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Choosing Not to Learn: The Case of the Missing Students

Bella didn’t show up for her assigned clinics. Instead, without informing anyone, she joined her classmates in other clinics that were more interesting to her. Another time, Bella didn’t show up in any clinic at all (as confirmed by faculty). When Dr. Harvey confronted her on her attendance, she lied.

 Charles seemed to show interest in the specialty and engaged well with the patients. Then one day he didn’t show up at work. Afterwards, he emailed Dr. Harvey to explain that he had decided to self-study instead of see patients. Later, Dr. Harvey heard from an administrator that Charles had returned his hospital badge and submitted his feedback days before the usual end of the rotation date.

 On the last day of the rotation, Dr. Harvey held a meeting with the students. He wanted to understand why they were absent so frequently, seemed disinterested, and didn’t notify him of schedule changes.

 Bella said the greatest learning value came from seeing standardized patients and doing simulations, followed by attending lectures and tutorials. To her, seeing real patients had the lowest learning value. She further believed that observing faculty deal with ‘patient administrative matters', such as completing insurance forms, was not useful for her future career.

 Charles said he was focused on passing the summative exam at the end of the rotation. He saw attending patient clinics as optional.

 Dr. Harvey heard that these students had had numerous absences in other clinical rotations and in other hospitals throughout the year. But no one had explicitly addressed this with them before.

 One month later, Dr. Harvey received the end of rotation feedback from these students. They gave him and his rotation a failing grade.

 Despite Dr. Harvey’s best efforts, why did the students choose not to acquire the knowledge, skills, and attitudes of their chosen profession?

The students believed that seeing patients was less important than self-studying and doing simulations. Are they demonstrating internal motivation as per humanistic theories such as self-directed learning? Is this a repudiation of experience as the source of learning and development, as per Kolb’s theory? Or is this consistent with generational theories, reflecting a millennial preference shaped by online social interactions and alternative realities?

The students didn’t notify faculty when they switched and missed clinics on their own. Is this simply disrespect or irresponsibility? Or a keen awareness of power as noted by social learning theory? When the university creates the exam and determines who passes and who fails solely through grades, are the students simply acting rationally by focusing on these incentives? If so, then how would a university incentivize professionalism, or clinical competence?

Despite numerous absences, the students failed Dr. Harvey and his rotation. Is this arrogance? Is this revenge for Dr. Harvey explicitly addressing their lack of professionalism? Or is this a negative example of reflective and transformative learning models? Kruger and Dunning noted that in many domains, people who are unskilled overestimate their abilities: ‘Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it.’

Please comment on the case with your thoughts below:

  1. Why do YOU think Bella and Charles chose not to adhere to the clinical rotation structure?
  2. How do we reach those who choose not to learn in the way we choose to teach?

References

  1. Taylor DCM, Hamdy H. Adult learning theories: Implications for learning and teaching in medical education: AMEE Guide No. 83. Med Teach [Internet]. 2013 Nov [cited 2018 Apr 15];35(11):e1561–72. Available from: http://www.tandfonline.com/doi/full/10.3109/0142159X.2013.828153
  1. Kolb DA. Experiential learning: experience as the source of learning and development. Prentice Hall; 1984.
  1. Farnsworth V, Kleanthous I, Wenger-Trayner E. Communities of Practice as a Social Theory of Learning: a Conversation with Etienne Wenger. Br J Educ Stud [Internet]. 2016 Apr 2 [cited 2018 Apr 15];64(2):139–60. Available from: http://www.tandfonline.com/doi/full/10.1080/00071005.2015.1133799
  1. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol [Internet]. 1999 Dec;77(6):1121–34. Available from: http://psycnet.apa.org/doiLanding?doi=10.1037%2F0022-3514.77.6.1121
#HMIchat June 2018 - What are We Really Teaching? ...
Seriously? A Board game?

Comments 2

 
Gregg Wells on Wednesday, 04 July 2018 12:45
Some reasons for medical students' problematic approaches to learning

Ambrose's wonderful vignette illustrates many conflicts, tensions, and inconsistencies in medical education and, indeed, in medical practice. Ambrose highlights many of these problems with his insightful questions and comments. The professionalism lapses in the vignette are highly problematic. But what causes the out-of-bounds behaviors from students like lying, unexcused absences, and dereliction of duty toward patients and other medical professionals? Here are some thoughts.

1. Medical professionals need to continually train medical students about all aspects of professionalism for a wide variety of contexts. Examples of out-of-bounds behaviors should be abundant during training. Explanations must be thorough about why unacceptable behaviors are unacceptable and about why appropriate behaviors are appropriate and needful for patients and the medical environment. During discussions with their instructors, students should analyze the mainstreams of professionalism and explore the boundaries of professionalism with guidance from mentors. Students must internalize professionalism and will do so only by reflection and practice. With lots of practice, students will follow and be equipped to explain professional behaviors when unprofessional behaviors are tempting.

2. Alignment of diverse goals of medical education is difficult. For example, the preparation needed for a high score on a standardized exam can conflict with spending effort caring for patients. Students, rightly, perceive conflicts among their many goals and responsibilities. Medical professionals experience similar conflicts with performance goals. A patient needs one hour of consultation time, but throughput goals allocate only 15 minutes. Recognizing conflicts among goals is a start toward dealing with those conflicts. Some of what medical professionals discern as unprofessional behavior from students arises from students' attempts to navigate through conflicting goals of their education.

3. Specific behavior standards must be explicitly conveyed to the students before the educational experience starts. Dr. Harvey's waiting until the last day of the rotation to discuss his perceptions of problems is profoundly poor timing. He should have discussed expectations at the beginning of the rotation. Moreover, all phases of medical education should be training students with congruent practices of professionalism. Dr. Harvey's standards of professionalism should be congruent with the standards that are enforced throughout the medical curriculum. From day one of medical school, students must be trained in professionalism that is appropriate for every context that students will encounter. This training requires that basic science instructors and clinically-oriented instructors across all phases of medical education discuss and agree on context-appropriate professionalism. Conflicts might arise because medical professionals do not agree about the boundaries of professionalism. A training environment, however, needs to become internally consistent in its practice of and training about professionalism. Students will deal with nuances about the demands of professionalism throughout their careers.

4. Students have few options about learning methods and schedules as they progress through clinical training. Medical education might improve if more flexibility is offered and more customization is available to students. Is a tailored medical education compatible with licensing exams, residency, and independent practice? Medical education requires that every medical student take the same clerkships of the same durations regardless of the student's career plans. In contrast, a student might want to customize the student's learning during medical school. Reasons for standardized training are persuasive. For example, familiarity with a wide range of specialties helps the student understand clinical conditions that cross specialty boundaries and equips the student to communicate with all specialties. And a student must perform well on standardized exams that include the standard set of UME specialties. But more tailored education and assessment for a student with specific career goals, in principle, also can prepare a student for residency and independent practice. Scheduling clinical training currently is difficult without any attempt to tailor clinical experiences for a student. Customizing a student's training seems impossible with current resources. We can look ahead to advances in scheduling and communication technology that equip the clinical environment to tailor learning experiences for students.

5. A conflict that is problematic and unresolved in today's training environment is the student's (and resident's) need for education and practice with procedures versus a patient's need for expert, expeditious, and safe care. A student's learning in a care-delivery environment adds complexities to responsibilities of a health care team. High fidelity simulation can train students without risk to patients and without adding responsibilities to health care teams. Regrettably, the fidelity to reality currently is inadequate for training simulation. Simulation must reproduce for the learner all sensory experiences, cognitive and procedural challenges, and behavioral and communications responsibilities with all participants in health care, including patients and families. Star Trek holodecks are not yet available to simulate all medical conditions, environments, and personnel. But someday, simulation will reach this level of fidelity for students, residents, and independent physicians.

Ambrose's vignette reminds us that medical education contains weaknesses for learners, teachers, and patients. We who participate in medical education strive to identify weaknesses and move to strengthen them. Our efforts produce better outcomes for all who participate in medical education and health care delivery. And we will not grow weary as we travel into the bright future!

Ambrose's wonderful vignette illustrates many conflicts, tensions, and inconsistencies in medical education and, indeed, in medical practice. Ambrose highlights many of these problems with his insightful questions and comments. The professionalism lapses in the vignette are highly problematic. But what causes the out-of-bounds behaviors from students like lying, unexcused absences, and dereliction of duty toward patients and other medical professionals? Here are some thoughts. 1. Medical professionals need to continually train medical students about all aspects of professionalism for a wide variety of contexts. Examples of out-of-bounds behaviors should be abundant during training. Explanations must be thorough about why unacceptable behaviors are unacceptable and about why appropriate behaviors are appropriate and needful for patients and the medical environment. During discussions with their instructors, students should analyze the mainstreams of professionalism and explore the boundaries of professionalism with guidance from mentors. Students must internalize professionalism and will do so only by reflection and practice. With lots of practice, students will follow and be equipped to explain professional behaviors when unprofessional behaviors are tempting. 2. Alignment of diverse goals of medical education is difficult. For example, the preparation needed for a high score on a standardized exam can conflict with spending effort caring for patients. Students, rightly, perceive conflicts among their many goals and responsibilities. Medical professionals experience similar conflicts with performance goals. A patient needs one hour of consultation time, but throughput goals allocate only 15 minutes. Recognizing conflicts among goals is a start toward dealing with those conflicts. Some of what medical professionals discern as unprofessional behavior from students arises from students' attempts to navigate through conflicting goals of their education. 3. Specific behavior standards must be explicitly conveyed to the students before the educational experience starts. Dr. Harvey's waiting until the last day of the rotation to discuss his perceptions of problems is profoundly poor timing. He should have discussed expectations at the beginning of the rotation. Moreover, all phases of medical education should be training students with congruent practices of professionalism. Dr. Harvey's standards of professionalism should be congruent with the standards that are enforced throughout the medical curriculum. From day one of medical school, students must be trained in professionalism that is appropriate for every context that students will encounter. This training requires that basic science instructors and clinically-oriented instructors across all phases of medical education discuss and agree on context-appropriate professionalism. Conflicts might arise because medical professionals do not agree about the boundaries of professionalism. A training environment, however, needs to become internally consistent in its practice of and training about professionalism. Students will deal with nuances about the demands of professionalism throughout their careers. 4. Students have few options about learning methods and schedules as they progress through clinical training. Medical education might improve if more flexibility is offered and more customization is available to students. Is a tailored medical education compatible with licensing exams, residency, and independent practice? Medical education requires that every medical student take the same clerkships of the same durations regardless of the student's career plans. In contrast, a student might want to customize the student's learning during medical school. Reasons for standardized training are persuasive. For example, familiarity with a wide range of specialties helps the student understand clinical conditions that cross specialty boundaries and equips the student to communicate with all specialties. And a student must perform well on standardized exams that include the standard set of UME specialties. But more tailored education and assessment for a student with specific career goals, in principle, also can prepare a student for residency and independent practice. Scheduling clinical training currently is difficult without any attempt to tailor clinical experiences for a student. Customizing a student's training seems impossible with current resources. We can look ahead to advances in scheduling and communication technology that equip the clinical environment to tailor learning experiences for students. 5. A conflict that is problematic and unresolved in today's training environment is the student's (and resident's) need for education and practice with procedures versus a patient's need for expert, expeditious, and safe care. A student's learning in a care-delivery environment adds complexities to responsibilities of a health care team. High fidelity simulation can train students without risk to patients and without adding responsibilities to health care teams. Regrettably, the fidelity to reality currently is inadequate for training simulation. Simulation must reproduce for the learner all sensory experiences, cognitive and procedural challenges, and behavioral and communications responsibilities with all participants in health care, including patients and families. Star Trek holodecks are not yet available to simulate all medical conditions, environments, and personnel. But someday, simulation will reach this level of fidelity for students, residents, and independent physicians. Ambrose's vignette reminds us that medical education contains weaknesses for learners, teachers, and patients. We who participate in medical education strive to identify weaknesses and move to strengthen them. Our efforts produce better outcomes for all who participate in medical education and health care delivery. And we will not grow weary as we travel into the bright future!
C. Kim Stokes on Monday, 13 August 2018 20:35
Potentially problematic on both sides

This is a great and very realistic case scenario. Thank you for this! I think the problems could be two-fold. As for why the students behaved the way they did, they gave likely realistic (from their perspective) answers that I believe can be taken as face value. Yes, professionalism (something I am passionate about) would need to be better defined possibly for them. But here's the thing: even with a great professionalism definition and model, if the perception is that they could learn better in a different environment, something needs to be done about the teaching. What we don't get in this scenario development is how bedside or clinical teaching is being done. Trust me, many preceptors/bedside teachers today don't teach. They send learners to do menial tasks or are so rushed they don't give the learners time to be active participants in the learning. If I were the course director, I'd go spend time observing the persons doing the teaching and see if they are actually teaching. There's no better critical reasoning teaching tool than real life patients who don't fit textbook criteria for every disease process. If the students feel they can learn better out of clinic, then there may be a problem in the clinic. Something to consider anyway. (Sorry it took me so long to read this. I really enjoyed it!)

This is a great and very realistic case scenario. Thank you for this! I think the problems could be two-fold. As for why the students behaved the way they did, they gave likely realistic (from their perspective) answers that I believe can be taken as face value. Yes, professionalism (something I am passionate about) would need to be better defined possibly for them. But here's the thing: even with a great professionalism definition and model, if the perception is that they could learn better in a different environment, something needs to be done about the teaching. What we don't get in this scenario development is how bedside or clinical teaching is being done. Trust me, many preceptors/bedside teachers today don't teach. They send learners to do menial tasks or are so rushed they don't give the learners time to be active participants in the learning. If I were the course director, I'd go spend time observing the persons doing the teaching and see if they are actually teaching. There's no better critical reasoning teaching tool than real life patients who don't fit textbook criteria for every disease process. If the students feel they can learn better out of clinic, then there may be a problem in the clinic. Something to consider anyway. (Sorry it took me so long to read this. I really enjoyed it!)
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