Is there a way for clinical teachers to assist struggling learners? A synthetic review of the literature

Figures & data

Figure 1 Flow diagram for article inclusion.

Table 1 Suggested approach to struggling learners

Subjective: Detecting a problem based on a subjective impression

• Clinical teachers should trust their impressions.

• Doubts should prompt further observation and documentation.

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

Objective: Gathering and documenting objective data

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

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

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

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

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

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

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

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

Plan: Planning a targeted remediation

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

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

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

Abbreviations: EPAs, “entrustable” professional activities.

Table 2 A synthesis of classification systems of underperformance in medical education

Cognitive causes	Insufficient knowledge^Citation7,Citation17,Citation18,Citation20,Citation22,Citation34,Citation35,Citation53^–^Citation56,Citation58	Insufficient investment in studies^Citation17^–^Citation19,Citation34 Learning disorders^Citation17,Citation18,Citation22,Citation34,Citation35,Citation54,Citation56 Organization related difficulties^Citation19,Citation20,Citation34,Citation51,Citation52,Citation54
	Clinical reasoning^Citation7,Citation18,Citation34,Citation71	Insufficient knowledge^Citation20,Citation34 Difficulty organizing information^Citation34,Citation51,Citation55,Citation56 Clinical reasoning difficulties^Citation71
Noncognitive causes	Attitude problems^Citation7,Citation18,Citation20,Citation22,Citation35,Citation52,Citation53,Citation57	Ignorance of professional responsibilities^Citation20 Different values and beliefs^Citation17,Citation18,Citation34,Citation55 Poor insight and self-regulation^Citation18,Citation22 Poor social skills^Citation7,Citation19,Citation22,Citation52,Citation56 Insufficient motivation^Citation22,Citation52^–^Citation56 Conflicts in the workplace^Citation34,Citation35,Citation54,Citation58
	Affective problems^Citation7,Citation17,Citation19,Citation34,Citation53	Anxiodepressive mood disorders^Citation17,Citation19,Citation20,Citation34,Citation35,Citation51^–^Citation55 Other mental health issues^Citation19,Citation20,Citation22,Citation35,Citation56,Citation58 Substance abuse^Citation17,Citation19,Citation20,Citation22,Citation34,Citation35,Citation56,Citation58 Stress (family, personal, relational)^Citation34,Citation35,Citation52^–^Citation54,Citation58

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