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• W2069269486 abstract "The teacher, aware of the indispensable steps in the process by which he himself has moved his mind up the ladder of learning, devises ways to help another individual engage in a similar process; and he applies them with sensitivity to the state of that other person’s mind and with awareness of whatever special difficulties the other must overcome in order to make headway. —Mortimer AdlerWhy do residents have difficulty in our training programs? How can we identify those who are struggling? What can we do to help them? By their very nature, these are educational opportunities for which careers in medicine should provide excellent preparation. In medical education as in medical practice, the first order of business is accurate diagnosis. That is, we need to recognize when a learner or a patient is having trouble [1Schwind C.J. Williams R.G. Boehler M.J. Dunnington G.L. Do individual attendings’ postrotation performance ratings detect residents’ clinical performance deficiencies?.Acad Med. 2004; 79: 453-457Crossref PubMed Scopus (49) Google Scholar]. The sooner we recognize that a problem exists, the greater the opportunity to intervene successfully. The next order of business is therapy, or, in educational parlance, remediation. But therapy is not possible without an accurate diagnosis. Only once we clearly understand both the problem and the learner can we help devise a new educational approach that enhances learning. Consider this illustration. A very detail oriented resident was having difficulty combining isolated facts into a comprehensive understanding of clinical radiology. One day, he was studying how to perform a lower extremity ultrasound examination to exclude deep venous thrombosis. The program director recognized that the resident was having trouble when she observed that he was spending most of his time studying an anatomy book, trying to visualize individual ligaments around the knee. She called him into her office, pulled out a piece of paper, and drew the outline of an amoeba-like shape. Then she gave the resident a crayon and asked him to color it in as darkly as possible. The resident started with a small area and ground the crayon into the paper until he created a very small dark patch. Then he started in on an adjacent area, and so on. The program director then told him that the shape represented what he needed to know as a radiologist. She told him that if he eventually chose to specialize, he would be able to color in one of the smaller areas very darkly. For now, though, as a radiology resident, he needed to be a generalist: not someone who knows a great deal about one thing but someone who knows a moderate amount about many things. Then she asked him to color in the shape again. This time he started coloring in the whole shape. Afterward, they had a productive conversation about how he could change his approach to studying, focusing less on each detail and more on the “big picture” of how the details fit together. This is only one example of the cognitive difficulties residents may experience over the course of their training. Such difficulties include distinguishing between more and less relevant information, organizing thoughts in a concise and coherent fashion, and posing incisive questions to patients and colleagues. Of course, cognitive difficulties are themselves but one category of problems learners may experience [2Wang M.C. Reynolds M.C. Walberg H.J. Handbook of special and remedial education. Pergamon, New York, NY1995Google Scholar]. A complete list of other types of problems would include divorce, depression, substance abuse, financial difficulties, and other health issues [3Sayer M. Chaput DeSaintonge M. Evans D. Wood D. Support for students with academic difficulties.Med Educ. 2002; 36: 643-650Crossref PubMed Scopus (90) Google Scholar]. Focusing purely on a struggling resident’s cognitive skills is likely to prove insufficient if underlying personal and social problems are involved. Struggling residents may be identified in a number of different ways. One sign of trouble is poor performance on standardized tests, such as the ACR’s In-Training Examinations. Another source of feedback is routine faculty evaluations collected at the end of each rotation. For example, a resident may display unusual difficulty performing procedures or formulating cogent reports. Informal feedback from faculty members can be equally helpful. Other residents and allied health personnel, who may pick up on signs of difficulty that busy faculty members do not detect, can also offer important perspectives. Finally, each resident can and should honestly appraise his or her own performance and share concerns with the program director. Not all residents will avail themselves of such opportunities, but those who do can benefit a great deal. One strategy for encouraging the prompt reporting of learning difficulties is to diminish the generally pejorative connotation of remediation. If there is any profession in which remediation should be widely understood, it is medicine. The word is derived from the Latin mederi, to heal or make whole again, as in our word remedy. For several decades, institutions of higher education have recognized the importance of identifying and helping struggling learners. They have had little choice, in view of the fact that approximately 40% of undergraduates take 1 or more remedial courses in their first year of undergraduate study [4Slotnick H.B. Identifying and remediating specific deficiencies of entering medical students.J Med Educ. 1981; 56: 91-102PubMed Google Scholar]. As radiology educators, we need to be on the lookout for struggling learners and develop approaches to help them enhance their performance [5Vaishnav A. Remedial requirements: associate professor Bridget Terry Long researches remediation. Available at: http://www.gse.harvard.edu/news/2005/0901_long.htmlGoogle Scholar]. Consider the analogy of a map. If we conceptualize learning as a journey to a distant city, many routes are possible. Some are relatively direct and make for easy going, whereas others take much longer and require more effort. In some cases, even bright learners may not clearly see their destinations or how to get there. They need a map, an approach to learning that enables them to move effectively from ignorance to understanding. Some learners operate with no map. Others have maps that are out of date or poorly suited to the contemporary educational environment. Still others have maps that are frankly defective. Given the growing workforce needs in radiology and the educational responsibility we assume when we accept learners into our programs, we cannot afford to simply cast residents into the swift waters of training and let them sink or swim. There will be rare cases in which both residents and the patients they would serve would be better off if the residents pursued other careers. In most cases, however, there is much that we can do to help struggling learners get back on track. If residents are to succeed, it is vital that they be actively engaged in learning. If otherwise bright people are simply “not getting it,” it usually means that they are not engaged in learning in a way that works for them. Perhaps they are trying to learn the wrong things, or they are not learning in a way that makes knowledge readily available for application in daily practice. One thing we can do to promote more effective learning is give learners a clearer sense of how their new knowledge and skills will be used. The better they can see how today’s lessons will contribute to tomorrow’s daily practice, the better prepared they will be to learn. Merely memorizing lists is not enough. Suppose, for example, that we are teaching cardiopulmonary resuscitation. It is not enough for learners to read about when and how to resuscitate a victim of cardiopulmonary arrest. They need actual hands-on practice using mannequins or, better yet, more sophisticated simulation devices. Similarly, radiology residents need to see the knowledge and skills they are learning as they will apply them in everyday practice and to understand the important difference their contributions can make in the health of a patient. One approach to struggling learners might be to require that they repeat rotations in which they performed poorly [6Eideiken B.S. Remedial program for diagnostic radiology residents.Invest Radiol. 1993; 28: 269-274Crossref PubMed Scopus (16) Google Scholar]. Yet this is problematic, because current payment policies for resident education make it difficult to extend a radiology resident’s training beyond 5 years [7Boiselle P.M. A remedy for resident evaluation and remediation.Acad Radiol. 2005; 12: 894-900Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. What alternatives to repetition can we offer? Part of the answer lies in helping learners gain insight into their own learning. How well do they understand their own strengths and weaknesses as learners? Are they becoming more effective and efficient at learning as they progress through their training? We should ask learners to describe their learning approaches. What amount of studying are they doing on a daily basis, and how do they go about it? How do they identify what to study as they move from rotation to rotation? How do they plan to study for the American Board of Radiology examinations? Are they seeking guidance from faculty members and other, more senior residents? Do residents think that they are learning radiology merely to pass the board examinations, or do they recognize that their first commitment should be to the development of their excellence as clinical radiologists? Are they developing good learning habits that will enable them to continue to grow and develop long after they have completed their formal training? To our knowledge, no one has established how much reading residents need to do to perform competently as clinical radiologists. Is there an average amount? How great is the variation between residents? Even in the absence of such data, it makes sense to encourage residents to examine the studying they do. Most residents will learn more effectively if they read about the clinical entities they encounter each day in practice rather than simply moving in lockstep through one book after another. Reading that responds to clinical practice is highly contextualized, enabling learners to embed the knowledge they are gaining more firmly in memory and in ways that are more accessible to practice. We believe that clinical practice itself is radiology’s most important learning opportunity. Residents should study principally not to pass tests but to take good care of patients. To facilitate this, we should explicitly encourage residents to read about what they see each day. We can further facilitate and consolidate the gains from such clinically directed reading by posing follow-up questions. Although it would be wonderful if all residents could graduate from every program knowing absolutely everything they will need to know to provide first-rate care to their patients, such a vision is unattainable. It would be like saying that we want every schoolchild to assimilate all the knowledge contained in the school library. A more realistic and in fact more productive goal is to say that we want every resident to become a highly effective learner. What if a resident is reading as much as others but does not derive the same benefit? Advice to read more is not likely to prove very helpful. The key educational mission is to determine what aspect of the reading or, more generally, learning is not working. Consider, for example, the case of a resident who has difficulty recognizing radiologic abnormalities. Suppose we review the resident’s approach to learning and discover that when the resident reads, too much time is being spent on the text and too little on the images. We need to help the resident focus more on the images. An effective remediation program for such a resident might entail the following advice: 1Do not read whole chapters of textbooks or whole journal articles.2Focus instead on looking at the images and reading only the legends. When you pick up a new textbook or journal article, go through all of the images and legends first, perhaps a chapter at a time.3Go back and hide the legends and see if you can identify the findings.4Repeat this process until you can successfully recognize all or most of the findings.5This time, hide the images and look only at the legends. Imagine what the image would look like. Keep doing this until you can successfully recreate in your mind the imaging findings. If necessary, sketch them on a piece of paper.6Once you have become proficient at moving from images to legends and legends to images, go back and read the full text, looking at images and legends as they are introduced. Learners for whom visual recall seems especially difficult often benefit from buttressing their visual memory with verbal memory. They can verbally describe what they are seeing and what they recall. This also fosters the development of the skills necessary to discuss cases effectively in case conferences, the oral board examination, and above all clinical practice. Learners with especially strong verbal capabilities can thus help compensate for what one learning expert referred to as a “leaky” visual memory [8Levine M. A mind at a time. Simon & Schuster, New York, NY2002Google Scholar]. Such approaches to fostering expertise in image recognition are grounded in learning research over the past 3 decades [9Bransford J.D. Brown A.L. Cocking R.R. How people learn. National Academies Press, Washington, DC2000Google Scholar]. We now know that new information is processed through multiple memory registers, each of which has different capabilities [10Gunderman R. Illuminating the “black boxes” of learning and recall.Acad Radiol. 2000; 7: 641-646Abstract Full Text PDF PubMed Scopus (3) Google Scholar]. Becoming proficient at a new task requires that we develop the ability to respond automatically to key aspects of complex tasks, thereby reducing the amount of information that must be retained in working memory [11Gunderman R. Williamson K. Fraley R. Steele J. Expertise implications for radiological education.Acad Radiol. 2001; 8: 1252-1256Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. Learning to recognize image features is not primarily the result of innate ability that people either have or do not but requires properly organized instruction and practice. Only if the requisite material is organized appropriately in long-term memory can we become proficient at a new task. By ensuring that imaging findings and diagnoses are represented appropriately in the minds of learners, we can help them perform at higher levels. It is unfortunate that remediation bears a somewhat pejorative connotation. Unless learners are simply failing to make the effort, learning difficulties should be regarded less as an educational burden than an educational opportunity. Educators of almost any quality can successfully teach the most gifted learners. Where educators really shine is in helping learners who might not otherwise clear the bar, by recognizing that they are struggling and working with them to devise better learning approaches. In some cases, a resident who scores in the 25th percentile on a standardized examination may represent a greater educational success story than one who scores in the 95th percentile." @default.
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• W2069269486 title "Identifying and Helping Struggling Residents" @default.
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