Section 5: More Detailed Scenario Examples

(needs a reality check)

These students may exhibit this lack of motivation by not seeming to make more than minimal effort in clinic when it comes to being willing to see patients. They sometimes stay in their exam room in between patients to avoid having to take another one. They might purposely take longer than necessary with their first pt. so they aren’t free when the next one comes up. Based on body language, and facial expression when asked to see someone new, it seems as if they aren’t eager to do so. They often have low patient numbers consistent with this. 

• How should we address this with these types of students?
  • “I’m wondering if you could help me understand some things I’ve been noticing in clinic while observing you.  It seems to me that you sometimes avoid taking patients by staying in the exam room a little longer than necessary or taking more time than might be necessary with your first patient of the day.  I wanted to address this with you as soon as possible because this type of behavior might be interpreted as not being professional/collegial/appropriate. I want to support your success in clinic so let’s try to figure out what’s going on so we can improve your performance in this area.”    
• What do we say if they offer various excuses for not seeing enough patients or they get defensive?
  • “But Dr. Brown, my last patient was really complicated and took longer than I thought so I wasn’t ready for another one.”
    • “Let’s problem-solve how you might work on your speed with cases like this one.”  
    • “What was particularly complicated about this case that slowed you down?”
    • “Could you help me understand why your performance with a case like this might be, on average, slower than some of your peers?”
  • Or complete denial if confronted with a suggestion that they are not seeming as if they want to see patients: 
    • • “No, that’s not true at all. I’m not avoiding patients.”
        • “Can you help me understand the context of what I’m observing?  Compared to your peers, you are not seeing as many patients while working in clinic.  Could you help me understand the difference in performance between you and your peers?”
        • “I’m glad to hear that you’re not avoiding patients.  We want to make sure you’re getting adequate exposure to training experiences.  What do you think needs to change to meet that goal?”

(seems oblivious as to why they are receiving your negative feedback)

• These students show facial expressions consistent with confusion or even surprise that they are being told that they are not performing to expectations.
  • “What do you mean that I am not doing well in clinic?”
    • “Why don’t we go into one of the exam rooms so we can speak privately?  I want to share some feedback with you on your performance so that we can work together to get you where you need to be at this point in your training.”
  • “From what I hear from some of my classmates, I thought I was doing as well as everyone else.” 
    • Start with what the student is doing well.
      “In some ways, you are performing at the level of your peers. You do x, y, z, really well.  Here are some areas that need development….”
  • “My classes this semester were really hard, and I am working as efficiently as I can.  I feel like I’m doing just as well as my classmates.” 
    • “Yes, some classes this semester are very hard–I hear that all the time!  It can be really hard to balance all of the tasks that are required of you as a doctoral student.  Let’s see if we can figure out some tips and tricks to make this process easier.  I know you can be successful if we make a few adjustments”
• Despite receiving low Meditrek grades they don’t comprehend the fact that they need to improve. 
  • “Well I know I got some 2’s on some patients but I got 4’s on some others and the ones I got the lower grades on were really tough cases.”
    • “Yes, you did get 4s on some patients–awesome job.  If we can get you moving more 2s to 4s, you’ll be well on your way to success.  Let’s figure out how to make that happen- I have some suggestions that might help.”
    • “Yes, some classes this semester are very hard–I hear that all the time!  It can be really hard to balance all of the tasks that are required of you as a doctoral student.  Let’s see if we can figure out some tips and tricks to make this process easier.  I know you can be successful if we make a few adjustments.”
  • “Some of my friends have gotten lower grades than me but they haven’t been told they need to get better.”
    • “That must be confusing to hear.  Our peers don’t always share the full picture of their grades and performance.  We don’t target students about their performance to make them feel bad.  When I’m giving you this feedback, it’s only because your performance needs to improve so that you can be successful in this program. I wouldn’t want you to get this feedback too late in the semester, because then you wouldn’t have an opportunity to make the necessary changes to be successful.”

• Even with lower grades and feedback written in Meditrek by faculty, they are still not aware of what they have to do to improve or what they have been doing wrong.
  • “I really don’t know what is expected of me. None of the faculty ever tells me what I need to do better or what I am doing wrong.”
    • “I’m really surprised to hear that no one has addressed these issues so far and I’m glad that I’m getting the opportunity to do that now because I don’t want you to feel lost or confused about your performance.  Let me give you some very specific feedback and things to work on.  I’m going to document this conversation here too so that we both know we’ve discussed these issues.”  (You might consider having the student summarize back to you the feedback so you confirm that you are on the same page and that the student heard you.  And then DOCUMENT it!).

(you suspect a Learning Difference, ADD, or underlying emotional, mental, or systemic health dx and want to address it with a referral)

• How do you tell them that you think they have a disorder and/or that you recommend they be tested or seek help from the appropriate professional?
  • “I’ve worked with students in the past who have struggled in similar ways to you.  I know you’re able to do this work–it just seems like something is getting in the way.  This is obviously beyond my scope of practice, so I’m going to suggest that you make an appointment with the counseling center because they may be able to give you a better understanding of what may be going on with your attention/processing/cognition/anxiety.”
  • What if they deny it, argue with you, or are resistant to your suggestions?
    • “No one ever told me this before.”
      • “It may be that the demands of this situation are just so big that you’ve been able to work around these issues up until this point.”
    • “Wouldn’t something like this have already been diagnosed?”
      • “I thought the same thing so I had a conversation with one of the counselors who shared that it is not uncommon for bright students to make it this far without being diagnosed.  Our overall intelligence and strong academic performance can mask attention/processing issues sometimes.”
    • “I’ve gotten through my education so far without any problems so how could I have a learning difference?”
      • “Bright students can often find workarounds to attention/processing issues until they reach this level of education.  At this point, sometimes the demands of the program become too big for any workarounds that may have been successful up until this point.”

• How should this be approached if a student has an actual physical disability that seems to be interfering with their progress or their ability to safely/accurately perform certain clinical tasks?
  • “I realize that what I’m about to say may be uncomfortable to discuss so please know that my intention is not to embarrass or shame you.  It seems to be that (description of disability or label of disability) may be interfering with your ability to perform this task–would you agree?  Should we spend some time problem-solving some workarounds?”
  • What if they get upset when you tell them that or they suddenly become very self-conscious, and withdrawn?
    • “What I’ve just shared with you seems to be upsetting to you.  Please know that this feedback is not intended to shame or embarrass you.  If I did hurt you or offend you, please know that it was not my intent to do that although I understand that it may have had that impact.”
  • What if they deny it and possibly become argumentative about it?
    • “Well I know I have that issue but I can still do all the parts of the exam. It’s not interfering with anything.”
      • “Okay, good to hear.  If this disability isn’t interfering with your ability to perform this task, what do you think is getting in the way?”
    • “I can just have a tech do that procedure for me or use an automated piece of equipment instead.”
      • “Once you practice under your own license, you are welcome to be as creative as you feel appropriate in completing necessary tasks of the job.  Here, however, you will need to be able to do this task manually so why don’t we problem-solve how to do that so you can pass this course?”

(Crying or angry upon receiving negative feedback)

• How do you calm down a student who starts crying? 
  • Normalizing/validating the emotion, encouraging deep breaths, offering a tissue. Look for a private area to talk, and slow down the pace of conversation.  Although being in the presence of someone crying can be uncomfortable, there’s nothing inherently wrong with crying.  Some people are just quicker to cry than others.  Your goal is to get them calm enough to hear the feedback.  
• What if in the process of becoming upset, they start to reveal underlying personal problems? What if they start telling us “too much”?
  • Empathy/validation/normalization first.  “Wow, it sounds like you’re going through an awful lot right now.  Have you thought about reaching out to counseling?”  “Anyone in your shoes would feel overwhelmed right now.  Let me give you some counseling center  emails so you can get in touch with a counselor and get some support.”
    • “I don’t know if I can handle all this because my boyfriend just broke up with me.” 
      •  “Ugh, couldn’t have happened at a worse time, right?” “It’s so hard to manage regular life stressors when you’re in graduate school, isn’t it?” “Breakups are so hard.  Heartbreak is just awful.”  Refer to the counseling center.
• They may become angry and start blaming others.
  • “Well, why haven’t my preceptors been telling me this all along?’
    • “It sounds like you feel blindsided by what I’m sharing.  I’m glad we’ve gotten the opportunity to discuss this feedback now so that you know what to work on going forward.”
  • “I only got the low grades from Dr. Perez and everyone knows she gives everyone low grades.”
    • “I hear you.  It’s frustrating that grading can feel subjective and even personal sometimes.  Let’s take a look at the bigger picture of your performance.  If you just received low grades from one professor, I wouldn’t be talking to you right now.  There seems to be a larger issue at play.  Let’s see what we can figure out.”
    • “I hear you.  It’s frustrating that grading can be subjective and it can feel personal sometimes.  Respectfully, not everyone is receiving the same grades from Dr. Perez as you are.  Compared to your classmates, even accounting for Dr. Perez’s tough grading, you’re not where we need you to be.  The good news is that we’re meeting right now and have some time to figure out a plan to help you be successful.”
  • “How am I supposed to know what to do when all the faculty want us to do things differently?”
    • “You’re right.  Faculty sometimes have different things that they focus on in more detail.  Over time, you’ll come to know everyone’s idiosyncrasies and adapt accordingly.  In the meantime, let’s figure out what is in your control to improve because the important thing to keep in mind is that all preceptors are looking for the same building blocks.  If we work on your foundation, idiosyncratic grading shouldn’t significantly impact your performance.”

(Panics, withdraws, appears ashamed, or seems to be in despair upon receiving negative feedback)

• May panic 
  • “Does this mean I am going to fail?”
    • “The reason we’re addressing this right now is so that you have time to make the necessary adjustments before it’s too late.” 
  • “Am I going to graduate on time?”
    • “I can’t imagine why you shouldn’t graduate on time if you apply this feedback now.”
  • “I can’t believe this is happening.”
    • “It’s normal to be upset at first when receiving feedback like this.  With a little space, I know you can take a breath, apply the feedback, and get to where you need to be.”
• May withdraw and suddenly become quiet and stop making eye contact.
  • What do we say to engage them at this point?
  • “ I’m noticing you’ve seemed to shut down a bit. Is there anything that would make you feel safer/more comfortable right now?  Do you want me to give you a few minutes to digest this feedback?  Could you use a minute alone?  Why don’t I grab you some water while you take a few breaths?  I’ll be right back.” 
• May show despair
  • • “I knew this was going to happen.”
      • “Even when we’re prepared to hear something, it can still be hard to digest.  I completely understand.”
    • “I don’t know how I am going to get better.”
      • “Good news-that’s where I come in.  I have some ideas to help you improve.  I know you can do this.”
    • “I have finals coming up and now this?”
      • “You’re juggling a lot right now.  I’ve worked with many students who have been in your situation before and they’ve been able to figure it all out.  I can’t see any reason that you won’t figure it out too.  You can do this!”
• Often it is suggested that they speak with specific preceptors to get specific or detailed feedback, guidance, and ask for help but they admit apprehension.
  • “I’m afraid to talk to Dr. Patel. He intimidates me too much.”
    • “It’s normal to feel anxious when interacting with people we respect.  It would be in your best interest to get specific feedback from Dr. Patel, however.  If your anxiety is getting in the way of you talking with Dr. Patel, I might suggest talking with someone from the counseling center so that you can work on some anxiety management tools.”
  • “Dr. S already thinks I am a poor student so I don’t want to make things worse by meeting with her.” 
    • “The only thing that meeting with Dr. Strayer will do is potentially improve your performance.  When a student takes the initiative to meet with me, I have a greater respect for them because I see that they are taking themselves seriously as a professional.  I’m willing to bet that Dr. Strayer feels the same way.”
    • “Help me understand how you think that meeting with Dr. Strayer will make things worse. If she already thinks that you are a poor student, you have the opportunity to change her mind by showing initiative to improve.”
• See the previous section for the ‘dismissive student’ script

(Late to arrive, leaves early, calls out of clinic sessions or wants to make switches frequently, not dressed appropriately, disrespectful towards faculty, staff, students, or worst of all, patients)

• Use verbiage to address these issues directly with the student.
  • “Hi there, I need to bring a few things to your attention.  Over the past few weeks, you’ve been arriving late/leaving early/calling out of the clinic more frequently and this concerns me.  There are a certain number of hours required of you in the clinic to graduate.  If the current pattern continues, you will be at risk of not meeting those requirements.  Do you want to share with me what is getting in the way of you being able to get in your required training hours? (help to problem solve, i.e. are there transportation issues? Redirect to counseling if personal issues).

• “Hello, (student name).  I need to share some feedback with you about interpersonal interactions with faculty/staff/students/patients. Could you talk with me so that I can try to fully understand what might be going on?”

• “Part of being a professional is how we dress and how we interact with people.  If you don’t mind, I’d like to share some feedback with you about these topics and then I’d like to work with you to improve these areas.”

• What would be effective and appropriate consequences for such behavior? 
  • Consider a verbal or written warning first, and let the student know that continued episodes of unprofessional behavior will impact their grade.
  • Connect with the Student Affairs team about whether this is a theme of behavior for this student.  There may be other issues going on in their home life.