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Do We Plan to Remediate or Attempt to Prevent?

Maholtz, Danielle, DO

doi: 10.1097/ACM.0000000000002524
Letters to the Editor

Chief resident, Pediatrics Residency Program, and pediatric hospitalist, Akron Children’s Hospital, Akron, Ohio;; ORCID:

Disclosures: None reported.

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To the Editor:

As a graduating resident, I’ve had my share of examination struggles. During medical school, I performed well on tests and scored mostly honors on clinical rotations, but licensing examinations were anxiety inducing. It was difficult to correlate my seemingly robust clinical knowledge and cognitive reasoning with my poor exam performance. I sought advice through many avenues and arrived at a singular outcome—the generic recommendation to read more and complete an abundance of questions. These suggestions left me feeling frustrated, unsupported, and hopeless.

A search for evidence-based strategies to improve medical examination performance produces few approaches previously grounded in educational theory and appropriately studied. The efforts of Andrews and colleagues1 are commendable. They developed an approach to recognize specific areas of difficulty for struggling learners with guided approaches to remediating each deficiency. While I applaud these steps, the authors only performed the intervention for second-year residents who were known strugglers; we need to consider the benefit of utilizing their method in recognizing strugglers and providing guidance earlier in training. Artino and colleagues2 studied the use of a similar approach in second-year medical students working through a written case. They found a correlation between forethought processing during practice cases and improved outcomes on later United States Medical Licensing Examination and National Board of Medical Examiner examinations.

Previous studies have demonstrated little variance in outcomes of basic science knowledge and/or clinical skill utilizing current methods of assessment in medical education.3 Additionally, they do not focus on identifying the underlying factors triggering poor performance, which can limit effective and critical feedback. Regardless of the perceived ability of performers, promotion of the self-regulated learning approach proposed by Andrews and colleagues1 from the beginning of residency can promote development of critical thinking skills and diagnostic scripts before a learner may begin to struggle. Furthermore, regular review of a resident’s self-regulatory learning process throughout residency may serve as a more adequate assessment tool than any other method that is currently available.

Danielle Maholtz, DO

Chief resident, Pediatrics Residency Program, and pediatric hospitalist, Akron Children’s Hospital, Akron, Ohio;; ORCID:

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1. Andrews MA, Kelly WF, DeZee KJ. Why does this learner perform poorly on tests? Using self-regulated learning theory to diagnose the problem and implement solutions. Acad Med. 2018;93:612–615.
2. Artino AR Jr, Cleary TJ, Dong T, Hemmer PA, Durning SJ. Exploring clinical reasoning in novices: A self-regulated learning microanalytic assessment approach. Med Educ. 2014;48:280–291.
3. Durning SJ, Cleary TJ, Sandars J, Hemmer P, Kokotailo P, Artino AR. Perspective: Viewing “strugglers” through a different lens: How a self-regulated learning perspective can help medical educators with assessment and remediation. Acad Med. 2011;86:488–495.
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