Table 1.

Suggested approach to struggling learners

Subjective: Detecting a problem based on a subjective impression

• Clinical teachers should trust their impressions.

• Doubts should prompt further observation and documentation.

• The goal should be early identification of difficulties, within the first quarter of a rotation.

Objective: Gathering and documenting objective data

• Data should be based on more than one context and on as many observations as possible, depending on available sources: direct or indirect observations, notes in patient files, formal and informal interactions with faculty and staff.

• Predefined milestones and EPAs are useful tools to document objective discrepancies with the expected performance level.

• At least a minimal amount of direct observation is recommended.

• An informal discussion, or a diagnostic conversation, should be held with the learner before any further step is undertaken.

Assessment: Making a pedagogical diagnosis based on assessment of the collected data

• A pedagogical differential diagnosis must consider cognitive, attitudinal, and mental health issues.

• These three types of difficulties are often interrelated. When this is the case, issues must be addressed one at a time, starting with that which has the most impact on clinical performance.

• Difficulties of cognitive origin are the most frequent; among them, both clinical reasoning difficulties and insufficient knowledge should be considered.

Plan: Planning a targeted remediation

• The first step in planning a targeted and efficient remediation is to pinpoint the underlying issue as precisely as possible.

• A clear process for remediation should be in place locally, since its absence could deter clinical teachers from following up on the identification of difficulties.

• Ideally, this remediation process should be integrated into the learner’s regular clinical activities.

Abbreviations: EPAs, “entrustable” professional activities.