"문제"학생: 이 문제는 누구의 문제인가? AMEE Guide No.76

"문제"학생: 이 문제는 누구의 문제인가? AMEE Guide No.76

The ‘‘problem’’ learner: Whose problem is it? AMEE Guide No. 76

YVONNE STEINERT

McGill University, Canada

Introduction

이 가이드는 문제학생들을 대처하는 방법에 대한 프레임워크를 제시하고자 한다.

Clinical teachers often work with students or residents whom they perceive as a “problem”. For some, it is a knowledge deficit that first alerts them to a problem; for others it is an attitudinal problem or distressing behaviour (Steinert & Levitt 1993). And in some cases, it is difficult to know if the learner is, indeed, presenting with a problem. The goal of this Guide is to outline a framework for working with “problem” learners, which includes strategies for identifying and defining learners’ problems, designing and implementing appropriate interventions, and assuring due process. The potential stress of medical school and residency training will also be addressed, as will a number of prevention strategies. Although some of the issues involved in teaching students and residents may differ (e.g. length of exposure to the learner; available methods of assessment), the principles for working with “problem” learners remain the same. Moreover, although many of the examples in the Guide come from working with students and residents in medical specialties, the approaches apply to learners in all of the health professions (e.g. Clark et al. 2008). Identifying learners’ problems early – and providing guidance from the outset – can be an important investment in the training and development of future health professionals. It is hoped that this Guide, based on experiences in working with students and residents (Steinert & Levitt 1993; Steinert 2008) will be of help to clinical teachers, program directors, and faculty developers.

정의 Definitions

다양한 용어가 사용된 바 있다. ABIM에서는 "문제 레지던트"를 "윗사람 - 대체로 프로그램 관리자나 수석전공의 - 으로부터 인터벤션이 필요할 정도로 중대한 문제를 일으킨 전공의"라고 정의하고 있다. 다른 연구자는 "정동적, 인지적, 구조적, 대인관계적 어려움으로 인해서 학업 수행능력이 크게 떨어지는 사람"이라고 정의한 바 있으며, 정서적 스트레스나 물질 남용으로 인한 이차적 손상으로 인한 문제를 지적하기도 한다. 본 가이드에서는 "지식, 태도, 술기의 중대한 문제로 인해서 훈련 프로그램의 기대치를 충족시키지 못하는 학생/레지던트"라고 정의하고자 함.

A variety of terms have been used to describe the “problem” learner: the “resident in difficulty”; the “troublesome learner”; the “disruptive student”; and the “impaired physician” (Shapiro et al. 1987; Grams et al. 1992; Gordon 1993; Steinert et al. 2001; Yao & Wright 2001). The American Board of Internal Medicine (1999) has defined a “problem resident” as a “trainee who demonstrates a significant enough problem that requires intervention by someone of authority, usually the program director or chief resident”, whereas Vaughn et al. (1998) have provided the following definition: “a learner whose academic performance is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty”. The term has also been used to refer to impairment, secondary to emotional stress or substance abuse (Grams et al. 1992). This Guide will define a “problem” learner as a student or resident who does not meet the expectations of the training program because of a significant problem with knowledge, attitudes or skills (Steinert 2008).

유병률 Prevalence

Prevalence를 보고한 연구는 적지만 적게는 5.8%에서 9.1%까지 있다. 한 연구에 따르면 가장 흔한 문제는 '불충분한 의학지식', '부족한 임상판단', '비효율적 시간사용' 등이다. 

Studies reporting the prevalence of “problem” learners are limited (Roback & Crowder 1989; Yao & Wright 2000; Reamy & Harman 2006). However, reported rates vary from 5.8% over a four-year period in a Psychiatry program (Yao & Wright 2000) to 9.1% over a 25-year period in a Family Medicine program (Reamy & Harman 2006). In one study (Yao & Wright 2000), the most frequent problems identified by teachers were: insufficient medical knowledge (48%); poor clinical judgment (44%); and inefficient use of time (44%). In another study (Reamy & Harman 2006), insufficient knowledge and attitudinal problems were identified as the most common challenges, followed by interpersonal conflict, psychiatric illness, family stress and substance abuse. Not surprisingly, “problem” residents rarely identify themselves (Yao & Wright 2000).

중요하게 기억해야 할 사실 중 하나는, '문제학생'을 다룰 때 우리는 흔히 선생으로서 선입견을 갖기 쉽지만, 대부분의 학습자는 강한 학업수행능력과 높은 성공 동기를 가지고 있다는 사실이다. 또한 Brenner et al은 "대부분의 지원자는 졸업할 때까지 별다른 간섭이 필요 없는 성공적인 레지던트가 될 것이다. 이들은 그 길을 가는 동안 평균적인 정도의 어려움을 겪을 것이다"라고 했다. 그러나 문제학생의 존재는 프로그램 전체에 영향을 줄 수 있다. 왜냐하면 이들에 대한 모니터링, 상담, remediation등이 프로그램과 교수의 자원을 잡아먹기 때문이다. 일부 교육자들은 '문제학생'의 존재가 프로그램 전체의 integrity를 손상시키거나, 동료들의 경험에 악영향을 줄 것을 우려한다.

It is also important to remember that, although working with “problem” students or residents can easily color our perceptions as teachers, the majority of learners demonstrate strong academic performance and high motivations to succeed (Hays et al. 2011). Moreover, as Brenner et al. (2010) have stated, “most applicants will become successful residents who progress without interruption towards graduation, facing only the usual stumbles of normal professional development along the way”. However, the presence of a “problem” learner can significantly affect an entire program (Brenner et al. 2010), as increased monitoring, counseling, or remediation may tax the resources of both the program and the faculty. Some educators also fear that the presence of a “problem” learner may damage the integrity of the training program or negatively influence the experience of peers (Yao & Wright 2001).

선생으로서 우리는 어떤 학생이 이러한 '문제아'가 될 것인가를 알고 싶어 한다. 미리 안다면 회피할 수 있기 때문이다. 그러나 지금까지 여러 연구에서 의과대학/레지던트 지원자를 screen하거나 예측하는 용도로 신뢰할 수 있는 요인은 밝혀진 바 없다.

As teachers, we often wonder if it is possible to predict who will become a “problem” learner, hoping that we can avoid some of the anguish that is related to this educational experience. To date, however, studies have not been able to isolate factors that we can reliably use to either screen applicants to medical school/residency or predict future problems (Dubovsky et al. 2005; Brenner et al. 2010).

증상과 증후 “Signs and symptoms”

학습자가 어려움에 있음을 보여주는 다양한 종류의 증상이 잇다. 

A range of “signs” may suggest that a learner is in difficulty (Evans & Brown 2010; Evans et al. 2010). These signs include 

• failing a written or practical test; 
• poor (or late) attendance at regularly scheduled events; 
• inadequate knowledge or clinical skills that are inconsistent with stage of training; 
• unprofessional behaviors with patients or peers; 
• poor interpersonal skills; 
• a lack of insight; 
• anxiety; 
• depression or reluctance to become part of the team. 
• A lack of professional behavior is also a common indicator (Bennett et al. 2005; Greenburg et al. 2007). 

Hay등은 전형적인 문제로 학습기술의 부족, 조직 기술의 부족, 정신건강 악화, 미성숙함, Insight 부족, 개인적 위기 등을 언급한다.

In an exploratory study, Hays et al. (2011) developed a framework of “typical” problems that included poor learning skills, poor organizational skills, poor mental health, immaturity, poor insight and major personal crises. Interestingly, a lack of insight has been identified as one of the most difficult problems to address.

학습자들이 다양한 요인의 결과로서 어려움을 겪을 수 있다는 것을 알아야 한다.

It is also important to note that learners can encounter difficulty as a result of many factors, including exhaustion and fear of failing, substance abuse, illness, family and personal issues or academic challenges (Bennett & O’Donovan 2001; Tyssen & Vaglum 2002; Evans & Brown 2010). Mental and physical illnesses, as well as learning disabilities, are relatively common in the general population; not surprisingly, they frequently occur among medical students and residents as well (Frank-Josephson & Scott 1997; Faigel 1998; Dyrbye et al. 2005; Midtgaard et al. 2008).

문제학생을 다루기 위한 프레임워크 A framework for working with “problem” learners

Although different approaches to working with problem learners exist in the literature (e.g. Shapiro et al. 1987; Gordon 1993; Vaughn et al. 1998; Kahn 2001; Mitchell et al. 2005), the following framework, which has been described previously (e.g. Steinert & Levitt 1993; Steinert 2008) and is outlined in Table 1, has been found to be helpful to clinical teachers and program directors.

직관에서 문제 파악까지 

From intuition to problem identification

학생이나 전공의의 문제를 정의하는 것은 여러 단계를 거치게 되며, 무언가 이상하다는 직관이나 느낌에서 시작되는 경우가 많다. 

Defining a student's or resident's problem usually involves several steps (Steinert & Levitt 1993), beginning with a hunch or intuition that something is amiss. This intuition may come from the direct observation of a learner with a patient or repeated interactions in both formal and informal settings. When teachers (or primary supervisors) first suspect a problem, they should ask themselves three initial questions in order to verify their suspicion: What is the problem? Whose problem is it? Is it a problem that must be changed? Answering these questions will help to determine whether the learner actually has a problem, what it might be, and whether something needs to be done. By going through this process, teachers will also be able to develop a working hypothesis that they can later confirm with the learner and other colleagues.

문제가 무엇인가? What is the problem?

우리의 경험상, 학습자의 문제는 대체로 지식, 태도, 술기 중 하나의 범주에 들어간다. 

In our experience, learners’ problems usually lie in one of three areas: knowledge, attitudes or skills (Steinert 2008). 

• Knowledge problems, sometimes called cognitive difficulties (Hicks et al. 2005), often include deficiencies in basic or clinical sciences. Attitude problems (often manifested as behaviors) usually include difficulties related to motivation, insight, doctor-patient relations or self-assessment. 
• For many, attitude problems are easy to identify but challenging to resolve. 
• Skill deficits can include problems with interpretation of information, interpersonal or technical skills or clinical judgment and organization of work. More importantly, there is often an overlap between skill deficits and attitudinal problems (Steinert & Levitt 1993). (...)

누구의 문제인가? Whose problem is it?

문제가 어디 있는지를 찾아내는 것은 문제 정의 단계에서 가장 어려운 것 중 하나다. 우리의 경험에 따르면, 교사들은 주로 학생들한테 문제가 있다고 생각한다. 그러나 문제는 교사나 시스템에 있을 수도 있다.

Determining where the problem lies may be one of the most challenging aspects of problem definition. Based on our experience, it appears that teachers often assume that it is the learner who has the problem. However, difficulties may also lie with the teacher or the system.

교사의 문제 Teachers’ issues

교사는 다양한 역할을 하고 있으며, 스스로 원하는 수준만큼 역할을 다해내지 못한 이유로 학생이나 레지던트에게 '문제아' 딱지를 붙일 수도 있다. 모든 경우에 교사들은 확인된 문제를 위해서 스스로 어떤 기여를 하고 있는가를 분석해봐야 한다. 예컨대, 교사들은 단순히 개인적으로 스트레스를 받거나 교사 역할에 불만족스럽기 때문에 - 학생이 문제학생이 아님에도 - '문제아'라는 딱지를 붙이곤 한다.

Teachers play many roles (Whitman & Schwenk 1997) and may label a student or resident as a “problem” because they cannot fulfill the role they wish to fill (Steinert & Levitt 1993). Teachers also enter educational situations with specific assumptions, expectations and experiences, all of which can lead to problems; so can the teachers’ own stresses or biases. At all times, teachers should try to carefully analyze to what extent they are contributing to the identified problem. For example, they may label a learner a “problem” because they are personally stressed or dissatisfied with their teaching role, not because the learner is “in trouble”.

문제학생을 다루는 것은 교사들에게 다양한 반응을 불러일으킨다. 보통 다음과 같다.

Working with “problem” learners also engenders a variety of reactions in teachers. Common responses reported by teachers include the following (Steinert 2008):

• Denial (Maybe he's just having a bad day …)
• Avoidance (I think I’ll schedule another clinic during my teaching session.)
• Desire to rescue or protect (If I work hard enough, I will be able to help her …)
• Anger/frustration (Oh no! Why do I always get the challenging residents?)
• Helplessness/impotence (It's so hard! We’ll never be able to do it.)
• Acceptance (Let's get on with it and design a good remediation!)

당연하지만, 교사의 감정은 학습자의 감정을 보여주는 거울이기도 하다. 따라서 개인의 반응을 확인하는 것은 유용한 평가도구가 될 수 있다.

Not surprisingly, teachers’ sentiments often mirror the learner's feelings. Identifying personal responses can, therefore, serve as a useful assessment tool.

학습자의 문제 Learners’ issues

학습자의 문제에는 다음과 같은 것들이 있을 수 있다.

In addition to gaps in knowledge, attitudes or skills (as described above), learners’ problems can include: 

• stress relating to training or career concerns; 
• life stresses, such as immigration, moving to another location, marriage or divorce; 
• medical or psychiatric illness; 
• substance abuse; 
• learning disabilities or interpersonal conflict. 

25%의 인턴은 약간의 우울함을 느끼며, 12.%의 주니어 의사는 알코올 남용을 하고 있다. 동시에 학습자의 기대/가정/반응이 문제 파악에 영향을 줄 수 있다. 추가적으로 학생이나 레지던트에게 '문제아'라는 딱지를 뭍이는 것도 중요한 영향력을 발휘하는데, 가급적 교사들은 어떤 딱지도 붙이지 말아야 한다. 장점보다 단점이 더 많다.

As an example, in one report, 25% of interns were mildly depressed and 12.5% of junior doctors were misusing alcohol (Lake & Ryan 2005). At the same time, learners’ expectations, assumptions, and reactions to the perceived problem (e.g. a sense of inadequacy or insecurity; anger or fear of losing control) may also contribute to problem identification. In addition, the process of labeling a student or resident as a “problem” can have a significant impact, and whenever possible, teachers should try to avoid all labels. They may cause more harm than good.

시스템의 문제 Systems’ issues

시스템의 문제는 보통 찾아내기가 쉽지 않을 수 있다. 

Systems problems, which are often difficult to identify, can include unclear standards and responsibilities beyond perceived levels of competence, an overwhelming workload, inconsistency in teaching or supervision, or a lack of feedback or assessment (Steinert & Levitt 1993). Learners will often report that they do not receive feedback from their supervisors on a routine basis or that their summative assessment is a “surprise,” while teachers will say that they did not have enough time to observe performance. Clearly, this challenge lies with the educational system and not the learner. Other systems’ issues include reduced clinical exposure, fragmentation of clinical teams (Evans et al. 2010), conflicting demands or expectations, and difficult patient problems. In multiple ways, identifying systems’ constraints is critical in defining the problem and designing an appropriate intervention. At the same time, teachers must feel supported by the system and know that they have access to resources when dealing with challenging situations.

반드시 바뀌어야 하는 문제인가? Is it a problem that must be changed?

학습자와 학습자의 동료들과 대화를 나누기 전에,교사들은 과연 그 문제가 반드시 해결되어야 하는 문제인지, 그리고 더 중요하게는, 만약 해결되지 않는다면 무슨 일이 생길지 생각해봐야 한다. 많은 교사들인 학습자들이 기쁘고 협력적이기를 바라나 이러한 기대는 현실적이지 않으며, 교사들은 어떤 행동이 자신들의 목적이나 가정에 위배되기 때문에 '문제'라고 바라보지는 않았는지 스스로 물어야 한다. 동시에, 초기에 문제를 발견하는 것이 중요한데, Evans et al은 "어려움에 빠진 학습자가 발견되더라도, 이들은 보통 큰 문제가 생기기 전까지는 방치되곤 한다"라고 했다. 가능하다면 이러한 '큰 문제'를 피해나가야 한다.

Before talking to the learner and other colleagues, a critical next step, teachers should ask themselves whether a particular problem must be changed, and more importantly, what would happen if it was not addressed (Steinert 2008). Although many teachers would like their learners to be happy, pleasant and cooperative (Steinert & Levitt 1993), this expectation is not realistic, and teachers must ask themselves whether they have labeled specific behaviors as problematic because they interfere with their own objectives or assumptions. It is not surprising for a teacher to realize that a suspected problem does not need to be addressed. At the same time, early identification is critical, for as Evans et al. (2010) have stated, “although learners in difficulty are often recognized, they frequently go unchallenged until a critical event occurs”. To the extent that is possible, we should try to avoid these critical events.

문제 발견에서 문제 정의까지 

From identification to problem definition

Once teachers have identified the problem(s) and considered their own role in the process, careful data-gathering is needed to confirm the teachers’ working hypothesis. This step includes a detailed description of the problem (e.g. when did it start; what makes it worse), the learner's perception of the problem, the learner's strengths and weaknesses in knowledge base, attitudes and skills (if not already identified), the learner's relevant life history (e.g. current life stresses; substance abuse; coping strategies), the teacher's perceived strengths and weaknesses, and colleagues’ perceptions, feelings, expectations and assumptions (Steinert 2008).

임상 교사들은 흔히 학생과 직접 이야기하는 것을 꺼린다. 일부는 그것은 자신들이 역할이 아니라고 느끼기 때문이며, 일부는 효과적으로 수행할 기술이 없기 때문에 오히려 벌집을 건드리는 격이 되는 것은 아닐지 걱정하기 때문이다. 일부 교사들은 이미 너무 일이 많아서 그런 것을 할 여력이 없다고 하고, 어떤 사람들은 보복적 법률 소송을 당할 것을 걱정한다. 이러한 것과 무관하게, 다음과 같은 질문이 필요하다.

Importantly, clinical teachers are often reluctant to talk to the learner directly. Some believe that it is not their role to do so; others feel that they lack the skills to do so effectively or worry that they are opening a potential “can of worms” that will make things worse (Evans et al. 2010). Some teachers feel that they are already “overstretched” and cannot take the time to get involved, whereas others fear reprisal through legal action (Lake & Ryan 2005). Irrespective of these sentiments, however, a direct approach is needed as teachers work through the following questions:

문제가 무엇인가?

1. What is the problem?

지식인지 태도인지 술기인지. 문제를 개선시키거나 악화시키는 요인 뿐 아니라 관찰가능한 행동이나 패턴을 찾아보아야 함. 학습자가 가진 문제의 "functional inquiry"를 위해서 임상기술을 활용할 수도 있음.

Teachers need to ascertain a detailed description of the learner's problem(s) and must decide if it is primarily one of knowledge, attitude, or skill. They must also try to identify observable behaviors and patterns as well as factors that either alleviate – or exacerbate – the problem. In multiple ways, teachers should rely on their clinical skills in order to conduct a “functional inquiry” of the learner's problem(s).

문제에 대한 학습자의 생각은 어떠한가?

2. What is the learner's perception of the problem?

교사가 문제가 있을 것이라는 의심을 가졌을 때, 그것이 실제로 문제인가를 확인하기 위해서는 학생이나 레지던트와 이야기해볼 필요가 있다. 어떤 경우에 많은 교사들은 이 단계를 회피하려고 하지만, 학습자가 자신의 어려움과 강점, 동기와 가정에 대해 어떤 생각을 가졌는지를 알아보는 것은 중요하며, 필수적 첫 단계이다. 더 중요하게는 학습자 중심의 인터뷰가 문제에 대한 학습자의 인식, 문제의 역사와 관련된 요인, 개인적 요인 등을 밝혀줄 수도 있다. 이러한 면담이 그 자체로 인터벤션이 될 수 있음을 기억하는 것이 중요한데, 왜냐하면 일부 학습자들은 그들이 겪고 있는 문제에 대해서 이야기할 기회를 갖는 것 자체를 좋아할 것이며, 자신에게 관심을 가지고 지지해주려는 교사에 대해 감사할 것이기 때문이다.

Talking to the student or resident is the most important step in confirming the teacher's suspicion that there is, indeed, a problem. For some reason, many teachers try to avoid this step, but ascertaining the learner's perception of his/her difficulties and strengths, motivations and assumptions, as well as training and career objectives, are an essential first step. More specifically, a learner-centred interview may uncover the learner's perception of the problem (as well as its causes), the history of the problem and related factors (e.g. academic difficulties) and personal factors (Evans & Brown 2010). It is also important to remember that such an interview can be considered an intervention in itself, as some learners welcome the opportunity to talk about what is troubling them and appreciate the teacher's support and interest in helping them from the outset.

자신의 강점과 약점에 대해서 어떻게 생각하는가?

3. What are the learner's perceived strengths and weaknesses?

학습자와의 대화는 학습자의 장점과 개선이 필요한 부분에 대한 철저한 평가가 필요하다. 그러나 안타깝게도 교사들은 부족한 부분을 찾아가는 식의 접근법에 의존한다. 대신 학습자의 강점과 개인적 자질에 대한 평가가 필요하다.

The discussion with the learner should include a thorough assessment of his or her strengths and areas for improvement in knowledge, attitudes and skills. Unfortunately, teachers often rely upon a deficit-based approach to teaching and learning; instead, an appreciation of the learner's strengths and personal qualities is needed. This information may also be gleaned by observing the learner in multiple situations (and different electives or rotations) or talking to colleagues and other members of the health care team. As described above, learners may struggle for a number of reasons. It behooves us to explore these issues together with the student or resident – and to draw upon our clinical skills in the assessment process.

학습자의 관련 과거 경험은 무엇이 있는가?

4. What is the learner's relevant life history?

비록 교사들은 '개인적'질문을 함으로서 도를 넘을 수 있다는 걱정을 하기도 하지만, 이러한 벙보가 진단을 내리고 적절한 개입 계획을 결정하는데 필요하다. Yao와 Wright는 학습자의 낮은 수행능력은 다음의 것과 관련되어 있을 수 있다고 했다.

Teachers often ask themselves how much – and what kind of – information they should gather. In fairness to the learner and the teacher's ability to make an accurate diagnosis and treatment plan (Steinert & Levitt 1993), teachers should inquire about current life stresses, recurrent problems and support systems. It is also important to inquire whether the learner has experienced similar problems in the past or whether this is a new challenge for him/her. As an example, a student with a learning disability is often aware of this problem long before the teacher has made the diagnosis. Although teachers are often concerned that they may be crossing a boundary by asking “personal” questions, this information is needed to make a diagnosis and to determine an appropriate intervention plan. Yao and Wright (2001) have suggested that a learner's poor performance may be related to one of the following causes: 

• behavioral issues, such as those related to professionalism; 
• medical conditions, including psychiatric illness; 
• difficulty coping with stress; 
• substance abuse and cognitive issues, including learning disabilities. 

Mitchell et al은 "레지던트의 수행능력을 수행능력에 영향을 미치는 배경요인에 대한 이해 없이 이해하려고 하는 것은 개별 환자와 그 환자가 처한 상황에 대한 이해 없이 특정 치료방침에만 매달리는 것과 같다"

This classification may be helpful in guiding this line of questioning. As Mitchell et al. (2005) have stated, “attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment”.

교사와 시스템의 강점 및 약점은 무엇인가?

5. What are the teacher's – and the system's – perceived strengths and weaknesses?

Cleland et al은 의학교육자들이 학생들의 underpeformance를 보고하기 꺼려하는 것을 보여준 바 있다.

As stated earlier, the problem may lie with the teacher and/or the system. It is therefore important to ascertain the teachers’ own strengths (and areas for improvement) in knowledge, attitudes and skills, as well as his/her current life stresses and challenges. In an interesting study, Cleland et al. (2008) explored the reluctance of medical educators to report underperformance in students. In multiple ways, their findings, which included teachers’ attitudes towards a specific student (as well as failing students in general), normative beliefs and motivations, skills and knowledge, and environmental constraints, are all relevant in this context. We must also be aware of the potential role that the system can play in contributing to a “problem” situation. As stated earlier, it is worthwhile to identify systems issues so that we can try to minimize their influence as a contributing factor to the learner's problem.

그 학습자의 동료들은 어떻게 바라보고 있는가?

6. How do colleagues perceive the learner?

(...)

자료를 효과적으로 모으기 위해서는 임상 교사들은 다양한 상황에서 학습자를 관찰해야 하며, 환자의 문제를 학생/레지던트의 문제와 함께 보아야 하고, 그들의 평가가 동료들의 평가와 일치하는지도 확인해보아야 한다. 공식적 시험 결과도 도움이 될 수 있으며, 다른 로테이션에서의 피드백도 도움이 될 수 있다. 그러나 학습자를 직접 관찰하는 것, 그리고 직접 이야기해 보는 것의 중요성을 간과해서는 안되며 Yao와 Wright가 보고한 바와 같이, 문제는 보통 '직접 관찰' 또는 '결정적 사건'을 통해서 드러나기 때문이다.

To gather data effectively, clinical teachers need to observe learners in multiple situations, systematically review patients’ problems with students and residents, and work to ensure that their assessments are congruent with those of their colleagues (Steinert & Levitt 1993). Formal test results may also be helpful (Evans et al. 2010), and when appropriate, so is feedback from other rotations. However, the importance of direct observation and talking to the learner cannot be undermined. As noted by Yao and Wright (2001), problems are most often identified through direct observation (82%) and critical incidents (52%).

From definition to intervention

어떤 문제들은 긴급한 조치가 필요할 수 있고, 어떤 것은 시간이 더 필요할 수도 있다. 앞에서 기술한 바와 같이, 학습자를 모든 단계에 포함시키는 것이 중요하며, 계획이 무엇이든 인터벤션은 학습자의 well-being에 대한 진지한 관심을 가지고, 환자와 환자 가족의 안전을 고려하여 진행되어야 한다.

Once a working diagnosis has been established, teachers must design an appropriate intervention. This step includes a consideration of the problem(s) to be addressed, the available intervention options, who should be involved in the intervention, the proposed timeline for both the intervention and the evaluation of outcomes, and the process for documentation. Some problems (e.g. psychiatric illness; substance abuse) will require urgent attention (Steinert 2008); others will require additional time for observation or monitoring. As stated previously, it is essential to involve the learner in every step. In addition, whatever the plan, the intervention should ideally be conducted with genuine concern for the well-being of the learner (Winter & Birnberg 2002) and the safety of patients and their families.

어떤 문제를 해결하고자 하는가?

1. What problem are you trying to address?

대부분의 문제가 독립적으로 발생하는 것이 아니므로, 문제의 우선순위를 정하고 어떤 것을 먼저 해결할 것인가를 정하는 것이 중요하다. 교사간, 교사와 학습자간의 합의를 이루는 것이 중요한 첫 단계이다. 이단계에서 교사들은 학습자들로 하여금 문제를 인지하고 인정하도록 도와야 한다. 또한 학습자가 가능한 전략이나 해결책에 대한 조언을 구하게 해야 한다. 경험에 따르면 공동의 의사결정이 필수적이다. 미리 설계된 인터벤션은 학습자가 그 계획에 동의하지 않으면 대체로 실패하고 만다.

Most problems are complex in nature and do not occur in isolation. It is therefore important to prioritize the perceived problems and to decide which one will be addressed first. Consensus between teachers, and between the teacher and the learner, is also a critical first step. During this phase, the teacher may need to help the learner recognize and acknowledge the issues affecting performance (Evans et al. 2010) and solicit feedback on possible strategies and solutions. Based on experience, shared decision-making is essential; in fact, the designed intervention will usually fail if the learner does not agree with the intended plan.

확인된 문제를 어떻게 해결할 것인가?

2. How will you address the identified problem?

A number of interventions, outlined in Table 2, can be considered when working with “problem” learners. In some instances, the clinical teacher will be involved in all components; at other times, program directors or other senior administrators will be responsible (Steinert 2008). However, in all situations, we must be aware of what options are available to us and one person must be accountable. Frequently, time with monitoring, or further assessment, is sufficient. In other cases, we need to enhance teaching and learning opportunities, either by increasing time for observation or feedback, or by arranging one-on-one coaching with staff or peers. In some situations, workloads might need to be reduced to allow for independent study and reading (for knowledge problems) or increased practice and feedback (for skill-related deficits). Alternatively, a formal remedial program may be required, with clearly defined goals and objectives, learning strategies, and evaluation methods (Steinert 2008). Although suspension, probation or dismissal (from the program) are not desirable options, they must, at times, also be considered (Ikkos 2000).

추가 시간

Additional time

As in medicine generally, time can be an effective healer (Steinert & Levitt 1993). Some learners can overcome their difficulties by moving out of a particularly challenging or stressful rotation, or by working with a different clinical teacher. Others gain confidence or skill as time progresses. Whenever possible, additional time should be accompanied by careful monitoring through observation.

추가 평가와 모니터링

Further assessment and monitoring

In other situations, further assessment will be needed. This will include spending more time with the learner and carefully monitoring what they do. It will also involve observing the student or resident in different contexts, with different patients and families. Including colleagues and other members of the team in this assessment phase can be equally beneficial. It is often surprising how invaluable team coordinators’ comments can be with regard to a student's or resident's behaviors with patients and other health professionals.

일대일 토론

One-on-one discussions

One-on-one discussion with the learner constitutes an important strategy that is often taken for granted. Although frequently not considered part of an intervention, meeting with the learner, to review specific issues or concerns, can be very worthwhile. Such a meeting can also be used to clarify expectations (which learners often feel are not explicit) and discuss pre-assigned readings, clinical problems or identified deficits (e.g. problem-solving).

교수 학습 기회 향상

Enhanced teaching and learning opportunities

At times, increased observation and feedback can help to address identified problems. This is especially true for knowledge-based problems or skill-related deficits. More frequent case discussions and chart reviews can facilitate knowledge acquisition, as can mini-tutorials, review of patient management problems and discussion of pre-assigned readings. Increased opportunities to observe role models in action can encourage the acquisition of interpersonal skills, as can time in a simulation-based environment. The latter can also help to address deficiencies related to technical skills, interviewing skills and team work. A skill-based training course, tailored to individual needs, might also be recommended.

근무량 감축

A reduced clinical workload

A reduced clinical workload, with protected time to focus on knowledge or skill acquisition, may at times be in order. If the learner is feeling overwhelmed by the clinical demands (in relation to their own expertise and competence), a lesser workload may decrease stress so that learning can occur.

로테이션, 장소, 감독관 변경

A change in rotation, venue or supervisor

Changes at the system level should also be considered. Changing the learner's rotations (e.g. scheduling an easier rotation, working in a different setting or clinical environment) can be another alternative, as can changing the primary supervisor or adding other teachers (with different skill sets) to the roster. Working with “problem” learners is generally quite time-consuming for teachers, and sharing the workload may be beneficial to all concerned.

동료나 멘토의 지지

Peer or mentor support

Medical school and residency training can be a stressful time for students and residents (Dyrbye et al. 2005) At times, a supportive peer or teacher can be very helpful. The role of peers in working with “problem” residents has been debated by clinical teachers and residents alike; however, the value of “near-peer” support cannot be underestimated as long as peers maintain confidentiality and respect.

레미디얼 프로그램

A remedial program, with defined goals, objectives and strategies

The above components are frequently used in a more formal remedial program, which may include a variety of teaching methods (e.g. videotape reviews of clinical encounters, role plays of difficult doctor–patient interactions) or extra rotations in a specific discipline, with protected time for increased supervision, study and review (Steinert & Levitt 1993). Known to address specific problems with reasonable success, such programs require clearly defined goals and pre-determined outcomes. Moreover, in some settings, they have had considerable success with both students (Schwartz et al. 1998) and residents (Catton et al. 2002).

상담, 치료

Counseling or therapy

Although most clinical teachers find this a difficult option to pursue, counseling or therapy may be indicated, especially if the learner is presenting with aggressive or depressive symptoms, substance abuse, or psychiatric problems. Learning disabilities can also not be ignored as an underlying factor for perceived problems and often require intervention (Coles 1990). This is also an area where outside consultants or expertise should be sought.

휴가

A leave of absence

A survey of internal medicine programs from 1979 to 1984 found that 1% of the residents required a leave, and 56% of the programs granted leaves of absence because of “emotional impairments” (Smith et al. 2007). Although teachers are often reluctant to consider this option, it should be part of the repertoire of interventions, especially as leaves of absence are one of the suggested options for health-related problems including substance abuse (Long 2009).

정학/퇴학

Probation, suspension or dismissal

명확한 정책이 있어야 하지만, 한편으로는 Ikkos가 언급한 바와 같이, 문제학생을 다루는 법적 제도적 장치는 국가이나 기관에 따라서 다르다.

Academic dismissal(학업능력에 따른 퇴학)과 displinary dismissal(그 조직이나 기관의 정책에 위배되는 행동에 따른 퇴학)은 구분되어야 한다.

무엇이 성공인지에 대한 장기적인 관점이 필요하다. 

In order for this option to work, clear policies must be in place. It is also true that this intervention is dependent on local norms and values, and as Ikkos (2000) had said, the legal and administrative framework to deal with “problem” learners differs across countries and authorities. In addition, only a few reports describe termination policies in medical training programs (Irby et al. 1981; Tulgan et al. 2001). However, this option must be seriously considered, despite teachers’ reluctance to do so. Irby and Milam (1989) distinguish between academic dismissals, which result from academic or clinical performance issues, and disciplinary dismissals, which follow violations of institutional rules or policies. Irrespective of the nomenclature, however, we might need to dismiss learners from their programs when remediation efforts fail (Catton et al. 2002). As Winter and Birnberg (2002) have stated in the description of their work with impaired residents, we must have a long range view of success and “recognize that suspension or dismissal may only be a temporary setback … short-term failure, including relapse, may in fact lead to long-term success”. It is also important to remember that re-directing a student to another specialty – or career – may not be a failure in the long run.

Dudek et al은 교사가 학생을 낙제시키기를 머뭇거리게 하는 네 가지 요인을 밝혔다.

In an interesting study, Dudek et al. (2005) identified four factors to explain teachers’ reluctance to fail students and residents: 

• a lack of documentation; 
• a lack of knowledge about what to document; 
• anticipation of an appeal; and 
• a lack of remediation options. 

These factors are equally important in this context and must be addressed by program directors, educational leaders and administrators. In fact, we must put systems into place to protect our teachers as well as our learners.

흔한 인터벤션의 방법들은 다음과 같다.

As described previously (Steinert 2008), experience has shown that common interventions include: 

• increased observation and feedback (for gaps in knowledge or skills); 
• increased time with a faculty advisor (for knowledge deficits, attitudinal problems, interpersonal conflict or family stress); 
• weekly study sessions, core content review and videotaping of clinical encounters (for knowledge, attitudinal or skill problems); and 
• psychiatric counseling (for attitudinal problems, interpersonal conflict, family stress or substance abuse). 

어떤 성과가 기대되는지, 인터벤션의 실패는 어떨지가 초창기에 결정되어야 한다.

Anticipated outcomes, and consequences of failed interventions, must also be determined early in the process, though it is heartening to note that close to 90% of “problem” learners succeeded after a structured intervention or remediation program (Winter & Birnberg 2002; Reamy & Harman 2006).

인터벤션에 누가 관여할 것인가?

3. Who will be involved in the intervention?

비록 규정에 따라 정해져 있을 수도 있지만, 가능하다면 프로그램 관리자나 관련된 부학장이 인터벤션 계획에 관여해야 한다.

At times, the primary supervisor (or clinical teacher) will be responsible for both designing and implementing the intervention. At other times, another member of the team or outside consultant will be involved. Although this decision is often dependent on institutional policy or local norms, whenever possible, the program director or associate dean (or someone in a similar position) should be consulted and involved in the intervention plan. So should the student or resident. Depending on the design and complexity of the intervention, and the specific educational context, it may also be helpful to have more than one person involved in the intervention plan, and ideally, this should be discussed with the learner. In all cases, it is important that the learner is comfortable with the teacher(s) involved in the intervention, all of whom should have the time and expertise to deal with the learner's difficulties. As highlighted above, peer support can also be invaluable.

인터벤션의 time frame은 어떻게 되는가?

4. What is the time frame for the intervention?

교사들이 흔히 하는 실수는 명확한 목적이나 목표, 시간계획 없이 인터벤션에 뛰어드는 것이다. 

Teachers often err by “jumping into” an intervention without clear goals, objectives or time frames. Clearly, both the teacher and the learner would benefit from knowing how long the intervention will last and what the expected outcomes will be. It is also important to recognize that time frames may be context-specific. For example, much of undergraduate training occurs in one-month blocks; postgraduate training often provides more time for intervention and problem resolution. Clearly, the dimension of time must be seriously considered.

인터벤션을 어떻게 평가할 것인가?

5. How will the intervention be evaluated?

Whatever the intervention, learners often lament that they do not know what is expected of them. Accordingly, the criteria for success must be carefully laid out from the outset. For example, if the teacher and learner are working on improving technical skills, the expectations for success should be clearly enunciated at the outset and a system for evaluating progress should be determined. It is equally important to schedule regular, pre-arranged meetings between the learner and the supervisor to monitor ongoing progress, to determine whether the intervention plan has been able to achieve its specified goals (Steinert & Levitt 1993), and to make mid-course corrections. These meetings should also be scheduled before the intervention starts so that they are not viewed as a method of crisis intervention. Finally, it is essential to outline what consequences will be considered if no improvement is noted. At times, the problem may need to be re-defined; at other times, the remediation program will need to be extended or altered. And as stated earlier, probation or dismissal may need to be considered as a viable option. In this era of outcomes-based education, clear outcomes are needed at every step of the way.

인터벤션의 기록을 어떻게 남길 것인가?

6. How will the intervention be documented?

필수적 요소임에도 이 단계는 보통 생략되거나 우연에 맡겨지곤 한다.

Although thorough documentation is an essential component of all interventions, this step is often omitted or left to happenstance. For example, 

• teachers must document the identified problem (with supporting data), 
• the discussions with the learner and colleagues, 
• the intervention plan, and 
• the observed outcome of designated activities. 

Some teachers find it helpful to write up the intervention plan as a “learning contract”, outlining how the problem will be dealt with, in a particular time period; others prefer to keep carefully documented process notes. Though often skeptical at first, learners frequently express appreciation at knowing what is expected of them and what outcomes are desired. Documentation is also essential in ensuring due process.

정당한 절차를 어떻게 확보할 것인가?

7. How will due process be assured?

교사들은 반드시 정당한 절차에 따라 협력적으로 접근해야 하며, 공정함을 담보해야 하고, 비밍르 유지해야 하며, 충분한 정보를 제공하고 동의를 받아야(informed consent)한다. 공정함이란 학습자가 교육 프로그램의 목적을 알고, 승진의 규칙을 아는 것이다. 이는 또한 정기적으로 피드백이 주어지며, 교사의 평가는 직접 관찰한 객관적 자료에 기반한다는 것을 말한다. Documentation은 자연정의(natural justice)를 공고히 하는데 중요하며, 교사들은 평가, 인터벤션, 토론 등을 기록해야 한다. 동시에 이러한 정당한 절차는 bilateral한 과정이며, 동료들을 위하여 natural justice를 확실히 해야 함을 기억해야 한다. 많은 교사들이 문제학생을 다루는데 있어서 '외로움' '취약함'등을 어려움으로 꼽았다. 

Teachers must work collaboratively to ensure due process (Rankin & Kelly 1986; Rose 1989) and to guarantee fairness, confidentiality, and informed consent. Fairness implies that the learner is aware of the program's educational objectives and rules of promotion. It also implies that feedback is given on a regular basis and that the teachers’ evaluations are based on first-hand exposure and objective data. Documentation is critical in assuring natural justice, and teachers must be encouraged to document their assessments, interventions, evaluations and discussions with the learner. At the same time, we must remember that due process is a bilateral process and we must work to ensure natural justice for our colleagues. Many a teacher has commented on the “loneliness” and “vulnerability” that they experience when working with “problem” learners (Steinert 2008).

조직 차원의 정책을 개발하고 학습자의 문제를 다루기 위한 프로토콜을 만드는 것은 레지던트의 권한과 정당한 절차를 확실히 하기 위해서 중요하다. 비록 이러한 정책이나 프로토콜이 각 조직마다 다르다고 하더라도, "chain of command"를 반드시 명시하여 누가 어떤 부분에 책임이 있는지, 보고 구조는 어떻게 되는지, 평가와 개입의 time frame은 어떤지, 명확하고 세심한 기록의 필요성 등이 기술되어 있어야 한다.

Developing an institutional policy and protocol for handling learners’ problems can also help to assure residents’ rights and due process. Although such a policy and protocol will differ for each organization (or institution), it should describe the preferred sequence of events, the “chain of command” and who is responsible for which part of the protocol, the reporting structure, the time frame for assessment and intervention, and the need for clear and careful documentation. For example, some schools have entrusted a Board of Examiners (Catton et al. 2002) to handle residents’ problems; others have designated program directors or postgraduate deans to be responsible. Irrespective of the chain of command, it is important that all faculty members are aware of local policies and protocols and that the institution maintain a uniform approach to learners requiring attention. 

왜 robust system이 필요한가?

Long (2009) has described a number of reasons why it is important to have robust systems in place to work with “problem” learners. This includes 

• the need for uniformity, 
• the development of expertise, and most importantly, 
• the early identification of learners in difficulty.

Prevention of problems

의과대학과 수련기간은 많은 학습자들에게 스트레스가 심한 혼란의 시기이다. 스트레스의 원인에는 다음과 같은 것들이 있다.

Medical school and residency training is “a time of stress and turmoil for many learners” (Dabrow et al. 2006). As stated earlier in this Guide, and as described in the literature, these stresses come from a number of sources, including 

• communication problems in the workplace, 
• feelings of not being respected, 
• the constraints of collaborative work, 
• the potential gap between the medical school and clinical care, 
• work overload, 
• responsibility towards patients, 
• worries about career plans and a perceived lack of knowledge (Luthy et al. 2004). 

Depending on their life experiences and coping strategies, students’ responses to stress may – or may not – be adaptive (Dyrbye et al. 2005). Although a full discussion of prevention strategies is beyond the scope of this article, a number of approaches are worth considering. 

유용한 프레임워크

For example, Langlois and Thach (2000) have provided a helpful framework by which to look at the prevention of difficult learning situations, modeled along the lines of primary, secondary, and tertiary prevention. 

1. At the level of primary prevention (i.e. preventing the problem before it occurs), they suggest a well-developed orientation program that includes the sharing of course expectations, a discussion of mutual goals and objectives, and ongoing assessment. 
2. With respect to secondary prevention (i.e. early detection), they concur with the suggestions made in this Guide and re-affirm the importance of paying attention to early clues, responding quickly, and providing ongoing feedback and monitoring. 
3. Tertiary prevention (i.e. managing a problem to minimize impact) is of course more complex and includes a number of carefully crafted intervention strategies; it is also wise at this stage to not try to “rescue” the learner by ignoring the problem or accepting poor performance. 

"다양한 잠재적 위험 상황은 기대를 설정하고, 피드백을 주고, 사려깊은, 지속적 평가를 제공함으로서 예방 가능하다"

Interestingly, few prevention programs for teachers in distress have been described in the literature. However, each of these suggestions would be equally relevant to the teacher and the system. As Langlois and Thach (2000) have said, “many potentially difficult situations can be prevented by setting expectations, giving feedback, and providing thoughtful, ongoing evaluation”.

수련과정의 스트레스 인정

Acknowledge the stress of training

As Hays et al. (2011) have said, “academically bright and ambitious medical students must cope with a combination of curriculum, assessment, career choice, [and] personal, family and social pressures”. As teachers, we must acknowledge the stress and strain of undergraduate and postgraduate training and offer support to deal with systemic issues (Howell & Schroeder 1984; Peterkin 1991). We must also provide an educational environment that allows for learner differences, timely feedback and ongoing assessment so that problems are identified early and evaluations are not a “surprise”. In addition, we should consider the role of faculty advisors or mentors, so that learners can receive support and guidance in an atmosphere of trust and respect. Peer support, which can help to guard against delay in problem identification, can also be a useful intervention (Steinert 2008).

학습 기술과 평생학습 전략 증진

Promote study skills and life-long learning strategies

Although life-long learning is often identified as an important attribute of competent practitioners, the skills inherent to this process are not frequently taught. Perhaps, it is time to re-dress this gap and teach students and residents ways in which to maximize learning in the workplace, direct their own learning, seek input from others, and use evidence at the point of care (Teunissen & Dornan 2008).

관련된 교육 이벤트 구성

Organize relevant educational events

Some programs have held annual retreats to combat stress in residency training (e.g., Klein et al. 2000). Others have developed wellness (or assistance) programs to deal with the stress inherent in medical training (Borenstein 1985; Zoller et al. 1985). Irrespective of the program design, these activities include a discussion of relevant stresses and ways of identifying high stress levels, strategies for coping with stress, and information about available resources. Some programs have also included psychiatric counseling as part of their wellness or assistance program (Dabrow et al. 2006). As an example, the program at the University of South Florida College of Medicine offers confidential evaluation, brief counseling, and referral services (as appropriate). Importantly, this program is not focused solely around crisis intervention; it also incorporates a number of components of a successful assistance program: total confidentiality; easy access; education regarding availability of services and overall integration with the educational program (Dabrow et al. 2006). Educational courses and seminars on professionalism may also be warranted (Marco 2002). Demonstrating a lack of unprofessional behaviour is often seen among “problem” learners. It is, therefore, important to both teach and assess these behaviors in an explicit manner (Cruess et al. 2009) and make expectations clear.

교수 개발

Develop your faculty

교육의 목적과 구성

As stated earlier, most teachers do not feel prepared to handle “problem” learners effectively and faculty development has a critical role to play in this context. In our setting, we frequently offer workshops on the “problem” student and resident to our faculty members. The goal of these workshops is to provide a systematic framework for teachers “to help them in their task by emphasizing early identification, accurate diagnosis, and appropriate interventions” (Steinert et al. 2001). Workshop topics include: defining the problem; data gathering: confirming the diagnosis; designing and implementing the intervention; and assuring residents’ rights. Participants work in small groups and are encouraged to focus on their own challenges and lessons pertinent to their own settings. Program evaluations have shown that this workshop can be an effective way to sensitize teachers to the challenges of working with “problem” learners, to increase their knowledge and skill, and to help them become more aware of systems issues that may impact learner progress. Muller et al. (2000) have also highlighted the benefits of a faculty development workshop in helping teachers to apply an “interactional model to working with learners in difficulty”. As they pointed out, such an activity can help faculty to explore critical issues, test out their assumptions, identify new ways of working with learners’ challenges and begin to work collaboratively.

Some general principles

In closing, some general principles will be emphasized. Although “success” is not always possible, most “problem” learners do succeed in finding their way to a fulfilling career.

조기 발견이 중요하다. Early identification is critical

As Evans et al. (2010) have stated, “early identification and early support, before the trainee or student runs into major difficulties, should be regarded as the gold standard for educational supervision.” Most educators have encountered learners with significant gaps in knowledge or professional behaviors that have not been addressed earlier in their training. We fail this group by not failing them, and at a minimum, we must provide them with feedback, remedial guidance, and a plan (LeBlanc & Beatty in press).

학생이나 레지던트는 고되다. It is not easy to be a student or resident

As teachers and program directors, we need to remember that it is not easy to be a student or resident. It is also true that some learners complete their trajectory without any problems, but the essence of training can be stressful for many. Awareness – and acknowledgement – of this fact can be very helpful for both the learner and the teacher.

성과에 초점을 두자 An outcomes approach is warranted

문제 해결에는 두 가지 프레임이 있다. 하나는 '문제'적 관점이고, 다른 하나는 '성과'적 관점이다. 

Claridge and Lewis (2005) describe two frames for problem solving: a problem frame and an outcome frame. 

• In the former, which focuses on the details of the problem and the deficiencies at hand, the over-riding motivation is to “escape”. 
• The outcome frame, on the other hand, focuses on internal motivation to change, finding solutions and moving towards a positive outcome. Belief in the individual as resourceful and capable underlies this frame, as does the notion of exploration and change. Clearly, all of these factors are important in working with “problem” learners.

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Med Teach. 2013 Apr;35(4):e1035-45. doi: 10.3109/0142159X.2013.774082. Epub 2013 Mar 15.

The "problem" learner: whose problem is it? AMEE Guide No. 76.

Steinert Y1.

Author information

• 1Centre for Medical Education, Faculty of Medicine, McGill Universit, Canada. yvonne.steinert@mcgill.ca

Abstract

Clinical teachers often work with students or residents whom they perceive as a "problem". For some, it is a knowledge deficit that first alerts them to a problem; for others it is an attitudinal problem or distressing behaviour . And in some cases, it is difficult to know if the learner is, indeed, presenting with a problem. The goal of this Guide is to outline a framework for working with "problem" learners. This includes strategies for identifying and defining learners' problems, designing and implementing appropriate interventions, and assuring due process. The potential stress of medical school and residency training will also be addressed, as will a number of prevention strategies. Identifying learners' problems early - and providing guidance from the outset - can be an important investment in the training and development of future health professionals. It is hoped that this Guide will be of help to clinical teachers, program directors and faculty developers.

PMID:

 

23496125

 

[PubMed - indexed for MEDLINE]