Untying the Gordian knot: remediation problems in medical schools that need remediation

Untying the Gordian knot: remediation problems in medical schools that need remediation This position paper discusses on-going academic remediation challenges within the field of medical education. More specifically, we identify three common contemporary problems and propose four recommendations to strengthen remediation efforts. Selecting or determining what type of remediation is needed for a particular student is akin to analyzing a Gordian knot with individual, institutional and systemic contributors. More emphasis, including multi-institutional projects and research funding is needed. Recommendations regarding language use and marketing of such programs are given. Keywords: Medical education, Academic remediation problems Background capable matriculants from diverse backgrounds [8–10] Academic remediation is a near universal problem faced which requires changes in views of learning. All of these by medical schools and residency training programs. provide a unique opportunity to evaluate and revise as- Studies suggest that the need for remediation is signifi- pects of the system. cant given 10% of medical students encounter an aca- Academic remediation within medical school pro- demic failure at some point during their training [1]. In grams is a topic of significant interest and has produced response to this need, a high percentage of medical notable publications (e.g., Guerrasio [11] and Kalet and schools now offer some form of academic support for Chou [12]). However, remediation as a systematic their students. Offering such services is laudable and ne- process has not been overhauled from the traditional cessary, but as many who have sat down across from a view that academic struggles are solely an individual struggling student can attest, analyzing the contributing problem which is handed off to remediation personnel. factors and deciphering a solution is akin to having a In this regard, we agree with Cleland and associates [13] Gordian knot perched on your desk. and with Kalet, Ellaway and colleagues [14, 15] that re- Curriculum reform efforts in the US are shifting to mediation should be an explicit part of the structure of learner-based strategies, competency-based programs medical education with shared responsibilities rather and respect for multiple modes of learning [2–5]. Similar than as an afterthought or “outsider” activity. curriculum reform efforts in Europe and the United Nearly all medical schools invest in remediation re- Kingdom (UK) have been discussed and debated in re- sources, but most err in not having cross-talk between cent years [6] including incorporation of the World remediation specialists and instructors or curriculum Health Organization and World Federation of Medical managers at strategic points throughout students’ devel- Education (WHO/WFME) guidelines [7]. In addition, re- opmental process of becoming a physician. Instead re- cruitment processes have widened their search for mediation is relegated away from the core action of medical education; consigned to manage the ‘penalty box’ where struggling learners are sent after committing * Correspondence: layne.bennion@usuhs.edu Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, academic ‘fouls’. Without avenues of two-way communi- Bethesda, MD 20814, USA cation between the remediation program and the larger Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bennion et al. BMC Medical Education (2018) 18:120 Page 2 of 10 educational program and without revising our view of re- that the above noted data points should be the sole identi- mediation as ‘fixing’ struggling learners, remediation will fiers of at-risk students. While these are known relation- remain, in our opinion, less effective and more costly to ships, to the best of our knowledge, no researchers have individual learners and to the school (see also [16]). combined known risk factors with concerning early per- Cleland and associates article [13] as well as others formance data in an effort to identify struggling learners have recently written about the disconnect between indi- at the beginning of their academic training. vidual remediation needs and the larger educational A second source for identifying struggling learners is system and have raised important associated questions. self-referral. Only a small percentage of students self- While Cleland and colleagues do offer some specific sug- refer to remediation resources. Combining 10 years of gestions, overall they highlighted more problems and data, Guerrasio et al. [21] found approximately 7% of points for discussion rather than providing specific solu- students were self-referred to a remediation program for tions. In this paper, we build upon their work and iden- medical students and professionals. Based on our experi- tify three common problems associated with the ences, many of these students tend to be high achievers disconnect between the larger medical education process whose drivers for self-referral include chronic anxiety and remediation and subsequently propose four recom- about their performance. Thus seeking assistance or re- mendations to minimize those problems. assurance is not a new behavior for them. In our view, there is little change needed at the system level for this Problem 1. Struggling learners—Can the system find them subset of struggling learners. early? A third source for identification of an at-risk student is There are four potential sources for identifying strug- through a more formal process led either by faculty gling learners: pre-matriculation and demographic data, (Ellaway et al. [14]) or an academic or competency review self-identification, student advancement or academic re- committee. Typically, committees review a student’ssitu- view committees, and the use of multiple-sourced, de- ation following a critical academic or performance failure tailed, across-time performance data (portfolios). and then make recommendations to the school’sleader- Many risk contributors have been studied and are ship regarding that particular student’s status within the known before the first day of medical school. Some of school. While there is little question that the students who those known risk factors are briefly reviewed below. are reviewed by such committees are ‘at-risk’ learners, this Ferguson, James and Madeley [17] in their meta-analysis action commonly occurs very late in the process. That is, of studies involving students attending UK medical remediation programs and experts sit by the “sidelines” schools found that (1) women slightly out-perform men, until there has been a significant failure or a series of fail- and (2) identification as an ethnic minority tends to be a ures by an individual student. These institutional-level slight disadvantage. More recently, Woolf, Potts & processes typically proceed slowly, are perceived as puni- McManus [18] found in their meta-analysis of UK phys- tive by students and are designed to capture those ician training, wide-spread differences between white students with the most serious academic or professional and non-white candidates. In addition, they found behavior problems, i.e., those who may be facing the pos- undergraduate grade point average (GPA) predicted only sibility of disenrollment. 23% of the variance in medical school grades, and learn- Stegers-Jager and colleagues [22] presented a different ing style (e.g., Kolb’s convergers or the tripartite model’s model from a Dutch medical school implemented re- deep and strategic) had weak correlations with academic cently which did include early identifications occurring performance (0.18 to 0.26). Donnon and associates’ [19] at 4, 7 and 12 months into the preclerkship studies. meta-analysis of Medical College Admissions Test Warnings were given at the 4- and 7-month time points, (MCAT) score’s’ predictive validity of medical school and academic probation was applied at 12-months. They performance found small to medium effect sizes (essen- did find more students participating in supportive ser- tially zero up to 0.4) for various measures of later per- vices under this model (than the previous process). They formance. Dyrbye et al. [20] found that students’ found those students participating in one-on-one re- “serious thought” of dropping out of medical school was mediation services were significantly more likely to satis- associated with demographic or event factors, e.g., being factorily complete their preclerkship studies. older in medical school (> 30 years old), having a child, As for longer-term functioning of students reviewed being in the 3rd year of medical school, and self- by an academic review committee, Durning et al. [23] identifying as an American Indian or Pacific Islander. As analyzed the performance of Post Graduate Year-1 anticipated, they also found greater risk of academic prob- (PGY1) residents comparing those who had been re- lems was associated with significant psychosocial stressors ferred for academic review to those who had not. They such as major personal illness, major illness in a signifi- found that being presented to the committee was associ- cant other, and divorce. No researchers have proposed ated with a higher risk of below average performance Bennion et al. BMC Medical Education (2018) 18:120 Page 3 of 10 during PGY-1. However, they also found that the overall activities. With a few notable exceptions (see below), lit- percentage of those students who interacted with the com- tle is available which dissects the procedure and, most mittee and had below average performance ratings during critically, details how to individualize remediation to internship was low. The authors noted the need for more meet the needs of a specific struggling learner. As noted research including: (a) the timing and intensity of remedi- by Winston [30] and others, simply teaching to pass the ation efforts and whether either is associated with higher next exam does not work in the longer-term for strug- risk for later performance problems and (b) looking at the gling learners. strength of the relationship with later performance compar- Over two thirds of medical school remediation pro- ing those students with primarily academic issues from grams make available services such as time management those with primarily professional problems. strategies, test taking techniques, note taking strategies, Similar to Kalet and colleagues [15, 24], we believe reviews of class exams, review of course content, model- that as a student is identified later into the curriculum, ing use of resources, and modeling problem-solving [31]. the higher the likelihood of that student presenting with As noted by Cleland and colleagues a most noticeable exhaustion, discouragement, and a lag in academic per- downside to the above practices can be summed up as a formance, which could have a potentially negative im- systemic view that quick and easy fixes have the ability pact on the student’s ability to modify or attempt to address the problem of struggling learners [13]. changes in their study process. Alternatively these generic services can ignore some of A fourth potential source for identification is the use of the individual contributors of a particular struggling multiple-sourced, across-time performance of students learner. Some medical schools address the needs of at- analyzed with the goal of early identification of struggling risk students by providing pre-matriculation programs learners. The notion of a learning or progress portfolio for focused on enhancing study-skills and/or tutoring to medical students is certainly not new (e.g., [25–28]. promote early exposure to and learning of the material. Portfolios can be used as to means to comprehensively Miller [32] described one such program which resulted collect available performance data including academics. in students modifying their anticipated study plan, but Recently, Kalet and Pusic [29] advocated use of a holistic unfortunately no data was presented related to actual and competency-based portfolio aggregating various academic outcomes. scores and ratings from multiple sources. This process is Remediation approaches applied in medical education currently in development at their program (New York research have been categorized into four models: ana- University School of Medicine). Unfortunately, few de- lytic, developmental, synthetic and competency-based tails were provided regarding the management and de- [33]. Unfortunately, such models have been found to ex- sign of this process. However, it is clear that the profile plain little of the outcome variance whether referring to metrics are available to the student and their mentor for clinical skills development, basic science knowledge or periodic review. One example table in their chapter professionalism [16, 34–37]. listed 21 specific content “buckets” for various perform- Winston [30] discussed an in-depth, year long, multi- ance metrics such as histology, pathology, pharmacology, pronged, intensive program for students repeating a etc. as well as displaying for each student their perform- portion of the curriculum involving regular faculty- ance as compared to their cohort for each content area facilitated, small group work with integration of study in a box-and-whisker format. This is an example of an skills and presented data indicating their success. Sayer individualized and very detailed tracking system for stu- et al. [38] described a small, reportedly successful pro- dents’ academic and professional performance and is in gram in a UK medical school specifically targeting concert with our intended meaning for portfolio. academic issues with lengthy one-on-one tutoring, a col- In Kalet and Pusic’s school, it appears such data re- laboratively designed remediation plan and a careful in- mains with the student and their mentor and is not used dividualized assessment process. by the larger system in identification of at-risk learners. An alternative approach is a listing of potential types Presumably, a student who consistently shows academic of learner deficits (“diagnoses”) such as difficulties in difficulties would be referred for additional assistance, fund of knowledge, clinical reasoning, history-taking, but when or how the system interacts with or uses indi- physical examination or professionalism [39]. Guerrasio viduals’ data in the portfolio is not clear. [11] adds the following additional remediation ‘diagno- ses’: time management and organizational skills, inter- Problem #2. Remediation—Which flavor works for which personal skills, communication, practice-based learning, student? system-based learning and mental well-being. Remediation, as a label, has been applied to a diverse set Beyond descriptive summaries and looking at scattered of processes including various skill-building presenta- outcome metrics, little research has focused on how to tions, tutoring, conceptual models, and one-on-one build an effective and individualized process to provide Bennion et al. BMC Medical Education (2018) 18:120 Page 4 of 10 successful remediation. Ascertaining what works and including strategic planning and motivational factors, (b) doesn’t work in remediation is difficult. Guerrasio [11] Performance involving metacognitive monitoring, self- has perhaps one of the most detailed and practical testing and self-control and (c) Self-Reflection about per- discussions based on their remediation process at formance such as causal attribution, self-evaluation and University of Colorado School of Medicine and she dili- satisfaction. These skills are intended for the application gently references many sources supportive of particular of immediate to longer-term work products. Notably, processes. Kalet and Chou [12] also document many this model is based on a solid foundation in educational practical aspects and viewpoints related to conducting research with data showing successful learning outcomes remediation with individual students. As these authors from multiple learning contexts and has been success- and others (e.g., [13, 40]) note most research on medical fully utilized in improving the diagnostic reasoning of education academic remediation is focused on a retake medical students [42]. of a failed examination and provides little basis for de- Fourth, rarely is there any formal assessment of the termining of what types of support are needed for which struggling learner, beyond an unstructured interview, to students or what type of remediation is most helpful. objectively measure their academic and cognitive Kalet, et al. [12] rightly note “as yet [there is] little evi- strengths and weakness. While many remediation pro- dence supporting how and why remediation in medical grams include an interview in their process, what is education works” (pg 24). meant by ‘an interview’, the degree of structure and A second complication in individualizing effective re- coverage for that interview and how that information is mediation is the varied background of staff who are used is a glaring hole. tasked to create or manage remediation programs. A A welcome exception is Yellin’s[43] work which dis- survey of 134 medical schools found that less than half cusses the issues associated with formal cognitive assess- of the staff who were responsible for remediation in ment, determining strengths and weaknesses and if medical schools had graduate degrees in education, testing supports it, applying diagnosis of learning disabil- learning or in enhancing individual behavioral change ities for medical students. He advocates for the use of [31]. Over one third of these staff members reportedly broad-based cognitive testing to ascertain struggling had no particular training nor prior experience in pro- medical students’ relative strengths and weaknesses viding academic support. Similar to above, this data sug- within six neurodevelopmental constructs (attention, gests remediation at the graduate level is a young field language, memory, temporal-sequential ordering, spatial with the added disadvantage of not having a solid basis ordering and higher-order cognition) to individualize the in theory or discipline. remediation plan. His process outlines the use of object- A third complication, as identified by Guerrasio [11], ive testing to create a cognitive profile used to help stu- Sayer et al. [38] and Mcloughlin [41] focuses on the nu- dents better understand their cognitive and learning merous contributors to academic difficulties. For a par- relative strengths and weaknesses. Based on the individ- ticular student, the number of contributors to academic ual profile, the remediation team develops a tailored struggles is typically multiple per struggling learner and learning plan or a “management by profile” plan. When many are related to the student’s background experi- testing is not utilized, some academic weaknesses may ences and/or to current vulnerabilities within their social not be recognized or addressed such as subtle reading and family settings. Thus, teaching specific skills, e.g., comprehension problems, a need for better writing skills time management or the notion of spaced learning, is or below average clinical reasoning skills [44]. A down- often an inadequate response for at least a portion of side to the above process is the high cost and time struggling students. Cleland and associates [13] also needed for formal assessment as well as a specialist (e.g., highlight the need to recognize pressures from institu- neuropsychologist) who is familiar with the necessary tional culture as well as individual student backgrounds. testing tools and, critically important, is willing to frame Durning and associates [33] take a different approach. an evaluation within the context of graduate medical Rather than attempting to match remediation strategies education (rather than simply using general population to a specific student or their learning difficulties, they or age-based norms). took an empirically and theory-based application of a At the individual student level, as Mcloughlin [41] and self-directed learning process which is generic to topic Yellin [43] noted many students use the same strategies and context and adapted it for struggling medical which produced success for them in their secondary and learners. This model, Self-Regulated Learning—Microan- post-secondary educational endeavors. When faced with alytic Assessment and Training (SRL-MAT), is a performance difficulties in medical school, these stu- problem-solving approach which functions as a three- dents often redouble their use of those same well-used phase cyclical loop and is applicable across learning situ- strategies. Finding a new strategy is time-intensive and ations. Specifically the three cycles are: (a) Forethought few medical students take the risk of potentially wasted Bennion et al. BMC Medical Education (2018) 18:120 Page 5 of 10 time in trying new strategies. Medical students, almost At the institutional level, few would find overt bias by definition, are highly successful learners across de- against students needing additional assistance. However, cades of learning and adaptation to many environments. there seems to be a subtle belief which may affect how For these students any serious academic problem, not to leaders and universities perceive remediation programs. mention consistent academic failures, is an unexpected Specifically, a view that students with early academic and foreign hardship which they have no experience difficulties will continue to struggle throughout their managing or learning from in productive ways. For the professional development, leading to a future of medi- student in the throes of early professional identity devel- ocre doctoring skills. For example, Cleland et al. [40] opment as a physician, serious academic problems can stated “weak medical students go on to become weak challenge their resiliency, motivation and career goals. doctors” and cited two references [53, 54]. Both of the Fifth, research which incorporates demographic and cited sources highlight professional behavior problems cultural differences as covariates beyond gender and age and/or communication problems between team mem- are lacking. There are many who advocate the need for bers. Neither source is focused on the relationship be- diversity and minority representation in the medical pro- tween early academic difficulties and later “poor” fessional [45–49]. Difficult issues such as communica- doctoring. For example, the first source, Papadakis and tion within cross-cultural supervision and mentoring of associates [53] concluded that low MCAT scores and medical trainees has been addressed [50]. Little if any at- low grades during the first two years of medical had tention is focused on any empirical remediation investi- “only ¼ the risk” of subsequent disciplinary action (as gations which also included broader diversity issues in compared to the risk faced by student with early profes- the medical literature. sional behavior problems). Based on the numbers Sixth, there is scant recognition in the remediation lit- Papadakis and colleagues presented, a student with an erature of the difficulties all learners face when attempt- academic failure of a medical course during the 1st or ing to change their well-learned and previously servable 2nd year of medical school, had only a 7% risk of subse- strategy. The most commonly used skills deficit model quent disciplinary action by state board. In contrast, in remediation asks students to change strategies and those with documentation of unprofessional behavior habits which have been personally effective for years and during medical school, had more than three times that successfully used for thousands of hours. Changing risk (26%) of subsequent disciplinary action by state deeply ingrained behaviors is difficult, stressful, and early board. In a similar study Papadakis [55] did not find aca- attempts can be easily abandoned before experiencing demic metrics (e.g., undergraduate GPA, lower quartile success with an alternative strategy. MCAT performance, not passing one or more medical A final consideration is acknowledgement that a school courses) were a significant predictor using logistic massive percentage of students are masterfully successful regression modeling of later professional behavior prob- in adapting to the challenges of graduate medical educa- lems. A statistically significant difference was noted be- tion. Unfortunately, almost nothing is known about how tween the undergraduate GPA of the group with later high performing versus ‘below average’ medical students disciplinary actions and other graduates (3.3 vs. 3.4), but adapt. Information regarding how ‘super’ learners in this is not a meaningful difference at the level of individ- medical school change, adapt and accomplish what they ual students nor was this variable a significant predictor do is lacking in the educational literature. Discovering in the logistic regression results. their successful adaptive strategies may add additional Similarly, a study of over 3000 Canadian physicians tools to the remediation process. found no statistically significant relationship between a score indicative of knowledge competency (score from a Problem 3. Stigma—It continues to interfere traditional written exam with 450 multiple choice ques- At the individual student level, most medical students are tions (MCQs)) and future patient complaints against the historically unacquainted with academic difficulties [13] physicians [56]. Guerassio [21] in a study of over 150 and are reluctant to come forward and ask for additional struggling learners spanning from undergraduate to assistance [41, 51, 52]. In addition, some students have a graduate medical education, found only professionalism bias in their perceptions of what causes these academic issues were a significant predictor of later probation, and problems. For example, Cleland and associates [40]found that medical knowledge was not a predictor. In Santen that 4th year medical students in a UK medical school and associate’s[57] study of students identified by stu- with below average performance tended to blame external dent academic promotions committee either through factors, believe that their most recent failure was an iso- academic issues or behavioral problems, approximately lated event and believe that faculty did not offer the ap- 4% of those students later had state medical board ac- propriate assistance (when in fact multiple messages to tions taken against them for unprofessional behavior. All aid these same students had been sent). of the students in their sample who had professional Bennion et al. BMC Medical Education (2018) 18:120 Page 6 of 10 behavior difficulties also had academic issues. Scrutiny Potential solutions of Santen’s published summary of their data suggests it Next we turn to potential solutions to deal with these is possible students who only had academic issues and challenges that face the medical education community. were not also identified as having behavioral problems, Here, we list four recommendations. were not later disciplined by state boards for unprofes- sional behavior (however, this is uncertain based on how Recommendation #1. Use systematically captured data, they presented their data). LaRochelle et al. [58] found across-time, multiple-sourced information with one of the evidence that pre-clerkship performance in clinical rea- goals being early identification of struggling learners soning (small group exercises, multiple choice examin- The concept of and use of portfolios in medical educa- ation focused on clinical reasoning and Objective tion is certainly not new. However, many uses of portfo- Structured Clinical Examination (OSCE) performance) lios cited in the medical education literature appears to did have small, but significant predictive value of resi- be a collection of student performance datum without dent ratings of medical expertise by faculty. organization into competency domains and without In addition, there are studies that suggest early aca- ways to represent growth over time within those compe- demic performance or even board examination scores tency domains. For example, Chertoff and associates are unrelated to other important non-knowledge-based [61] surveyed 71 Liaison Committee on Medical Educa- aspects of physician care. For example, Hojat et al. [59] tion (LCME) accredited medical school. Approximately found no relationship between scores on United States half reported use of portfolios, but less than 10% of total Medical Licensing Examination (USMLE) Step 1 exam- respondents noted they felt their portfolio process in- ination and empathy scores. No studies were found dir- cluded a visual display of competency growth. Other re- ectly linking early low academic performance (pre-med cent publications noting uses of portfolios are within school or pre-clerkship) as a primary or substantial con- particular modules or rotations, e.g., Sanchez Gomez tributor to later poor quality of doctor-patient relation- [62] or within particular aspects of training such as ships, diagnostic errors, treatment errors, or patient simulation centers [63]. While helpful, these do not pro- satisfaction. This view is perhaps the flip side of a long vide indications of overall growth or, in the case of re- tradition of high academic performance being the princi- mediation, lack of individual progress. pal gatekeeper for entry into certain specialties; aca- We advocate for the use of a portfolio as an across- demic performance is seen as a proxy for doctoring the-curriculum, integrated longitudinal assessment tool capacity or aptitude (see Prober et al. [60] for additional to guide and help the remediation process such as dis- discussion of the pros and cons of using Step exam cussed by Van Tartwijk et al. [64]. A comprehensive scores as primary selection variable of residents). portfolio includes an organizational schema such that An additional factor to be identified when considering various assessments are gathered from multiple sources the subtle institutional bias against remediation is that and placed into one or more general competency do- much of academic remediation literature borrows heavily main or “bucket” as labelled by Kalet’s group [29]. It al- from the universally familiar medical model, that is, find lows learner and teachers to support students’ learning the diagnosis and once the diagnosis is known, that diag- and closely assess students’ progression [65]. nosis ‘determines’ treatment. While this view obviously Specifically, we recommend a comprehensive portfolio has heuristic usefulness, the extent that this viewpoint of all performance data (knowledge-based, group per- should be extended to remediation of individual students formance, OSCE-type performance, written reports of is unclear. Given this model is steeped in the assumptions patient encounters, self-assessment of professional of disease, pathology processes and (body) system failures, growth, ratings or commentary of videotapes of leaning it is easy to imagine how, even if unintentionally, promo- interactions, etc.) be collected. Further that this collected tion of this view can carry negative assumptions. For ex- data be made available to the student as well as to se- ample, even if a student is identified as a struggling lected key individuals on the academic team (e.g., the re- learner, this does not necessarily mean that the student mediation team and those charged with tracking has a fundamental flaw or set of deficits that would nega- performance and with early identification of struggling tively impact that student’s functioning as a physician. learners). Importantly, we recommend that at least one Much of medical education support services, e.g., teaching reviewer of student portfolio data should be tasked with a specific and presumed missing skill, are based on the taking a longitudinal view of the learner’s progress par- above unstated assumption that the pace and rigor of ticularly within competency ‘buckets’ as discussed above. medical school exposes a pre-existing skills deficit. That That is, the longitudinal reviewer is not as concerned is, the student performed lower on an examination than with rating or grading a student performance related to expected, therefore the student has an academic or study current courses, but is to monitor, over time, for mar- skills deficit and/or a motivational problem. ginal performance within a competency area. Thus, Bennion et al. BMC Medical Education (2018) 18:120 Page 7 of 10 remediation is not just studying for the next exam, but large or may consider it a non-problem as only affects a also analyzing developmental patterns. Furthermore the small percentage of students and thus doesn’t need add- concept of portfolio-based monitoring and learning may itional funding or focus. In our view, this perspective is be particularly important in the remediation process [25, out-of-touch with the current directions and values of 27]. The use of a portfolio that contains a large amount medication education. of longitudinal information about learning interactions Acquiring large numbers of struggling learners to study and learners’ performance across settings and topical do- is difficult at the institutional level, but is less so if collab- mains. Thus, such information may be particularly use- orative multi-institutional studies are implemented. ful in developing and implementing remediation plans Implementation of work might involve consortiums across for some students which otherwise would have gone a small number of medical schools, shared development unrecognized. In addition, once such a longitudinal port- of performance portfolios, identification of similar per- folio process is put into place, the school could eventu- formance metrics, as well as integrating and analyzing ally analyze previous years of data to potential identify de-identified performance data across institutions. school-specific performance markers within early cur- In addition, many remediation programs appear to func- riculum experiences which, when paired with known tion as independent islands and offer services that are pre-matriculation risk factors, could help identify stu- based on the experience and skillsets of individual remedi- dents at risk for later serious academic problems. ation specialists. More coordination and sharing of ideas, The use of performance portfolio raises the concern of resources, and processes could help more remediation for- ‘forward-feeding’ performance problems to subsequent ward as well as generate data to answer hypothesis-driven faculty or clerkship directors. This has been debated in questions concerning optimum remediation methods. the literature [16, 24, 66–68]. Clearly there are privacy concerns and other issues to consider. Much of above dialogue centered upon who should have access to such Recommendation 3. Use of De-stigmatizing processes and information including clerkship directors and/or faculty language and discusses the potential for negative (and positive) The traditional ‘diagnosis➔treat’ view of remediation is biases. Our opinion is that there should exist a separ- problematic. No heuristic is perfect. But perhaps a better ation of the processes which determines official student model for conceptualizing struggling learners within status (typically a slow-moving, large group-based medical education is that of athletic conditioning for a process triggered by significant failure or string of fail- team of gymnasts or decathlon athletes. Each athlete has ures) and the remediation team (desirably a faster- years of experience, a history of many high-level perfor- moving, dynamic process). Ideally this latter team is a mances, but each athlete, each coach and the institution small group, is closer to ‘real time’ in its tracking of stu- understand qualification is at an individual level and dent performance and is skilled in its identification of must occur in a variety of skillsets or performances. struggling students. Its function falls within student ad- Every athlete experiences strong events and weak perfor- vocate services and it should engage early and often with mances. For these high-functioning athletes, condition- the struggling student. We strongly recommend those ing (or remediation) is not about discovering a involved in reviewing and using that data for early iden- pre-existing flaw. The foundation of conditioning is a tification of struggling learners be either separate from careful and detailed analysis of recent performances, iden- or not have a formal vote into procedures which deter- tification of relative strengths and weaknesses and then mine student status within the program. designing targeted exercises to enhance performance, ded- icated time to build up weaker skills as well as developing and practicing strategies for key performances. Recommendation 2. Encourage and fund research investigating We recommend reducing the use of terms such as re- the complex processes of medical education at the level of mediation, diagnosis, deficits, etc. A more useful articu- individual change including a variety of contributors lation may be using terms such as ‘not meeting a Directly assessing remediation is difficult. However, find- qualification standard’. While cumbersome, such phras- ing active change agents is critical. In medical research, ing suggests a student did not achieve their maximum we sensitively delve into individuals’ complex personal potential for a particular performance event rather than lives to probe aspects of cancer, diabetes, degenerative the implication that the student, as a holistic organism, diseases, etc. and compare treatment alternatives. is dysfunctional, incapable or lacks an essential skillset However, we are slower to apply similar rigor, energy which bars them from a success within the medical and funding to medical remediation. Critics may argue school context. academic difficulties during medical education is not a We are working with highly qualified and gifted stu- disease nor a pathology which affects the population at dents who are being stretched to their near maximum Bennion et al. BMC Medical Education (2018) 18:120 Page 8 of 10 capacity for years at a time. Thus, we recommend terms them as needed through their schooling via networks in- such as academic conditioning, performance coaching, ternal to the medical school. Making it known that cer- learning strengths and weaknesses (or cognitive and tain individuals within leadership and faculty of the learning profile), and adaptive strategies. Perhaps even medical school are willing to provide such testimonials terms such as “ath-learner” or “aca-lete” should be con- may encourage graduating students to do the same. sidered. While this last suggestion is somewhat tongue- In addition, brief messages from the current school in-cheek, the underlying notion detailed above is not. leadership supporting appropriate help-seeking by stu- We are not simply recommending a change in the label. dents being available within the same venue may be The recommendation is to move the culture away from helpful as well. Also, as part of school leadership terminology which inherently supports an assumption of messages, referencing studies noting the percentage of pathology and deficit and instead use language which medical students who do seek assistance can be a nor- recognizes: (a) there are complex factors impacting per- malizing factor. For example, Dyrbye and associates [71] formance and (b) these students are above average found approximately 40% of medical students annually learners operating in a very high-demand environment. seek out formal or informal supports. Third, we recommend applying the well-established medical model of consultation to academic issues and Recommendation 4. Encourage self-identification and normalize struggling learners. Again, leadership and supervisor help-seeking messaging is critical. That is, rather than telling students A one-time lecture simply reiterating above messages is with academic problems they are in need of an evalu- unlikely to provoke change in student’s help seeking be- ation to detect and diagnosis weakness and deficits, we havior (see [69] for example). Friedman and associates recommend referring to need for additional resources as [70] found, in their efforts to reduce de-stigmatizing atti- an academic consultation. As physicians, providers are tudes toward mental health usage, that a lecture-based expected to recognize when specialty care or evaluation format was perceived as patronizing by medical students. is needed particularly when standard treatments are not However, they did find that students were more recep- effective. Why should not a similar attitude be fostered tive to testimonials from individuals who were using from the beginning of their medical training? The mes- mental health-related services. In recent work, Cleland sage should be, “If you have adequately applied the rec- and colleagues [13] discussed the importance of the in- ommended ‘treatments’ to your studies and those are stitutional culture affecting help-seeking behavior and not effective, it is time to obtain a consultation!”. they offered a few specific suggestions, e.g., asking the There are, of course, limitations to our discussion and student their views of contributors to academic difficul- proposals. All of these issues are challenging and no so- ties, working in partnership with struggling learners, and lution will fit all situations or schools. Along with re- the staff role-modeling self-care. search investigating active ingredients of successful A useful option to normalize help seeking over time remediation, research into the links between remediated may be for medical schools to annually ask for volun- students and longer-term outcomes is needed. teers among graduating students and faculty to record brief personal audio or video ‘testimonials’ of healthy help-seeking options they utilized during medical school Conclusions (each volunteer choosing to specifically identify them- This position paper discusses some on-going problems selves or not). A brief suggested outline or reminders (e. within the field of medical education, identifying four g., list of common hurdles) might assist volunteers to ad- contemporary problems and proposing four recommen- dress known barriers, e.g., confidentiality, worries about dations to strengthen remediation efforts. Earlier identi- effect on career as a student, being reluctant to self- fication and assistance to learners “not meeting identify as having additional needs, etc. [71, 72]. It may qualification standards” has been discussed by many, but be appropriate to instruct the volunteers to not individu- is rarely implemented in a systematic manner. We rec- ally name less-than-helpful local individuals or providers. ommend the use of a professional performance portfolio Obviously, the volunteers would not be expected to dis- organized by competency domains and include tech- closure personal details of their difficulties, but are asked niques to show learner progress over time as a way of to provide only a generic reference to how stressors im- addressing this long-standing problem. Curriculum revi- pacted them personally while in medical school and then sion offers opportunities to incorporate programmatic focus on helpful options they experienced which helped approaches to remediation. Selecting or determining them not only manage, but succeed. These personalized what type of remediation is needed for a particular stu- help-seeking declarations could then be made electronic- dent is a Gordian knot. More emphasis, including multi- ally available to successive cohorts who could access institutional projects and research funding is needed. Bennion et al. BMC Medical Education (2018) 18:120 Page 9 of 10 Remediationasaneffort continuestobea seenasane- 11. Guerrasio J. Remediation of the struggling medical learner. Irwin PA: Association for Hospital. Med Educ. 2013;184. cessary evil within the larger mission of medical educa- 12. Kalet A, Chou CL, editors. Remediation in medical education. New York: tion as opposed to a program that strengthens and Springer; 2014. p. 367. conditions individual learners, and in turn the institu- 13. Cleland J, Cilliers F, van Schalkwyk S. The learning environment in remediation: a review. 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Untying the Gordian knot: remediation problems in medical schools that need remediation

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Abstract

This position paper discusses on-going academic remediation challenges within the field of medical education. More specifically, we identify three common contemporary problems and propose four recommendations to strengthen remediation efforts. Selecting or determining what type of remediation is needed for a particular student is akin to analyzing a Gordian knot with individual, institutional and systemic contributors. More emphasis, including multi-institutional projects and research funding is needed. Recommendations regarding language use and marketing of such programs are given. Keywords: Medical education, Academic remediation problems Background capable matriculants from diverse backgrounds [8–10] Academic remediation is a near universal problem faced which requires changes in views of learning. All of these by medical schools and residency training programs. provide a unique opportunity to evaluate and revise as- Studies suggest that the need for remediation is signifi- pects of the system. cant given 10% of medical students encounter an aca- Academic remediation within medical school pro- demic failure at some point during their training [1]. In grams is a topic of significant interest and has produced response to this need, a high percentage of medical notable publications (e.g., Guerrasio [11] and Kalet and schools now offer some form of academic support for Chou [12]). However, remediation as a systematic their students. Offering such services is laudable and ne- process has not been overhauled from the traditional cessary, but as many who have sat down across from a view that academic struggles are solely an individual struggling student can attest, analyzing the contributing problem which is handed off to remediation personnel. factors and deciphering a solution is akin to having a In this regard, we agree with Cleland and associates [13] Gordian knot perched on your desk. and with Kalet, Ellaway and colleagues [14, 15] that re- Curriculum reform efforts in the US are shifting to mediation should be an explicit part of the structure of learner-based strategies, competency-based programs medical education with shared responsibilities rather and respect for multiple modes of learning [2–5]. Similar than as an afterthought or “outsider” activity. curriculum reform efforts in Europe and the United Nearly all medical schools invest in remediation re- Kingdom (UK) have been discussed and debated in re- sources, but most err in not having cross-talk between cent years [6] including incorporation of the World remediation specialists and instructors or curriculum Health Organization and World Federation of Medical managers at strategic points throughout students’ devel- Education (WHO/WFME) guidelines [7]. In addition, re- opmental process of becoming a physician. Instead re- cruitment processes have widened their search for mediation is relegated away from the core action of medical education; consigned to manage the ‘penalty box’ where struggling learners are sent after committing * Correspondence: layne.bennion@usuhs.edu Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, academic ‘fouls’. Without avenues of two-way communi- Bethesda, MD 20814, USA cation between the remediation program and the larger Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bennion et al. BMC Medical Education (2018) 18:120 Page 2 of 10 educational program and without revising our view of re- that the above noted data points should be the sole identi- mediation as ‘fixing’ struggling learners, remediation will fiers of at-risk students. While these are known relation- remain, in our opinion, less effective and more costly to ships, to the best of our knowledge, no researchers have individual learners and to the school (see also [16]). combined known risk factors with concerning early per- Cleland and associates article [13] as well as others formance data in an effort to identify struggling learners have recently written about the disconnect between indi- at the beginning of their academic training. vidual remediation needs and the larger educational A second source for identifying struggling learners is system and have raised important associated questions. self-referral. Only a small percentage of students self- While Cleland and colleagues do offer some specific sug- refer to remediation resources. Combining 10 years of gestions, overall they highlighted more problems and data, Guerrasio et al. [21] found approximately 7% of points for discussion rather than providing specific solu- students were self-referred to a remediation program for tions. In this paper, we build upon their work and iden- medical students and professionals. Based on our experi- tify three common problems associated with the ences, many of these students tend to be high achievers disconnect between the larger medical education process whose drivers for self-referral include chronic anxiety and remediation and subsequently propose four recom- about their performance. Thus seeking assistance or re- mendations to minimize those problems. assurance is not a new behavior for them. In our view, there is little change needed at the system level for this Problem 1. Struggling learners—Can the system find them subset of struggling learners. early? A third source for identification of an at-risk student is There are four potential sources for identifying strug- through a more formal process led either by faculty gling learners: pre-matriculation and demographic data, (Ellaway et al. [14]) or an academic or competency review self-identification, student advancement or academic re- committee. Typically, committees review a student’ssitu- view committees, and the use of multiple-sourced, de- ation following a critical academic or performance failure tailed, across-time performance data (portfolios). and then make recommendations to the school’sleader- Many risk contributors have been studied and are ship regarding that particular student’s status within the known before the first day of medical school. Some of school. While there is little question that the students who those known risk factors are briefly reviewed below. are reviewed by such committees are ‘at-risk’ learners, this Ferguson, James and Madeley [17] in their meta-analysis action commonly occurs very late in the process. That is, of studies involving students attending UK medical remediation programs and experts sit by the “sidelines” schools found that (1) women slightly out-perform men, until there has been a significant failure or a series of fail- and (2) identification as an ethnic minority tends to be a ures by an individual student. These institutional-level slight disadvantage. More recently, Woolf, Potts & processes typically proceed slowly, are perceived as puni- McManus [18] found in their meta-analysis of UK phys- tive by students and are designed to capture those ician training, wide-spread differences between white students with the most serious academic or professional and non-white candidates. In addition, they found behavior problems, i.e., those who may be facing the pos- undergraduate grade point average (GPA) predicted only sibility of disenrollment. 23% of the variance in medical school grades, and learn- Stegers-Jager and colleagues [22] presented a different ing style (e.g., Kolb’s convergers or the tripartite model’s model from a Dutch medical school implemented re- deep and strategic) had weak correlations with academic cently which did include early identifications occurring performance (0.18 to 0.26). Donnon and associates’ [19] at 4, 7 and 12 months into the preclerkship studies. meta-analysis of Medical College Admissions Test Warnings were given at the 4- and 7-month time points, (MCAT) score’s’ predictive validity of medical school and academic probation was applied at 12-months. They performance found small to medium effect sizes (essen- did find more students participating in supportive ser- tially zero up to 0.4) for various measures of later per- vices under this model (than the previous process). They formance. Dyrbye et al. [20] found that students’ found those students participating in one-on-one re- “serious thought” of dropping out of medical school was mediation services were significantly more likely to satis- associated with demographic or event factors, e.g., being factorily complete their preclerkship studies. older in medical school (> 30 years old), having a child, As for longer-term functioning of students reviewed being in the 3rd year of medical school, and self- by an academic review committee, Durning et al. [23] identifying as an American Indian or Pacific Islander. As analyzed the performance of Post Graduate Year-1 anticipated, they also found greater risk of academic prob- (PGY1) residents comparing those who had been re- lems was associated with significant psychosocial stressors ferred for academic review to those who had not. They such as major personal illness, major illness in a signifi- found that being presented to the committee was associ- cant other, and divorce. No researchers have proposed ated with a higher risk of below average performance Bennion et al. BMC Medical Education (2018) 18:120 Page 3 of 10 during PGY-1. However, they also found that the overall activities. With a few notable exceptions (see below), lit- percentage of those students who interacted with the com- tle is available which dissects the procedure and, most mittee and had below average performance ratings during critically, details how to individualize remediation to internship was low. The authors noted the need for more meet the needs of a specific struggling learner. As noted research including: (a) the timing and intensity of remedi- by Winston [30] and others, simply teaching to pass the ation efforts and whether either is associated with higher next exam does not work in the longer-term for strug- risk for later performance problems and (b) looking at the gling learners. strength of the relationship with later performance compar- Over two thirds of medical school remediation pro- ing those students with primarily academic issues from grams make available services such as time management those with primarily professional problems. strategies, test taking techniques, note taking strategies, Similar to Kalet and colleagues [15, 24], we believe reviews of class exams, review of course content, model- that as a student is identified later into the curriculum, ing use of resources, and modeling problem-solving [31]. the higher the likelihood of that student presenting with As noted by Cleland and colleagues a most noticeable exhaustion, discouragement, and a lag in academic per- downside to the above practices can be summed up as a formance, which could have a potentially negative im- systemic view that quick and easy fixes have the ability pact on the student’s ability to modify or attempt to address the problem of struggling learners [13]. changes in their study process. Alternatively these generic services can ignore some of A fourth potential source for identification is the use of the individual contributors of a particular struggling multiple-sourced, across-time performance of students learner. Some medical schools address the needs of at- analyzed with the goal of early identification of struggling risk students by providing pre-matriculation programs learners. The notion of a learning or progress portfolio for focused on enhancing study-skills and/or tutoring to medical students is certainly not new (e.g., [25–28]. promote early exposure to and learning of the material. Portfolios can be used as to means to comprehensively Miller [32] described one such program which resulted collect available performance data including academics. in students modifying their anticipated study plan, but Recently, Kalet and Pusic [29] advocated use of a holistic unfortunately no data was presented related to actual and competency-based portfolio aggregating various academic outcomes. scores and ratings from multiple sources. This process is Remediation approaches applied in medical education currently in development at their program (New York research have been categorized into four models: ana- University School of Medicine). Unfortunately, few de- lytic, developmental, synthetic and competency-based tails were provided regarding the management and de- [33]. Unfortunately, such models have been found to ex- sign of this process. However, it is clear that the profile plain little of the outcome variance whether referring to metrics are available to the student and their mentor for clinical skills development, basic science knowledge or periodic review. One example table in their chapter professionalism [16, 34–37]. listed 21 specific content “buckets” for various perform- Winston [30] discussed an in-depth, year long, multi- ance metrics such as histology, pathology, pharmacology, pronged, intensive program for students repeating a etc. as well as displaying for each student their perform- portion of the curriculum involving regular faculty- ance as compared to their cohort for each content area facilitated, small group work with integration of study in a box-and-whisker format. This is an example of an skills and presented data indicating their success. Sayer individualized and very detailed tracking system for stu- et al. [38] described a small, reportedly successful pro- dents’ academic and professional performance and is in gram in a UK medical school specifically targeting concert with our intended meaning for portfolio. academic issues with lengthy one-on-one tutoring, a col- In Kalet and Pusic’s school, it appears such data re- laboratively designed remediation plan and a careful in- mains with the student and their mentor and is not used dividualized assessment process. by the larger system in identification of at-risk learners. An alternative approach is a listing of potential types Presumably, a student who consistently shows academic of learner deficits (“diagnoses”) such as difficulties in difficulties would be referred for additional assistance, fund of knowledge, clinical reasoning, history-taking, but when or how the system interacts with or uses indi- physical examination or professionalism [39]. Guerrasio viduals’ data in the portfolio is not clear. [11] adds the following additional remediation ‘diagno- ses’: time management and organizational skills, inter- Problem #2. Remediation—Which flavor works for which personal skills, communication, practice-based learning, student? system-based learning and mental well-being. Remediation, as a label, has been applied to a diverse set Beyond descriptive summaries and looking at scattered of processes including various skill-building presenta- outcome metrics, little research has focused on how to tions, tutoring, conceptual models, and one-on-one build an effective and individualized process to provide Bennion et al. BMC Medical Education (2018) 18:120 Page 4 of 10 successful remediation. Ascertaining what works and including strategic planning and motivational factors, (b) doesn’t work in remediation is difficult. Guerrasio [11] Performance involving metacognitive monitoring, self- has perhaps one of the most detailed and practical testing and self-control and (c) Self-Reflection about per- discussions based on their remediation process at formance such as causal attribution, self-evaluation and University of Colorado School of Medicine and she dili- satisfaction. These skills are intended for the application gently references many sources supportive of particular of immediate to longer-term work products. Notably, processes. Kalet and Chou [12] also document many this model is based on a solid foundation in educational practical aspects and viewpoints related to conducting research with data showing successful learning outcomes remediation with individual students. As these authors from multiple learning contexts and has been success- and others (e.g., [13, 40]) note most research on medical fully utilized in improving the diagnostic reasoning of education academic remediation is focused on a retake medical students [42]. of a failed examination and provides little basis for de- Fourth, rarely is there any formal assessment of the termining of what types of support are needed for which struggling learner, beyond an unstructured interview, to students or what type of remediation is most helpful. objectively measure their academic and cognitive Kalet, et al. [12] rightly note “as yet [there is] little evi- strengths and weakness. While many remediation pro- dence supporting how and why remediation in medical grams include an interview in their process, what is education works” (pg 24). meant by ‘an interview’, the degree of structure and A second complication in individualizing effective re- coverage for that interview and how that information is mediation is the varied background of staff who are used is a glaring hole. tasked to create or manage remediation programs. A A welcome exception is Yellin’s[43] work which dis- survey of 134 medical schools found that less than half cusses the issues associated with formal cognitive assess- of the staff who were responsible for remediation in ment, determining strengths and weaknesses and if medical schools had graduate degrees in education, testing supports it, applying diagnosis of learning disabil- learning or in enhancing individual behavioral change ities for medical students. He advocates for the use of [31]. Over one third of these staff members reportedly broad-based cognitive testing to ascertain struggling had no particular training nor prior experience in pro- medical students’ relative strengths and weaknesses viding academic support. Similar to above, this data sug- within six neurodevelopmental constructs (attention, gests remediation at the graduate level is a young field language, memory, temporal-sequential ordering, spatial with the added disadvantage of not having a solid basis ordering and higher-order cognition) to individualize the in theory or discipline. remediation plan. His process outlines the use of object- A third complication, as identified by Guerrasio [11], ive testing to create a cognitive profile used to help stu- Sayer et al. [38] and Mcloughlin [41] focuses on the nu- dents better understand their cognitive and learning merous contributors to academic difficulties. For a par- relative strengths and weaknesses. Based on the individ- ticular student, the number of contributors to academic ual profile, the remediation team develops a tailored struggles is typically multiple per struggling learner and learning plan or a “management by profile” plan. When many are related to the student’s background experi- testing is not utilized, some academic weaknesses may ences and/or to current vulnerabilities within their social not be recognized or addressed such as subtle reading and family settings. Thus, teaching specific skills, e.g., comprehension problems, a need for better writing skills time management or the notion of spaced learning, is or below average clinical reasoning skills [44]. A down- often an inadequate response for at least a portion of side to the above process is the high cost and time struggling students. Cleland and associates [13] also needed for formal assessment as well as a specialist (e.g., highlight the need to recognize pressures from institu- neuropsychologist) who is familiar with the necessary tional culture as well as individual student backgrounds. testing tools and, critically important, is willing to frame Durning and associates [33] take a different approach. an evaluation within the context of graduate medical Rather than attempting to match remediation strategies education (rather than simply using general population to a specific student or their learning difficulties, they or age-based norms). took an empirically and theory-based application of a At the individual student level, as Mcloughlin [41] and self-directed learning process which is generic to topic Yellin [43] noted many students use the same strategies and context and adapted it for struggling medical which produced success for them in their secondary and learners. This model, Self-Regulated Learning—Microan- post-secondary educational endeavors. When faced with alytic Assessment and Training (SRL-MAT), is a performance difficulties in medical school, these stu- problem-solving approach which functions as a three- dents often redouble their use of those same well-used phase cyclical loop and is applicable across learning situ- strategies. Finding a new strategy is time-intensive and ations. Specifically the three cycles are: (a) Forethought few medical students take the risk of potentially wasted Bennion et al. BMC Medical Education (2018) 18:120 Page 5 of 10 time in trying new strategies. Medical students, almost At the institutional level, few would find overt bias by definition, are highly successful learners across de- against students needing additional assistance. However, cades of learning and adaptation to many environments. there seems to be a subtle belief which may affect how For these students any serious academic problem, not to leaders and universities perceive remediation programs. mention consistent academic failures, is an unexpected Specifically, a view that students with early academic and foreign hardship which they have no experience difficulties will continue to struggle throughout their managing or learning from in productive ways. For the professional development, leading to a future of medi- student in the throes of early professional identity devel- ocre doctoring skills. For example, Cleland et al. [40] opment as a physician, serious academic problems can stated “weak medical students go on to become weak challenge their resiliency, motivation and career goals. doctors” and cited two references [53, 54]. Both of the Fifth, research which incorporates demographic and cited sources highlight professional behavior problems cultural differences as covariates beyond gender and age and/or communication problems between team mem- are lacking. There are many who advocate the need for bers. Neither source is focused on the relationship be- diversity and minority representation in the medical pro- tween early academic difficulties and later “poor” fessional [45–49]. Difficult issues such as communica- doctoring. For example, the first source, Papadakis and tion within cross-cultural supervision and mentoring of associates [53] concluded that low MCAT scores and medical trainees has been addressed [50]. Little if any at- low grades during the first two years of medical had tention is focused on any empirical remediation investi- “only ¼ the risk” of subsequent disciplinary action (as gations which also included broader diversity issues in compared to the risk faced by student with early profes- the medical literature. sional behavior problems). Based on the numbers Sixth, there is scant recognition in the remediation lit- Papadakis and colleagues presented, a student with an erature of the difficulties all learners face when attempt- academic failure of a medical course during the 1st or ing to change their well-learned and previously servable 2nd year of medical school, had only a 7% risk of subse- strategy. The most commonly used skills deficit model quent disciplinary action by state board. In contrast, in remediation asks students to change strategies and those with documentation of unprofessional behavior habits which have been personally effective for years and during medical school, had more than three times that successfully used for thousands of hours. Changing risk (26%) of subsequent disciplinary action by state deeply ingrained behaviors is difficult, stressful, and early board. In a similar study Papadakis [55] did not find aca- attempts can be easily abandoned before experiencing demic metrics (e.g., undergraduate GPA, lower quartile success with an alternative strategy. MCAT performance, not passing one or more medical A final consideration is acknowledgement that a school courses) were a significant predictor using logistic massive percentage of students are masterfully successful regression modeling of later professional behavior prob- in adapting to the challenges of graduate medical educa- lems. A statistically significant difference was noted be- tion. Unfortunately, almost nothing is known about how tween the undergraduate GPA of the group with later high performing versus ‘below average’ medical students disciplinary actions and other graduates (3.3 vs. 3.4), but adapt. Information regarding how ‘super’ learners in this is not a meaningful difference at the level of individ- medical school change, adapt and accomplish what they ual students nor was this variable a significant predictor do is lacking in the educational literature. Discovering in the logistic regression results. their successful adaptive strategies may add additional Similarly, a study of over 3000 Canadian physicians tools to the remediation process. found no statistically significant relationship between a score indicative of knowledge competency (score from a Problem 3. Stigma—It continues to interfere traditional written exam with 450 multiple choice ques- At the individual student level, most medical students are tions (MCQs)) and future patient complaints against the historically unacquainted with academic difficulties [13] physicians [56]. Guerassio [21] in a study of over 150 and are reluctant to come forward and ask for additional struggling learners spanning from undergraduate to assistance [41, 51, 52]. In addition, some students have a graduate medical education, found only professionalism bias in their perceptions of what causes these academic issues were a significant predictor of later probation, and problems. For example, Cleland and associates [40]found that medical knowledge was not a predictor. In Santen that 4th year medical students in a UK medical school and associate’s[57] study of students identified by stu- with below average performance tended to blame external dent academic promotions committee either through factors, believe that their most recent failure was an iso- academic issues or behavioral problems, approximately lated event and believe that faculty did not offer the ap- 4% of those students later had state medical board ac- propriate assistance (when in fact multiple messages to tions taken against them for unprofessional behavior. All aid these same students had been sent). of the students in their sample who had professional Bennion et al. BMC Medical Education (2018) 18:120 Page 6 of 10 behavior difficulties also had academic issues. Scrutiny Potential solutions of Santen’s published summary of their data suggests it Next we turn to potential solutions to deal with these is possible students who only had academic issues and challenges that face the medical education community. were not also identified as having behavioral problems, Here, we list four recommendations. were not later disciplined by state boards for unprofes- sional behavior (however, this is uncertain based on how Recommendation #1. Use systematically captured data, they presented their data). LaRochelle et al. [58] found across-time, multiple-sourced information with one of the evidence that pre-clerkship performance in clinical rea- goals being early identification of struggling learners soning (small group exercises, multiple choice examin- The concept of and use of portfolios in medical educa- ation focused on clinical reasoning and Objective tion is certainly not new. However, many uses of portfo- Structured Clinical Examination (OSCE) performance) lios cited in the medical education literature appears to did have small, but significant predictive value of resi- be a collection of student performance datum without dent ratings of medical expertise by faculty. organization into competency domains and without In addition, there are studies that suggest early aca- ways to represent growth over time within those compe- demic performance or even board examination scores tency domains. For example, Chertoff and associates are unrelated to other important non-knowledge-based [61] surveyed 71 Liaison Committee on Medical Educa- aspects of physician care. For example, Hojat et al. [59] tion (LCME) accredited medical school. Approximately found no relationship between scores on United States half reported use of portfolios, but less than 10% of total Medical Licensing Examination (USMLE) Step 1 exam- respondents noted they felt their portfolio process in- ination and empathy scores. No studies were found dir- cluded a visual display of competency growth. Other re- ectly linking early low academic performance (pre-med cent publications noting uses of portfolios are within school or pre-clerkship) as a primary or substantial con- particular modules or rotations, e.g., Sanchez Gomez tributor to later poor quality of doctor-patient relation- [62] or within particular aspects of training such as ships, diagnostic errors, treatment errors, or patient simulation centers [63]. While helpful, these do not pro- satisfaction. This view is perhaps the flip side of a long vide indications of overall growth or, in the case of re- tradition of high academic performance being the princi- mediation, lack of individual progress. pal gatekeeper for entry into certain specialties; aca- We advocate for the use of a portfolio as an across- demic performance is seen as a proxy for doctoring the-curriculum, integrated longitudinal assessment tool capacity or aptitude (see Prober et al. [60] for additional to guide and help the remediation process such as dis- discussion of the pros and cons of using Step exam cussed by Van Tartwijk et al. [64]. A comprehensive scores as primary selection variable of residents). portfolio includes an organizational schema such that An additional factor to be identified when considering various assessments are gathered from multiple sources the subtle institutional bias against remediation is that and placed into one or more general competency do- much of academic remediation literature borrows heavily main or “bucket” as labelled by Kalet’s group [29]. It al- from the universally familiar medical model, that is, find lows learner and teachers to support students’ learning the diagnosis and once the diagnosis is known, that diag- and closely assess students’ progression [65]. nosis ‘determines’ treatment. While this view obviously Specifically, we recommend a comprehensive portfolio has heuristic usefulness, the extent that this viewpoint of all performance data (knowledge-based, group per- should be extended to remediation of individual students formance, OSCE-type performance, written reports of is unclear. Given this model is steeped in the assumptions patient encounters, self-assessment of professional of disease, pathology processes and (body) system failures, growth, ratings or commentary of videotapes of leaning it is easy to imagine how, even if unintentionally, promo- interactions, etc.) be collected. Further that this collected tion of this view can carry negative assumptions. For ex- data be made available to the student as well as to se- ample, even if a student is identified as a struggling lected key individuals on the academic team (e.g., the re- learner, this does not necessarily mean that the student mediation team and those charged with tracking has a fundamental flaw or set of deficits that would nega- performance and with early identification of struggling tively impact that student’s functioning as a physician. learners). Importantly, we recommend that at least one Much of medical education support services, e.g., teaching reviewer of student portfolio data should be tasked with a specific and presumed missing skill, are based on the taking a longitudinal view of the learner’s progress par- above unstated assumption that the pace and rigor of ticularly within competency ‘buckets’ as discussed above. medical school exposes a pre-existing skills deficit. That That is, the longitudinal reviewer is not as concerned is, the student performed lower on an examination than with rating or grading a student performance related to expected, therefore the student has an academic or study current courses, but is to monitor, over time, for mar- skills deficit and/or a motivational problem. ginal performance within a competency area. Thus, Bennion et al. BMC Medical Education (2018) 18:120 Page 7 of 10 remediation is not just studying for the next exam, but large or may consider it a non-problem as only affects a also analyzing developmental patterns. Furthermore the small percentage of students and thus doesn’t need add- concept of portfolio-based monitoring and learning may itional funding or focus. In our view, this perspective is be particularly important in the remediation process [25, out-of-touch with the current directions and values of 27]. The use of a portfolio that contains a large amount medication education. of longitudinal information about learning interactions Acquiring large numbers of struggling learners to study and learners’ performance across settings and topical do- is difficult at the institutional level, but is less so if collab- mains. Thus, such information may be particularly use- orative multi-institutional studies are implemented. ful in developing and implementing remediation plans Implementation of work might involve consortiums across for some students which otherwise would have gone a small number of medical schools, shared development unrecognized. In addition, once such a longitudinal port- of performance portfolios, identification of similar per- folio process is put into place, the school could eventu- formance metrics, as well as integrating and analyzing ally analyze previous years of data to potential identify de-identified performance data across institutions. school-specific performance markers within early cur- In addition, many remediation programs appear to func- riculum experiences which, when paired with known tion as independent islands and offer services that are pre-matriculation risk factors, could help identify stu- based on the experience and skillsets of individual remedi- dents at risk for later serious academic problems. ation specialists. More coordination and sharing of ideas, The use of performance portfolio raises the concern of resources, and processes could help more remediation for- ‘forward-feeding’ performance problems to subsequent ward as well as generate data to answer hypothesis-driven faculty or clerkship directors. This has been debated in questions concerning optimum remediation methods. the literature [16, 24, 66–68]. Clearly there are privacy concerns and other issues to consider. Much of above dialogue centered upon who should have access to such Recommendation 3. Use of De-stigmatizing processes and information including clerkship directors and/or faculty language and discusses the potential for negative (and positive) The traditional ‘diagnosis➔treat’ view of remediation is biases. Our opinion is that there should exist a separ- problematic. No heuristic is perfect. But perhaps a better ation of the processes which determines official student model for conceptualizing struggling learners within status (typically a slow-moving, large group-based medical education is that of athletic conditioning for a process triggered by significant failure or string of fail- team of gymnasts or decathlon athletes. Each athlete has ures) and the remediation team (desirably a faster- years of experience, a history of many high-level perfor- moving, dynamic process). Ideally this latter team is a mances, but each athlete, each coach and the institution small group, is closer to ‘real time’ in its tracking of stu- understand qualification is at an individual level and dent performance and is skilled in its identification of must occur in a variety of skillsets or performances. struggling students. Its function falls within student ad- Every athlete experiences strong events and weak perfor- vocate services and it should engage early and often with mances. For these high-functioning athletes, condition- the struggling student. We strongly recommend those ing (or remediation) is not about discovering a involved in reviewing and using that data for early iden- pre-existing flaw. The foundation of conditioning is a tification of struggling learners be either separate from careful and detailed analysis of recent performances, iden- or not have a formal vote into procedures which deter- tification of relative strengths and weaknesses and then mine student status within the program. designing targeted exercises to enhance performance, ded- icated time to build up weaker skills as well as developing and practicing strategies for key performances. Recommendation 2. Encourage and fund research investigating We recommend reducing the use of terms such as re- the complex processes of medical education at the level of mediation, diagnosis, deficits, etc. A more useful articu- individual change including a variety of contributors lation may be using terms such as ‘not meeting a Directly assessing remediation is difficult. However, find- qualification standard’. While cumbersome, such phras- ing active change agents is critical. In medical research, ing suggests a student did not achieve their maximum we sensitively delve into individuals’ complex personal potential for a particular performance event rather than lives to probe aspects of cancer, diabetes, degenerative the implication that the student, as a holistic organism, diseases, etc. and compare treatment alternatives. is dysfunctional, incapable or lacks an essential skillset However, we are slower to apply similar rigor, energy which bars them from a success within the medical and funding to medical remediation. Critics may argue school context. academic difficulties during medical education is not a We are working with highly qualified and gifted stu- disease nor a pathology which affects the population at dents who are being stretched to their near maximum Bennion et al. BMC Medical Education (2018) 18:120 Page 8 of 10 capacity for years at a time. Thus, we recommend terms them as needed through their schooling via networks in- such as academic conditioning, performance coaching, ternal to the medical school. Making it known that cer- learning strengths and weaknesses (or cognitive and tain individuals within leadership and faculty of the learning profile), and adaptive strategies. Perhaps even medical school are willing to provide such testimonials terms such as “ath-learner” or “aca-lete” should be con- may encourage graduating students to do the same. sidered. While this last suggestion is somewhat tongue- In addition, brief messages from the current school in-cheek, the underlying notion detailed above is not. leadership supporting appropriate help-seeking by stu- We are not simply recommending a change in the label. dents being available within the same venue may be The recommendation is to move the culture away from helpful as well. Also, as part of school leadership terminology which inherently supports an assumption of messages, referencing studies noting the percentage of pathology and deficit and instead use language which medical students who do seek assistance can be a nor- recognizes: (a) there are complex factors impacting per- malizing factor. For example, Dyrbye and associates [71] formance and (b) these students are above average found approximately 40% of medical students annually learners operating in a very high-demand environment. seek out formal or informal supports. Third, we recommend applying the well-established medical model of consultation to academic issues and Recommendation 4. Encourage self-identification and normalize struggling learners. Again, leadership and supervisor help-seeking messaging is critical. That is, rather than telling students A one-time lecture simply reiterating above messages is with academic problems they are in need of an evalu- unlikely to provoke change in student’s help seeking be- ation to detect and diagnosis weakness and deficits, we havior (see [69] for example). Friedman and associates recommend referring to need for additional resources as [70] found, in their efforts to reduce de-stigmatizing atti- an academic consultation. As physicians, providers are tudes toward mental health usage, that a lecture-based expected to recognize when specialty care or evaluation format was perceived as patronizing by medical students. is needed particularly when standard treatments are not However, they did find that students were more recep- effective. Why should not a similar attitude be fostered tive to testimonials from individuals who were using from the beginning of their medical training? The mes- mental health-related services. In recent work, Cleland sage should be, “If you have adequately applied the rec- and colleagues [13] discussed the importance of the in- ommended ‘treatments’ to your studies and those are stitutional culture affecting help-seeking behavior and not effective, it is time to obtain a consultation!”. they offered a few specific suggestions, e.g., asking the There are, of course, limitations to our discussion and student their views of contributors to academic difficul- proposals. All of these issues are challenging and no so- ties, working in partnership with struggling learners, and lution will fit all situations or schools. Along with re- the staff role-modeling self-care. search investigating active ingredients of successful A useful option to normalize help seeking over time remediation, research into the links between remediated may be for medical schools to annually ask for volun- students and longer-term outcomes is needed. teers among graduating students and faculty to record brief personal audio or video ‘testimonials’ of healthy help-seeking options they utilized during medical school Conclusions (each volunteer choosing to specifically identify them- This position paper discusses some on-going problems selves or not). A brief suggested outline or reminders (e. within the field of medical education, identifying four g., list of common hurdles) might assist volunteers to ad- contemporary problems and proposing four recommen- dress known barriers, e.g., confidentiality, worries about dations to strengthen remediation efforts. Earlier identi- effect on career as a student, being reluctant to self- fication and assistance to learners “not meeting identify as having additional needs, etc. [71, 72]. It may qualification standards” has been discussed by many, but be appropriate to instruct the volunteers to not individu- is rarely implemented in a systematic manner. We rec- ally name less-than-helpful local individuals or providers. ommend the use of a professional performance portfolio Obviously, the volunteers would not be expected to dis- organized by competency domains and include tech- closure personal details of their difficulties, but are asked niques to show learner progress over time as a way of to provide only a generic reference to how stressors im- addressing this long-standing problem. Curriculum revi- pacted them personally while in medical school and then sion offers opportunities to incorporate programmatic focus on helpful options they experienced which helped approaches to remediation. Selecting or determining them not only manage, but succeed. These personalized what type of remediation is needed for a particular stu- help-seeking declarations could then be made electronic- dent is a Gordian knot. More emphasis, including multi- ally available to successive cohorts who could access institutional projects and research funding is needed. Bennion et al. BMC Medical Education (2018) 18:120 Page 9 of 10 Remediationasaneffort continuestobea seenasane- 11. Guerrasio J. Remediation of the struggling medical learner. Irwin PA: Association for Hospital. Med Educ. 2013;184. cessary evil within the larger mission of medical educa- 12. Kalet A, Chou CL, editors. Remediation in medical education. New York: tion as opposed to a program that strengthens and Springer; 2014. p. 367. conditions individual learners, and in turn the institu- 13. Cleland J, Cilliers F, van Schalkwyk S. The learning environment in remediation: a review. Clin Teach. 2018;15:13–8. tion and ultimately medical practice. Recommendations 14. Ellaway RH, Chou CL, Kalet AL. Situating remediation: accommodating success regarding language use and marketing of such pro- and failure in medical education systems. Acad Med. 2018;93(3):391–8. grams are given. 15. Kalet A, Chou CL, Ellaway RH. To fail is human: remediating remediation in medical education. Perspect Med Educ. 2017;6(6):418–24. Abbreviations 16. Frellsen SL, Baker EA, Papp KK, et al. Medical school policies regarding GPA: Grade Point Average; LCME: Liaison Committee on Medical Education; struggling medical students during the internal medicine clerkships: results MCAT: Medical College Admissions Test; MCQ: Multiple Choice Questions; of a national survey. Acad Med. 2008;83:876–81. OSCE: Objective Structured Clinical Examination; PGY1: Post Graduate Year 1; 17. Ferguson E, James D, Madeley L. Factors associated with success in medical SRL-MAT: Self-Regulated Learning—Microanalytic Assessment and Training; school: systematic review of the literature. BMJ. 2002;324:952–7. UK: United Kingdom; USMLE: United States Medical Licensing Examination; 18. Woolf K, Potts HWW, McManus IC. Ethnicity and academic performance in WFME: World Federation for Medical Education; WHO: World Health Organization UK trained doctors and medical students: systematic review and meta- analysis. BMJ. 2011;342:d901. 19. Donnon T, Paolucci EO, Violato C. The predictive validity of the MCAT for Disclaimer medical school performance and medical board licensing examinations: a The views expressed herein are those of the authors and not necessarily those meta-analysis of the published research. Acad Med. 2007;82:100–6. of the Department of Defense or other federal agencies. 20. Dyrbye LN, Thomas MR, Power DV, et al. Burnout and serious thoughts of dropping out of medical school: a multi-institutional study. Acad Med. 2010; Authors’ contributions 85:94–102. LB initial draft and corresponding author. SD, JL, MY, DS-G, BR, DT all contributed 21. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic editorial comments and review. All authors read and approved the final outcomes of medical students, residents, fellows, and attending physicians manuscript. referred to a remediation program, 2006–2012. Acad Med. 2014;89:352–8. 22. Stegers-Jager KM, Schotanus J, Splinter TAW, Themmen APN. Academic Ethics approval and consent to participate dismissal policy for medical students. Med Educ. 2011;45:987. Not applicable. 23. Durning SJ, Cohen DL, Cruess D, et al. Does student promotions committee appearance predict below-average performance during internship? A Competing interests seven-year study. Teach Learn Med. 2008;20:267–72. The authors declare that they have no competing interests. 24. Chou CL, Kalet A, Hauer KE. A research agenda for remediation in medical education. In: Kalet A, Chou CL, editors. Remediation in medical education: a mid-course correction. New York: Springer Hill; 2014. p. 339–48. Publisher’sNote 25. Snadden D, Thomas ML, Griffin EM, et al. Portfolio-based learning and Springer Nature remains neutral with regard to jurisdictional claims in published general practice vocational training. Med Educ. 1996;30:148–52. maps and institutional affiliations. 26. Driessen E, van Tartwijk J, Vermunt J, et al. Use of portfolios in early undergraduate medical training. Med Teach. 2003;25:18–23. Author details 27. Thomas DS, Snadden M. The use of portfolio learning in medical education. Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Med Teach. 1998;20:192–9. Bethesda, MD 20814, USA. University of Central Florida, 6850 Lake Nona 28. Challis MAMEE. Medical education guide no. 11 (revised): portfolio-based Blvd, Orlando, FL 32827, USA. learning and assessment in medical education. Med Teach. 1999;21:370–86. 29. 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BMC Medical EducationSpringer Journals

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