Prediction and prevention of failure: an early intervention to assist at-risk medical students.

BACKGROUND: Consistent identification and prevention of failure for at-risk medical students is challenging, failing courses is costly to all stakeholders, and there is need for further research into duration, timing and structure of interventions to help students in difficulty. AIMS: To verify the value of a new exam two weeks into medical school as a predictor of failure, and explore the requirements for a preventative intervention. METHODS: Students who failed the two-week exam were invited to a series of large-group workshops and small-group follow-up meetings. Participants' subsequent exam performance was compared with non-participants. RESULTS: About 71% of students who performed poorly in the new exam subsequently failed a course. Attendance at the workshops made no difference to short- or long-term pass rates. Attendance at more than three follow-up small group sessions significantly improved pass rates two semesters later, and was influenced by teacher experience. CONCLUSIONS: Close similarity between predictor task and target task is important for accurate prediction of failure. Consideration should be given to dose effect and class size in the prevention of failure of at-risk students, and we recommend a systemic approach to intervention/remediation programmes, involving a whole semester of mandatory, weekly small group meetings with experienced teachers.

Remediation of at-risk medical students: theory in action.

BACKGROUND: Previous work has shown that a programme that draws on a blend of theories makes a positive difference to outcomes for students who fail and repeat their first semester at medical school. Exploration of student and teacher perspectives revealed that remediation of struggling medical students can be achieved through a cognitive apprenticeship within a small community of inquiry. This community needs expert teachers capable of performing a unique combination of roles (facilitator, nurturing mentor, disciplinarian, diagnostician and role model), with high levels of teaching presence and practical wisdom. Yet, despite participants' convergent opinions on the elements of effective remediation, significant differences were found between outcomes of students working with experienced and inexperienced teachers. The current study explores the actual practice of teachers on this remediation course, aiming to exemplify elements of our theory of remediation and explore differences between teachers. METHODS: Since it is in the classroom context that the interactions that constitute the complex process of remediation emerge, this practice-based research has focused on direct observation of classroom teaching. Nineteen hours of small group sessions were recorded and transcribed. Drawing on ethnography and sociocultural discourse analysis, selected samples of talk-in-context demonstrate how the various elements of remediation play out in practice, highlighting aspects that are most effective, and identifying differences between experienced and novice teachers. RESULTS: Long-term student outcomes are strongly correlated to teacher experience (r, 0.81). Compared to inexperienced teachers, experienced teachers provide more challenging, disruptive facilitation, and take a dialogic stance that encourages more collaborative group dynamics. They are more expert at diagnosing cognitive errors, provide frequent metacognitive time-outs and make explicit links across the curriculum. CONCLUSIONS: Remediation is effective in small groups where dialogue is used for collaborative knowledge construction and social regulation. This requires facilitation by experienced teachers who attend to details of both content and process, and use timely interventions to foster curiosity and the will to learn. These teachers should actively challenge students' language use, logical inconsistencies and uncertainties, problematize their assumptions, and provide a metacognitive regulatory voice that can generate attitudinal shifts and nurture the development of independent critical thinkers.

The role of the teacher in remediating at-risk medical students.

BACKGROUND: Previous work identified complex ingredients of a remediation programme for at-risk medical students: mandatory, stable, facilitated small groups promote both cognitive and affective developments, with improved self-regulation, metacognition and reflection resulting in significant performance gains. AIM: We explore the teachers' role in this intervention, aiming to expand and deepen understanding of remediation methods in medical education. METHODS: Extensive qualitative data from student surveys and in-depth teacher interviews, along with quantitative student performance data, produced a rich description of remediation processes. RESULTS: Remediation should support emotional needs and foster cognitive and metacognitive skills for self-regulation and critical thinking. Teachers of remediation need to motivate, critique, challenge and advise their learners, applying teaching and contextual expertise in a constructivist, student-centred environment that fosters curiosity and joy for learning. Teachers of remediation can mediate these processes through embodiment of five core roles: facilitator, nurturing mentor, disciplinarian, diagnostician and modeller of desired skills, attitudes and behaviours. CONCLUSION: Remediation of struggling medical students can be achieved through a cognitive apprenticeship within a small community of inquiry that motivates and challenges the students. This community needs teachers capable of performing a unique combination of roles that demands high levels of teaching presence and practical wisdom.

At-risk medical students: implications of students' voice for the theory and practice of remediation.

OBJECTIVES: A mandatory remedial programme for students who repeat their first semester at medical school has resulted in large gains in academic performance and greatly reduced attrition. Here, we explore the students' views of this in order to clarify understanding of optimal remediation practice. METHODS: Using a mixed-methods approach, quantitative and qualitative data were gathered from student surveys (n=333) and three in-depth focus groups. Results were analysed for emergent themes. RESULTS: Remedial programmes for at-risk medical students should be mandatory, but should respect students' identity as repeaters. Attitude and motivation are key, and working in stable groups provides essential emotional and cognitive support. The learning environment needs to foster changes in students' ways of thinking and their development as flexible, reflective learners. These endeavours require support from honest teachers with rigorous expectations and good facilitation skills. CONCLUSIONS: Successful remediation needs to challenge students' conceptions of learning, works best in groups with skilled facilitators, and must take into account a blend of cognitive and affective factors and the complex interplay between learner and environment. Given a carefully designed programme, at-risk medical students can learn to make effective and lasting changes to their approach to study, and their views of learning can come to converge with influential ideas in the education literature.

An investigation into the design and effectiveness of a mandatory cognitive skills programme for at-risk medical students.

BACKGROUND: Many medical schools provide academic support programmes to aid increasing numbers of students from diverse backgrounds. There have been calls for research into successful intervention programmes, and for detailed descriptions of how they work. AIMS: To explore the efficacy of a mandatory intervention programme for at-risk medical students. METHOD: Students who failed and then repeated first semester were required to participate in a cognitive skills programme, following a syllabus based on principles drawn from both educational experience and multi-disciplinary theory and practice. Performance of programme participants was compared to the performance of students who repeated prior to the mandatory programme. RESULTS: Of the participants (n = 216), 91% passed their repeat semester, compared to 58% (n = 715) for controls (p < 0.0001). This significant effect persisted for progression through the school for the subsequent three semesters (p < 0.0005). CONCLUSION: A mandatory programme that draws on a blend of theories and research-proven techniques can make a positive difference to the outcomes for at-risk medical students.