Working with the “Difficult” Student: Part 1

Step 1- Define Difficult
Life doctor.jpeg
For the purposes of the next two blog posts, we are going to look at two different definitions of difficult:
1. Students who are experiencing academic difficulty
2. Students who you are uncomfortable working with.
There are other definitions but making this distinction allows us to approach this issue with two very different solutions. This Blog will examine definition #1.

Students who are Experiencing Academic Difficulty

Step 2 – Diagnose the Difficulty
This step requires knowledge about the Learning Cycle developed in 1962 by P.Dubin. Everyone who is learning something new goes through the following 4 stages.
1. Unconscious Incompetence
At this stage, the person has no idea that they don’t know and in some cases may even assume that they do know because watching an expert makes it look easy or they may dismiss the importance of learning because the student fails to see the relevance. Sometimes this student will aggressively try to prove you wrong or blame others. In some cases, they learned incorrectly the first time and the incorrect behaviour is automatic. This is the most dangerous stage for patients who work with the student and the most difficult for preceptors to cope with.
2. Conscious Incompetence
This stage represents the beginning of willingness to learn something new. Occasionally students will be so afraid of appearing incompetent that they will avoid admitting that they are at this stage. This person may avoid learning by standing at the back of a group, giving joke responses to questions, freezing up or missing a session.
3. Conscious Competence
This stage is the awkward stage, every step has to be rehearsed, fingers don’t seem to work properly, or the student may forget a step and freeze. The preceptor is often tempted to do or reteach the steps for the student because they seem so slow.
4. Unconscious Competence
At this stage the student is doing things automatically. In the case of skills, muscle memory has kicked in, and they can use their minds to do other things like talk about the weather. The draw back with this stage is they have forgotten the steps they took to learn the skill and teaching it to someone else can be frustrating.
Techniques that can help you identify which stage the student is at can be found here.
Step 3 – Treat the Difficulty
Once you have a clear diagnosis, you can move on to developing a strategy for working with the student. Rewards and punishment are ineffective because they have unpleasant long term consequences.
1. Unconscious Incompetence
The simplest solution at this stage is to demonstrate what you expect but that won’t work with a student who is seriously imbedded in this stage and denying that they need to change. Here are some alternatives:
• direct feedback
• 360 degree feedback from nurses, patients, and/or families
illness scripts
• videotaped encounters
• failure as a last resort.
2. Conscious Incompetence
At this stage, the student needs direct teaching. Some things to think about with a student having a difficult time at this stage are:
• use numbered steps
• use repetition by asking students to explain steps to the patient or you before they practice
• if a student is fearful of appearing incompetent, build their confidence by
o giving them written steps to memorize
o asking them questions they can answer
o asking them to demonstrate a piece of something
o using positive support strategies.
3. Conscious Competence
This is the practice stage and students need to do X until it becomes automatic. If there aren’t patients, use simulators; no simulators, practice on self, family, each other. This is the stage when students should be teaching each other and students in lower levels because the act of teaching improves the skill level of the teacher.
4. Unconscious Competence
At this stage, the person needs new challenges.

Report of the Conference on Revisiting the Medical School Educational Mission at a Time of Expansion

The Josiah Macy, Jr. Foundation is a privately endowed philanthropy located in the borough of Manhattan, New York City. The Foundation supports programs designed to improve the education of health professionals in the interest of the health of the public, and to enhance the representation of minorities in the health profession.
It has just published the Chairman’s Summary of the Conference on Revisiting the Medical School Educational Mission at a Time of Expansion.
Here is an excerpt from the press release.
“What medical education needs to recognize is that it has a fundamental social mission to train future physicians for a rapidly changing health care system that seeks different competencies than in the past,” says Cohen. “The leaders of medical education institutions need to seize the opportunity that expansion affords to ensure that their
institutions are responsive to their public purpose.”
Highlights of what areas schools should focus on:
• Giving student more opportunities to learn the principles of quality improvement,
patient safety and patient-centered care;
• Preparing students to work effectively and collaborative as members of health
care teams and as part of a system of care;
• Using community-based settings more as classrooms, and hospital settings less, to
expose students to a more realistic practice environment;
• Ensuring that physicians have more background in public health education and
the role that social factors play in affecting patient health; and
• Emphasizing the importance of problem solving and self-directed learning as a
way to keep up with the fast-paced health care environment.

1st Annual People’s Health Blogger Awards

A message from Wellshere:
“We’re excited to announce Wellsphere’s 1st Annual People’s Health Blogger Awards, a competition where YOU get to decide who is the world’s #1 Health Blogger!
Wellsphere’s Health Blogger Network has more than 1,700 of the world’s top health writers and you can help us decide who are the Best of the Best!
You can cast your vote for your favorite health blogger anywhere you see a Vote Now! badge or button on Wellsphere, including on the blogger’s Wellsphere profile, or any of their articles. To learn more about how to vote for your favorite health bloggers, visit:
The competition is free and open to all bloggers who primarily write about health or healthy living topics. Voting has begun and runs through end of day Thursday, January 15th 2009. You can vote for as many bloggers as you like (but can vote for each blogger only once). If you know someone who you think should be up for the Award, tell them to fill out our entry form at:”

Another Second Life Medical Program

Virtual Ability Island
Join Gentle Heron for a tour of the orientation areas of Virtual Ability Island. Virtual Ability is a joint project of Alliance Library System and Virtual Ability Inc., ‘Share the Health’ funded by the National Library of Medicine. Visit Infointernational Island in Second Life to find out more from the librarians at the reference area or take a look at the Infoisland blog:

Funding came through an initial grant from the National Library of Medicine to the Alliance Library System and is sustained by the generosity of individual contributors to Virtual Ability, Inc.
Virtual Ability, Inc. is a Non-profit, Tax-Exempt Organization under Section 501(c)(3) of the United States Internal Revenue Code and is based in Colorado, USA.
Their mission is to enable people with a wide range of disabilities to enter into virtual worlds like Second Life®, and provide them with a supporting environment once there.

Yes We Care! Video

Yes We Care! Video
From the campaign
“I want to give a huge thank you to all of you who submitted a personal video. I was again overwhelmed by the response and outpouring of genuine caring and selflessness that so many of you describe in your videos. Your stories brought tears to my eyes. We included as many of these videos as we could in the truly heartwarming and touching video montage that is part of the “Yes We Care!” campaign. PLEASE take the time to WATCH THE VIDEO! It is a truly remarkable collection of your personal stories, and we know that you’ll be as moved as we are by your colleagues.”
Here is al link to the video: (scroll down and click Play Video) if it doesn’t appear below.

Nominate YOUR Everyday Heroes
Do you know a fellow blogger, friend or family member who you think deserves to be recognized for going out of their way each day to care for others? Nominate them today at This is an amazing opportunity to help spread the movement of caring and recognize those bloggers who deserve acknowledgment, and those individuals who make a big difference in your life. We will acknowledge your heroes by adding them to our Map of Caring, and honoring them with an Everyday Hero badge of their own.

Yes, We Care! Campaign

Yes We Care! Campaign
Wellsphere just launched the Yes, We Care! Campaign to publicly express their deep appreciation for the extraordinary efforts YOU and others like you are making to help, support and care for others. Thank you for opening your heart and mind to help others by sharing your expertise and personal experiences!
Please accept this “Everyday Hero” badge for your blog, and enjoy the recognition you deserve amongst your many readers and visitors. We’ve pasted the embed code for the badges below.

Yes, we care!

Dangerous email message

ITS has received several reports of e-mail messages asking individuals for USASK usernames and passwords. These messages are “phishing” attempts — attempts to acquire sensitive information fraudulently.
Do not respond to these “phishing” messages.
ITS never asks for passwords.
One of the fraudulent messages currently being circulated threatens to suspend the user’s e-mail and states that the recipient must confirm “webmail identity” to prevent account closure.
ITS requires no such action.
If you know of anyone who has received such a message and sent their username (NSID) and password as requested in the message, they should change their password immediately through PAWS or
If you require assistance, please contact the ITS Help Desk.

Open Disclosure

I’m blogging from CabinFever, the University of Alberta’s conference for medical faculty. The first session I attended dealt with the issue of open disclosure to patients of harm resulting from medical errors. I thought I would share the Health Quality Council of Alberta’s suggestions about what should be included in the initial disclosure conversation.
1. An appropriate apology
2. Known and agreed upon facts
3. Patient’s questions/concerns
4. Consequences of harm and any side effects to look for
5. Discussion of ongoing care
6. What happens next
7. Arrangements for future meetings
8. Contact details in case of further questions.
Given these guidelines, how might you assist students, residents to develop skills in this area?