and systems level contributors to suboptimal performance. It also involves identifying competency area deficiencies that require remediation. Step 3 Collaboration on a Learning Plan: This step includes involving the learners in the remediation process, emphasizing metacognitive skills, aligning explicit and tacit curricula with valid, reliable assessments, developing faculty to highlight best teaching practices, and fostering a culture of ongoing feedback for improvement. Step 4 Intervention: This step includes creating activities that promote reflection, self-regulation, and growth, avoiding information overload, and providing consistent coaching and feedback. Step 5 Programmatic Assessment/Systems Intervention: This step includes identifying measurements of academic success, creating a timeline, analyzing environmental effects on the learner both as an individual and as a member of a learning cohort, and appraising systems-level contributors to suboptimal performance such as implicit bias, stereotyping, and patient load.

Dr. Chou concluded the session by reinforcing the concept that remediation is a team effort. He recommended training frontline faculty, expert remediation coaches, and arbiters who can make defensible, ethical judgments to serve on the remediation team.

The Off-Cycle Curriculum: Intention vs. Impact

Presenter: Jason Walker, PhD, Assistant Dean of Transformational Learning, Associate Professor Physiology, Philadelphia College of Osteopathic Medicine South Georgia.

In the second session of the series, Dr. Jason Walker began his presentation by remarking that the 2020 pandemic had served as a catalyst for both chaos and change in medical education. As a result of the pandemic, he indicated that health professions educators are rebuilding their learners, but he cautioned that educators must continuously ask themselves if they are building them on a foundation of sand or bedrock. He pointed out that a new group of struggling learners surfaced upon the removal of the assessment supports implemented during the pandemic. He indicated that this prompted the development of an off-cycle curriculum in order to provide engagement with learners on academic suspension and to keep them connected to the institution. Dr. Walker noted the following considerations when placing a student on academic suspension. 1. What happens when a learner is placed on academic suspension? 2. What institutional resources can the learner access while on academic suspension? 3. What are the expectations placed on the learner upon returning from academic suspension? 4. What are the expectations and accountability for faculty, administrators, and the institution? 5. What programs are in place to check in with a learner while on academic suspension? 6. What is the financial impact for a learner on academic suspension?

To better support struggling learners, Dr. Walker proposed creating a decelerated/off-cycle curriculum. He described the decelerated curriculum as an alternative distribution of the preclinical courses that allows learners to complete the first- and second-year curricula in 3 years. Characteristics of this type of curricular program include: 1. creation of an off-cycle Curriculum Council to recommend potential candidates, 2. provision of counseling for the candidates and review of the off-cycle curricular requirements, and 3. clarification that the learner makes the final decision to participate in the program and must sign a contract. Dr. Walker highlighted the necessity for accountability in a decelerated program and recommended the following accountability measures: 1. maintenance of the off-cycle curriculum plan in the permanent program record, 2. evaluation of learners during each term of the off-cycle curriculum plan, 3. learner achievement of an assessment average of 75% during each recaptured term, and 4. consideration of the possibility of dismissal for learners who fail to meet academic or professional standards while participating in the decelerated curriculum. Dr. Walker suggested that integration into the off-cycle curriculum can serve as an alternative method for diagnosing learning deficiencies. He also noted that accreditation concerns, institutional finances, and space considerations pose potential challenges for implementing an off-cycle program.

Dr. Walker completed his presentation by encouraging faculty educators to consistently address the struggling learners’ question, “Why am I here?” He proposed that by continuously probing this question, learners can better understand how to create change from the inside out. He closed the session by stating that it is time to re-imagine remediation as RISE: Restructured, Integrated, Supplemental Education.

Mental Health and the Struggling Learner

Presenter: Michael Redinger, MD, MA, Co-Chair Department of Medical Ethics, Humanities, and Law, Interim Chair, Department of Psychiatry, Associate Professor Psychiatry, Western Michigan University, Homer Stryker MD School of Medicine.

Dr. Michael Redinger opened the third webinar in this series by underscoring that mental health issues can interfere with learners’ success, both academically and professionally. He then provided a detailed overview of potential drivers of mental illness in struggling learners. These drivers included: 1. Learners often experience high levels of burnout, depression, and anxiety, all of which have been exacerbated by COVID. 2. Physicians and medical students are poor at self-care, seeking assistance for themselves or colleagues, and assuming the patient role. 3. Learners who have significant exposure to adverse childhood experiences (ACE) are more likely to report an effect on their mental health compared to their peers. 4. Learners who come from other disadvantaged circumstances are more likely to experience ACE and might require more support. 5. A significant number of medical students compared to other graduate level students develop mental health issues over the course of their training. 6. External stressors are the primary drivers of medical school stress. 7. Mood and anxiety disorders are the most common conditions in medical school.

Dr. Redinger proposed implementing a Psychiatric Fitness-for-Duty (FFD) evaluation, which he described as a means for determining if someone is able to do a job with reasonable skills and safety. He noted that problematic behaviors in the medical profession occur across demographics and specialties and can trigger FFD evaluations. He stated that the seeds of these behaviors emerge early in the course of one’s medical career. The FFD consists of the following fundamental questions. 1. Does a psychiatric illness exist? 2. Does that illness impair specific functions? 3. To what degree do impaired functions impact job performance? Dr. Redinger described physicians as a population that is not identical to the general population in terms of their cognitive abilities. He also pointed out that medical student cognitive norms are different than the general population. He noted that medical students may be functioning at the mean of a population-wide sample but are impaired compared to physicians as a whole. He emphasized that this is an important consideration when thinking about providing accommodations or sending a learner for cognitive assessments.

In response to professionalism lapses, Dr. Redinger recommended the following strategies: 1. holistic responses that include mental health evaluations, 2. remediation activities beyond a mandated mental health evaluation, 3. additional efforts to help reverse the process, 4. reappraisal of current services prior to having learners return to the curriculum, and 5. viewing remediation or discipline through a “just” systems lens [3].

Dr. Redinger reiterated that mental health is a positive contributor to professionalism lapses and later misconduct. He suggested that addressing depression and burnout might help in minimizing learners’ academic difficulties. He emphasized that behavior change is hard, especially for those with certain personality disorders. He cautioned that causation vs. correlation is difficult to determine in individual cases. He concluded the session by remarking, “No one knows how to really do this well.”

Learning Communities: Creating Structures for Peer Support

Presenters: Caroline Harada MD, Associate Professor Internal Medicine, Leader of Geriatrics Consult Service and Assistant Dean for Community Engaged Scholarship at the Heersink School of Medicine at the University of Alabama at Birmingham; Lauren Parker MA, Director of Programs at the University of Kansas School of Medicine.

For the fourth session in this series, Dr. Caroline Harada introduced the Learning Communities Institute (LCI) [4]. This is an organization of health professions schools with the mission of building connections in medical education to serve as a resource and a source of support. She described a learning community as an intentionally developed longitudinal group that aims to enhance students’ medical school experience and maximize their learning. She stated that the goal for learning communities is to foster among students a higher level of engagement and intellectual interaction with peers, faculty, and the curriculum. She noted that learning communities are well-established in higher education, but relatively new to medical education.

Dr. Harada pointed out that student progress is a collective effort that reflects the principles of flexibility, inclusivity, interconnectivity, and collaboration among many faculty across different departments. She stated that these principles are essential operational processes for increasing student engagement and facilitating student success.

Following Dr. Harada’s presentation, Ms. Lauren Parker introduced different ways to structure a learning community. She highlighted the necessity for fostering peer support within the learning community and described the following essential functional areas to facilitate peer support: 1. encouraging community building as an investment in the future. This helps to prevent learners from getting into difficulty because they are well-supported through strong relationships. 2. Peer advising/coaching/mentoring/tutoring. These interactions can help to mitigate feelings of inadequacy, anxiety, and social isolation. 3. Programming to support group development. Working within a group facilitates building interpersonal connections and engages learners in activities that cultivate an awareness and collective value for inclusion and belonging, and an appreciation for differences. Ms. Parker then described the benefits of creating learning communities which included better clinical skills, increased learner satisfaction with advising, improved interpersonal relationships among learners and faculty, and enhanced faculty satisfaction.

Ms. Parker concluded the session by providing the following resources to aid in the development of inclusive teaching practices: Institute for Inclusive Teaching at the University of Michigan [5] and StoryCorps Civil Discourse Conversation Guide [6].

Breaking Barriers for Racial/Ethnic Groups Underrepresented in the Health Professions

Presenter: Janet Coffman, PhD, Professor of Health Policy, HealthForce Center, Philip R. Lee Institute for Health Policy Studies, Department of Family and Community Medicine, University of California, San Francisco, Co-Associate Director for Policy Programs, Institute of Health Policy Studies.

Dr. Janet Coffman began the fifth and final session of this series by providing an overview of diversity challenges in health professions education. She noted that racial and ethnic diversity in the US population is increasing and that Native Americans, African Americans, Latinos, and some Asian Pacific Islander ethnic groups remain underrepresented in most health professions that require a college or graduate degree. She also pointed out that the diversity level decreases as the required educational level for the profession increases. She stated that health professions leadership needs to better understand the barriers faced by people from these racial/ethnic groups to help create a more representative workforce.

Dr. Coffman identified structural racism a barrier to increasing racial/ethnic diversity in the health professions, especially for Black, Indigenous, and People of Color (BIPOC). She defined structural racism as multiple, interconnected levels of racism embedded in societal structures, all of which are socially mediated [7]. She categorized these social structures as institutional barriers, personally mediated barriers, and internalized barriers.

For institutional barriers, Dr. Coffman noted that BIPOC students are more likely to have attended poorly resourced public schools with inadequate preparation for a health professions career. She also stated that BIPOC learners tend to work during college which limits the amount of time available to attend school, adequately study, and participate in internships. She underscored that the length and cost of health professions education and the lack of role models concordant with students’ race/ethnicity also create institutional barriers to pursuing a health professions career. In terms of personally mediated barriers, Dr. Coffman identified overt bias, microaggressions, and a lack of guidance and support from pre-health advisors as ongoing barriers. For internalized barriers, Dr. Coffman highlighted stereotyping threats, especially negative stereotypes about the intellectual capacity of BIPOC students. She explained that these tacit perceptions can negatively impact students’ academic performance. She emphasized that all these barriers send messages to BIPOC students that they do not belong.

Dr. Coffman recommended the following framework for increasing racial/ethnic diversity in the health professions: 1. form institutional partnerships, 2. provide tailored student support to create academic success, 3. engage faculty in institutional change, 4. build confidence and independent thinking through improved remediation practices, 5. establish a Chief Diversity Equity and Inclusion (DEI) officer and Vice Chair for DEI positions and provide sufficient protected time and resources for these people to do the work, 6. establish communities of practice and partnerships across colleges and professional schools, 7. create post baccalaureate programs focused on those who unsuccessfully applied to health professions schools, 8. combine and condense undergraduate and graduate education, 9. implement an accelerated, year-round program focused on BIPOC students, and 10. change admissions requirements.

In her concluding remarks, Dr. Coffman noted that breaking barriers for BIPOC students in the health professions requires multiple strategies. She emphasized that in order to ensure student success, these strategies need to address all forms of racism, encompass partnerships and collaborations across all levels of education, and focus on providing strong support, confidence-building skills, and independent thinking throughout all health professions curricula [7].

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