[The following notes were generated by Michele Haight, PhD.]

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

Mental Health and the Struggling Learner

The goal of this presentation is to assist educators in understanding how mental health difficulties can interfere with student success, both academically and professionally, and provide strategies for preventing and remediating failures attributed to mental illness.

The challenging issue is how to work through when a learner has been identified as having a mental health issue and is struggling either academically or professionally in the curriculum.

Recognizing Mental Illness in the Struggling Learner

• As a population, physicians and medical students are under increasing stress that has been exacerbated by COVID, and they are experiencing high levels of occupational burnout, depression, and anxiety.
• Physicians and medical students are also poor at self-care, seeking assistance for themselves or colleagues, and assuming the patient role.
• Students who have had significant exposure to adverse childhood experiences (ACE) are significantly more likely to report a moderate to significant effect on their mental health compared to their peers.
• Students who come from other disadvantaged circumstances are more likely to experience ACE and might require more support.
• A significant number of medical students compared to other graduate level students develop mental health issues over the course of their training. This indicates that there is something about medical school training that predisposes students to some type of mental health issues.
• External stressors and not patient interactions are the primary drivers of medical school stress.
• There are observable signs and behaviors that might signal the onset of the conditions described in the DSM-5. Mood and anxiety disorders are the most common conditions in medical school. Substance-Related and Addictive Disorders are not uncommon in medical school.

Psychiatric Fitness-for-Duty (FFD): Ascertaining if someone is in a position to do the job with reasonable skill and safety, which might otherwise be impaired by illness or injury.

• Impairment: The inability to practice medicine with reasonable skill and safety as a result of illness or injury.
• Psychiatric illness includes substance use disorders (SUD).
• Consultation is often triggered by inappropriate or problematic behavior BUT these behaviors do not always result from disability or impairment from psychiatric illness.

Fundamental Questions:

• Does a psychiatric illness exist?
• If so, does that illness impair specific functions?
• To what degree do impaired functions impact job performance?
  (All three of the above need to be present before one is considered impaired.)
  Can functional impairment be mitigated to allow for successful job performance, and, if so, how?

Physicians as a population are not identical to the general population in terms of their cognitive abilities.

• Measures of the intellectual performance of medical students and physicians on standardized tests of intelligence historically have found that intellectual performance is approximately one to two standard deviations above the mean of the general public.
• 7%-10% of practicing physicians may be classified as impaired, and 16% may be classified as underperforming.
• Data on the impact of test-taking anxiety is weak, regardless of the assessment tool.
• Data regarding the impact of mental illness on academic performance is more robust for college and high school students, not medical students.
• In one study, physicians who were referred for competency (fitness-for-duty) evaluations scored lower than their colleagues, but not necessarily different than the general population.

Medical student cognitive norms are different than the general population.

• Medical students who are impaired may be functioning at the mean of a population-wide sample, but are impaired compared to physicians as a whole.
• Medical students don’t have to necessarily score at a level that is worse than the general population to be considered impaired when compared to their colleagues. This is an important consideration when thinking about accommodations and/or sending a student for cognitive assessments.

Mental Illness and Academic Performance

• There is insufficient, low-quality data to draw strong conclusions regarding the degree of impact specific mental illnesses have on medical student academic performance.
• We can infer from other populations that mental illness is likely to impact medical student academic performance for at least some students. The degree of impact remains an open question.

Mental Illness and Professionalism Impairment

• Most FFD evaluations are triggered by problematic behavior that occurs across specialties and demographics.
• The seeds of these behaviors are seen early in the course of one’s medical career.
• Personality disorders are significant contributors to maladaptive behaviors, but are much more difficult to diagnose.
• Studies suggest correlations between prior grades and test scores and professionalism scores and future disciplinary actions. (Cuddy et al. 2017, Papadakis et al., 2004, 2008) This is an indication that there might be the potential to intervene early.
• Research also suggests that students with flourishing mental health are less likely to commit even minor professional lapses.

At what point should a physician training program remove students or residents?

• Medical schools graduate 97% of matriculated students.
• Unprofessional behavior during medical school was associated with a threefold increase in subsequent disciplinary action by a medical board (Papadakis, 2005).
• Can we do something about this? Or should we be more judicious about those who we pass through the curriculum?

An Approach to Professionalism Remediation

• Responses to professionalism lapses need to be holistic and include mental health evaluations.
• Remediation goes beyond a mandated mental health evaluation.
• Consider what further efforts can be made to help students access these support and reverse this process?
• Appraise to what degree different services are mandated or enforced prior to having students return to the curriculum.
• Look at professionalism through a “just” culture, systems lens when considering remediation or discipline.
• Consider how we can reverse this.

In Summary:

• Mental health is a positive contributor to professionalism lapses and later misconduct.
• Treatment of SUD seems to be the mental illness most amenable to remediation.
• Depression and burnout are worth addressing. This may help with addressing and minimizing academic difficulties.
• Behavior change is hard, particularly for those with certain personality traits/disorders.
• Determining correlation versus causation is difficult in individual cases.
• No one knows how to do this really well.

[The following notes were generated by Michele Haight, PhD.]

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

The Off-Cycle Curriculum: Intention vs. Impact

Even though curricular change is a constant in undergraduate medical education (UME), the structure of medical education has not substantially evolved since the Flexner Report of 1910.

The 2020 Pandemic served as a catalyst for both chaos and change in UME.

Lessons Learned:

Increased interest in medical school

Increased and creative use of hybrid learning

Learning medicine takes a community (Learners felt isolated)

Struggling learners were allowed to progress (Implemented supports to advance struggling learners)

We are rebuilding our learners after the pandemic.  In this process, we need to continuously ask ourselves if we are building students on sand or on bedrock.

What is a decelerated curriculum?

• Deceleration is an alternative distribution of the preclinical courses that allows student to complete the first and second year curricula in three years.
• Deceleration may allow students to decompress their curriculum or repeat a course or courses in which they have deficiencies.
• Deceleration: Mandatory vs. Voluntary (based upon student, environment, and institution)

Considerations when placing a student on academic suspension:

• What happens when a student is placed on academic suspension?
• What resources does a student have access to while on an academic suspension that are provided by the institution?
• What expectations are placed on a student when they return from academic suspension? What are the expectations and accountability faculty, administrators, the institution?
• Are there any programs in place to track or check in with a student while on academic suspension? We must remember that the student has “failed” and is deeply feeling that sense of failure.
• What is the financial impact on the student who is placed on academic suspension?

Creating an Off-Cycle Program: To provide engagement to separated students to keep them connected to the institution.

Student Needs

1. Academic structure
2. Improvement of Knowledge Base
3. Improved Study Habits
4. Confidence Rebuilding

Implementation

1. ScholarRx (short bites of information)
2. Creation of Modules (post Module 30-40 item quiz)
3. Creation of a Book Club (all campuses; Make it Stick)
4. Bi-weekly small group advising with faculty
5. Monthly “authentic” small group sessions

As faculty, we need to consistently address the question of “Why am I here?” for our students in order to help them better understand how to create individual change from the inside out.

Small group interactions resulted in the creation of a strong support group for all of the off-cycle learners.

When the assessment supports that were implemented during the pandemic were removed, a new group of struggling students was identified. This prompted the following:

• Creation of an Off-Cycle Curriculum Council (OCC) to recommend candidates for the Off-Cycle curriculum.
• Provision of counseling for the candidates and review of the Off-Cycle curricular requirements: withdraw from basic science courses, stay enrolled in small credit courses to keep financial aid, fully audit all M1 courses, and engage in all labs.
• Clarification that the student makes the final decision to participate in the Off-Cycle curriculum and must agree to sign a contract.

Off-Cycle Accountability

• Off-cycle curriculum plan will be maintained in the permanent program record.
• Off-cycle students will be evaluated each term within the off-cycle curriculum plan.
• Off-cycle students must achieve an assessment average of 75% during each M1 term they are recapturing.
• Off-cycle students who fail to meet academic or professional standard while decelerated may be dismissed from the program.

Limitations of the Off-Cycle Curriculum:

• Lack of student motivation to extend medical school.
• Insufficient data on Off-Cycle student progress and outcomes.
• Lack of reliable and valid procedures for student outcomes and readiness prior to leaving the Off-Cycle curriculum.

Diagnosis of Deficiency

We make assumptions based on: MCAT scores, race/ethnicity, previous academic history, time management, study plan. We make decisions based on what we think we know.

Truth will determine the Real Impact: family issues, undiagnosed medical issues, undiagnosed disabilities, trauma, Nobody Ever Asked!!!!

Process for determining academic deficiency:

Deficiency in Assessments>Development of Remediation Strategy>Remediation with deliberate repetition, feedback and reflection>Reassessments>Reintegration into Regular Curriculum

OR

>Integration into the Off-Cycle Curriculum>Diagnosis of Deficiency

Considerations for creating a 5-year curriculum:

Identify at risk matriculants prior to first day of the first year of medical school based on the following:

• Learners’ discretion at understanding how they learn
• Socioeconomic status
• Mental Health concerns
• Non-Traditional Students

Potential external challenges: Accreditors, Institutional finances, Space accommodation

It is time to re-imagine remediation as Restructure, Integrated, Supplemental Education or RISE.

[The following notes were generated by Michele Haight, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To Infinity and Beyond: Expanding the Scope of Basic Sciences in Meeting Accreditation Standards” finished with its fifth seminar on Thursday, March 31, 2022, t

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

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

Remediation is facilitating a correction for trainees who started out on the journey toward becoming an excellent health professional but have moved off course.

Remediation is not kicking the “can” down the road; it’s kicking the “can’t” down the road.

Definitions and Framing

For learners, there are four different zones of performance with different rules, roles, responsibilities, and thresholds for movement between zones.

Zone 1: Performance above-expected level…no corrective action

Zone 2: Performance below expected level…corrective action

Zone 3: Performance below acceptable level…remediation

Zone 4: Performance below unacceptable level…exclusion

The learners’ trajectory in each of these zones is not wholly linear. However, for learners in Zone 4, their progression and performance over time can be a steep downward slope.

Failing learners is a multi-tiered decision that involves many participants. Failing to fail learners is an ongoing issue across the health professions that impacts health professions’ social duty and responsibility.

Steps of Remediation

There are five steps to remediation:

1. Identification
2. Set clear expectations.
3. Decrease cognitive load.
4. Create fair assessments.
5. Engage in early identification.
6. Clarification
7. Identify learner-specific contributors to suboptimal performance. Can be assessed through discussion with the learner and requires trust and rapport to be built.
8. Identify systems-level contributors to suboptimal performance. Can be assessed through discussion with the learner and requires trust and rapport to be built.
9. Identify competency area deficiencies requiring remediation. Can be assessed by acquiring multi-source feedback on the learner’s performance.

         Remember, an identified concern/contributor is merely the tip of the iceberg.

3. Collaborating on a learning plan
4. Foster a feedback culture toward expertise development.
5. Involve students throughout the process.
6. Emphasize metacognitive skills.
7. Develop faculty to highlight best teaching practices.
8. Align explicit/tacit curriculum with valid, reliable assessments.
9. Provide ongoing formative feedback.

Define “SMART” goals and meaningful assessment methods at the beginning.

Document the remediation plan and determine who gets a copy and how progress will be assessed.

4. Intervention
5. Include activities that promote reflection, self-regulation, and a growth mindset.
6. Provide consistent coaching and feedback.
7. Avoid information overload.
8. Provide ongoing formative feedback.

Systems Intervention

5. Programmatic Assessment
6. Identify measurements of academic success.
7. Create a timeline.
8. Weigh the possible effects on the learner as an individual and as a member of a learning cohort.
9. Appraise systems-level contributors to the suboptimal performance (e.g., implicit bias, stereotyping, toxic learning environment, patient load, etc.).
10. Provide ongoing formative feedback.

Recommendations:

1. Do not do this alone! Develop the following educator groups for support:
2. Frontline faculty.
3. Expert remediation coaches.
4. Ultimate arbiters who can make defensible, ethical judgments based on a portfolio of imperfect, mixed source data.

Remediation is getting someone back on track by helping our learners and doing our societal duty.