Managing the struggling ophthalmology learner: a review

Introduction

Background

Struggles for learners in undergraduate medical education (UME) and graduate medical education (GME) are increasingly common, with up to 15% of medical students and between 6% and 26% of residents, in various specialties, having performance deficiencies (1,2). As students encounter difficulties in their education, it is important for clinical educators to be prepared with knowledge to identify and diagnose deficiencies as well as tactics for assistance and informal remediation.

The struggling learner is an individual who has not met the outlined competencies of their rotation, clerkship, course, or residency program and may not be on an appropriate trajectory to do so in a standard timeframe. These competencies can vary depending on the educational scenario, but should be clearly outlined to both the learner and educator. Six core competencies have been outlined by the Accreditation Council for Graduate Medical Education (ACGME): medical knowledge, patient care, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning (3). Competencies can be measured based on the performance of pre-determined ‘entrustable’ professional activities (EPAs) (4). An EPA is a unit of professional work (e.g., a discrete task) that can be entrusted to a learner once they are determined to be competent to perform the work without direct supervision (4). Each EPA may reflect on multiple competencies and can serve as a bridge that translates these abstract competencies into real-world clinical responsibilities. For example, performing a direct ophthalmoscope examination could be an EPA that requires competence in communication skills, professionalism, and systems-based practice.

Medical schools and residency programs are responsible for ensuring that future physicians maintain a high level of competency. Performance problems in knowledge and professionalism have been correlated with future disciplinary action by state medical boards, making it important that both categories of issues are addressed through remediation (5,6). GME training programs have valuable opportunities for the recognition of learner deficits and early intervention, which can improve future patient care. However, if educators are not equipped with skills to assist struggling learners, the increased scrutiny and negative feedback can result in increased stress and decreased motivation, worsening learner performance (7).

Knowledge gap

With the prevalence of struggling learners, clear methods for addressing the struggling learner as an educator are necessitated. For resident physicians, institutions have policy to guide educators through the formal remediation process, as required by the ACGME (8). However, before formal remediation is initiated, informal remediation efforts are often attempted in clinical clerkships and residency programs. Research on teaching methods for specific ophthalmic procedures and overall mentoring has been conducted, however within current literature there is little written on evidence-based processes for informal remediation of ophthalmology learners (9,10).

Objective

Instead of creating a fully unique framework for educators to learn and implement, we can modify the clinical method which educators use on a daily basis to be applicable to education. The clinical SOAP (subjective, objective, assessment, and plan) framework is beneficial in ophthalmology education for the same reason it is used in medicine. It provides a systematic method for ensuring that one gathers the appropriate information to formulate an accurate assessment and logical plan for intervention, whether it is for a medical condition or struggling learner. In this article, we propose evidence-supported strategies for educators of medical students on ophthalmology rotations and ophthalmology residents to assist the struggling learner.

Applying a familiar model

Many authors have proposed applying a clinical model to medical education for learners experiencing difficulties, beginning with Langlois and Thach integrating the SOAP clinical model in 2000 (11-15). The SOAP method is commonly used in practice as a method to both document and organize clinical reasoning (16). The application of an already commonly used method allows educators to address the struggling learner using a familiar process. Clinical educators can apply the same cognitive framework used for sick patients to struggling learners in gathering information, assessing for risk factors and diagnosing the problem before creating an individualized plan to correct the issue. In addition to this model, steps for prevention, screening and reassessment can be added to further aid in the management of struggling learners (Figure 1).

Figure 1 Clinical model applied to the struggling learner. SOAP, subjective, objective, assessment, and plan.

Prevention

Before diseases emerge, public health efforts can be implemented to preserve health. Similarly, actions can be taken to prepare for or prevent learner challenges. One such action is to outline student performance expectations at the beginning of their learning experience (17). For example, without expectations for learner attire, a student may report to rounds with a “disheveled appearance” of sneakers, scrubs, and untidy hair. For the student, this may be their normal classroom attire, while, in the clinic, the educator may have expected business casual and a white coat.

As an educator who may have guided numerous students and residents through their training, standards of performance may seem obvious. However, the everyday actions and dynamics of longtime educators are almost always novel to students. Learners and educators may have differing expectations for their own responsibilities and actions, potentially leading to both teacher and learner dissatisfaction (18). Quillin et al. surveyed students and faculty on clinical clerkships regarding the perceived responsibilities of each party. The study found that while both students and faculty agreed that students were responsible for examining patients and gathering patient data on rounds, more students expected to be responsible for writing daily progress notes while less faculty expected task to be completed by students. Misaligned expectations may cause students to spend their time performing unnecessary tasks, increasing student fatigue and worsening performance in tasks which the educator is evaluating.

For learners beginning rotations at any level, providing an orientation as they begin each rotation can assist them in learning the mechanics of the facility, expected duties or EPAs, the performance standards, and assessment means (19). The student should be oriented to both the basic mechanics of the rotation, such as hours, electronic medical records, and access to facilities, as well as to the learning process at that clerkship site. The learning process includes the covered curriculum, expected competencies, and resources available for learning. Questions should be asked of the learner to better orient the teacher to the learner’s past experiences, specific learning goals, and expectations. Students value an organized learning environment which can be achieved through clear communication and goals (20).

At the orientation, the daily actions of learners can be outlined as their EPAs. These EPAs may be defined by the core curriculum, even if not referred to as such, but need to be modified as the learner develops progressive autonomy. For example, a resident is expected to be capable of performing a full history and physical on their first day of residency; therefore, it may be a starting EPA. Once the student has completed more training, they will progress through more advanced EPAs, such as performing specialized procedures.

Screening

Similar to its impact on disease prevention and progression, screening identifies a deficiency in learning early enough to successfully intervene. Learner deficits are easier to correct if addressed quickly (21). Methods for screening learners for deficits include Objective Structured Clinical Examinations (OSCEs), quizzes, standardized testing, direct observation, and regular feedback sessions.

Oftentimes, clinical rotations have a final summative evaluation at the end of the learner’s rotation, when the most critical time for formative feedback and intervention has already passed. Including weekly quizzes or a pre-test during the clerkship could help to assess knowledge gaps with enough time to assist the learner before the final assessment (12).

Structured feedback sessions at regularly scheduled intervals can provide the opportunity for the learner and teacher to openly express their perceptions of performance to date. This is important to ensure both participants’ expectations are being met or to allow early opportunity to adjudicate. It is recommended that feedback sessions encourage learners to actively participate in the feedback process, with self-evaluation being a helpful method of gauging learner self-awareness. The feedback sessions are most effective when they provide dedicated time/space, focus on growth opportunities, and contain adequate structure to mitigate bias and provide actionable feedback (22).

The SOAP process for struggling learners

Subjective

There are a multitude of subjective ways in which deficits can be identified prior to an objectively poor patient outcome. These subjective observations include: poor reviews from patients, comments from other faculty or staff, or direct observation of patient interactions. Much like in patient care, a struggling learner may be unaware of their deficit or may be fully cognizant of their problem with various levels of willingness to address it. Once a general deficit is noticed by the educator, the process to improve the learner’s performance can begin.

Objective

The first step after a deficit has been noticed is to gather more objective information to determine which expectations were not met and generate a differential for why this learner may be struggling. This information should come from a variety of sources, such as other faculty who have observed the learner, direct observation, written assessments, or learner feedback.

In addition to the broad six core competencies outlined by the ACGME which were discussed earlier, the ACGME also provides specialty specific milestones which can be used to evaluate resident performance and identify areas for improvement (23). The Ophthalmology, ACGME Report Worksheet can be accessed through the ACGME website and utilized to provide more objective criteria for evaluation of resident performance. There is currently not an equivalent standardized list for evaluation of medical students on ophthalmology clerkships, however individual institutions may provide an evaluation form which can be utilized to evaluate learners. These clerkship evaluation forms may vary between institutions. This lack of a standardized evaluation method for medical students on ophthalmology clerkships underscores the importance of setting expectations at the beginning of a clerkship. Additionally, educators may benefit from the development of a standardized evaluation form for medical students on clerkships equivalent to the Ophthalmology, ACGME Report Worksheet.

If possible, direct observation of the learner interacting with patients and completing clinical tasks can provide clear information on the learner’s abilities (24). When managing multiple learners, it may be difficult to observe them directly and others who work more closely may have more insight into the learner’s performance (1). For example, a resident who goes on teaching rounds with a third-year medical student may have more direct experience with the student’s bedside manner compared to the attending.

The learners themselves can also be an important source of information regarding their own performance. An informal meeting with the learner can allow for self-reflection and gauge self-awareness and motivation. These meetings can therefore serve a dual purpose of gaining information to guide intervention while also stimulating awareness and prompting learner directed self-assessment. Self-reflection has been shown to assist in resident learning in many ways including solidifying professional values, increasing comfort in difficult learning situations, and enhancing engagement (25). Studies have found varying levels of accuracy in student self-assessments, potentially due to student lack of confidence or overconfidence, value in modesty, pressure to appear successful, or a lack of guided parameters for self-assessment (26,27). The uncertainty on the accuracy of self-assessments increases the importance of multiple sources of information regarding the learner’s performance (17,24). Educators may gather information regarding learner performance from multiple sources then compare the information and look for patterns of learner deficits. This can increase the accuracy of the overall evaluation.

Meeting directly with learners can assist in further evaluating reasons for unmet expectations by opening lines of communication and reducing hierarchical barriers to seeking help. Many extrinsic stressors can impact students’ lives and academic performance while remaining largely unnoticed by educators unless openly discussed. Without asking for information about the difficult situations that students may be facing, educators will not know what resources the students may benefit from or the approach that might be most effective in addressing a deficiency.

Each of these preceding steps should be documented along with the learner’s overall progress. By increasing documentation, educators and program directors retain a record of issues which can allow them to see future improvement and can assist in evaluating potential interventions (15,17). Additionally, in the unfortunate circumstance that the intervention does not work, documentation of the learner’s deficit and the educator’s efforts at remediation are necessary to justify further intervention or dismissal from the program.

Many residency programs use a learning platform to submit evaluations, forming an electronic file for each resident. However, faculty may be hesitant to codify negative feedback in formal evaluations. Instead, educators often communicate feedback through emails or personal conversations with the program director. Without a method of continuous documentation, other faculty may be unable to see trends of deficits or improvements and therefore are less prepared to assist learners. Programs may benefit from providing faculty with informal mechanisms for expressing concerns that can be documented and used to produce actionable feedback for residents. Additionally, faculty may benefit from instructions on how to provide and document meaningful formal feedback without fear of alienating a learner or facing backlash.

Assessment

Much like patients with multiple comorbidities, struggling students often have multifactorial issues and they can interact in complex ways. Illness scripts, like those we use to identify how diseases typically present, can be used to identify underlying student difficulties and their presentation. Broadly, difficulties experienced by learners can be categorized as cognitive challenges, non-cognitive personal challenges, and systemic factors (15). These challenges act like disease risk factors, predisposing learners to lack competency and display deficient performance, the symptom (Figure 2).

Figure 2 Parallel progression of disease and learning struggles.

Cognitive challenges include difficulties involving organized clinical thinking, sparse knowledge base, poor test-taking, or ineffective time management (15,28). For example, a learner who performs a thorough history and examination but fails to generate a comprehensive differential may lack a sufficient knowledge base or struggle with synthesizing information. Assessment tools, such as quizzes or case-based exercises, can help determine whether the issue lies in knowledge acquisition or reasoning, allowing for targeted remediation. Behaviors such as frequent tardiness or missed deadlines—while sometimes interpreted as professionalism lapses—may stem from cognitive challenges like poor time management or attention deficits.

Non-cognitive personal challenges involve one’s physical and mental wellbeing, life responsibilities, and sociocultural background (15). These may impact professionalism (e.g., tardiness due to caregiving responsibilities), medical knowledge (e.g., stress-related performance decline), and interpersonal communication (e.g., differences in bedside manner shaped by cultural norms) (29,30). In these cases, interventions aimed at cognitive development may be insufficient unless the root cause is also addressed.

Systemic factors within the learning environment also contribute to academic difficulties. Overcrowded clinical settings may limit feedback, reduce opportunities for independent decision-making, and hinder learner growth and confidence. Excessive demands or unsupervised experiences can increase stress and burnout, leading to errors, erosion of confidence, and the development of poor habits. Inadequate faculty resources may further restrict observation, mentorship, and timely correction of issues. An inherent systemic challenge is the transition from structured undergraduate learning to asynchronous and experiential medical education. Without defined learning units, students must rely on intrinsic motivation and time management to apply theoretical knowledge in unpredictable real-world scenarios.

Specific challenges in ophthalmology provide systemic difficulties in ophthalmologic education. As there is no standardized ophthalmology core curriculum from the Liaison Committee on Medical Education, ophthalmology exposure in UME varies greatly and many students are not provided opportunities to develop fundamental ophthalmologic knowledge and clinical skills (31). Students often do not have required clinical skills labs or dedicated rotations to develop the skills necessary to examine ocular problems, which may worsen as medical schools shorten curricula (9,10,31,32).

Beyond challenges with knowledge acquisition, the clinical skills necessary for ophthalmology are technical and unfamiliar to most beginning learners. Optical physics and diagnostic testing are unique to the field and have little space in medical school curricula. The use of slit lamps, retinoscopes, phoropters, lensometers, and many other fundamental tools are critical to diagnostic accuracy, but difficult to learn, and UME in the United States of America often offers limited training and practice opportunities with these tools due to time and resource constraints (33). Ophthalmology requires development of both microsurgical and macro-surgical skills in a small operative field with high complexity. The novelty of the tools and surgical techniques to residents can create a steep learning curve. Program directors have been shown to believe that residents are underprepared in surgical skills by UME (34).

It is important to recognize that while this article examines the impacts of these issues on ophthalmology education, similar issues can be encountered in every specialty, and the tactics proposed in this article may be applied across a broad range of specialties.

Taken together, cognitive challenges, personal challenges, and systemic factors often coexist and interact in complex ways. By carefully identifying not only the observable performance issues but also the contributing factors, educators can more effectively tailor support and remediation strategies to the individual learner.

Plan

After observations and assessments, an individualized plan should be formulated (17). Much like in patient care, the plan may be simply ongoing observation or reassurance when struggles are mild. However, in cases with severe deficits, a deliberate, structured, and strategic plan for remediation should be formed. These plans can be developed in collaboration with struggling learners to ensure that the plan is aligned with their needs and motivations and to increase learner skills in self-reflection and lifelong learning ability. It should be decided if the remediation plan is required or voluntary, and the learner should be informed of the consequences for non-remediation (24). Once strategies have been implemented, documentation should be made of the strategies utilized (7).

Educators may feel great responsibility for the challenges faced by their students, but if they attempt to solve all issues independently, they could experience fatigue and burnout. Remediation, like clinical medicine, should be seen as a group effort and can include the use of interprofessional experts such as mental health professionals, learning specialists, tutors, and simulation experts (17). It has been suggested and is already implemented at some institutions that a “third party” other than the learner and educator should be involved in the remediation plan (17). This allows the learner to feel safer in the process and allows the educator to maintain enough distance to make difficult decisions if the outcome of remediation is not successful. At some institutions, formal remediation programs include a referral to the university ombudsman program, where faculty members who are selected by residents as known resident advocates volunteer their time to help support residents in a time of need.

A combination of strategies may be employed for each learner targeting their specific challenge. Non-cognitive issues are more frequently managed by referral to outside resources specific to the challenges experienced by the learner (24). Each institution may have a variety of available resources to assist students struggling with mental health issues, financial strain, or other hardships. Educators may benefit from reviewing the available resources at their institution or from connecting with a student support office to inquire about available resources. A comprehensive list of wellness resources was not included in this article, but many academic health centers, state or county medical societies and licensing boards have physician health programs to provide confidential assistance and resources. Included below is a chart of potential strategies for intervention to assist with cognitive and non-cognitive issues (Table 1).

Reassess

After the intervention, the learner should be reassessed for competence (12,24). Formal remediation efforts of resident physicians often last between 6 and 12 months at which point the learner is reassessed for competence (35). An informal remediation process may have a more varied time frame. For informal resident remediation, it is important to reassess quickly, within weeks, to determine the need for potential formal remediation. The reassessment can be in the same form as the first assessment, allowing the educator to compare the outcome to their previous documentation and determine if improvements were made. In the case of clerkships lasting between 2 and 4 weeks, the reassessment may instead be the shelf exam and the end of clerkship evaluation.

Ideally, competence was achieved, and learners developed improved clinical skills, autonomy, and resilience. Early interventions in clinical education improve patient care for years to come. If a learner does not gain competency through the initial informal remediation effort, additional steps may need to be taken. If the learner is in medical school on a clerkship, the medical school can be notified and activate their process for greater remediation, such as the repetition of the clerkship and utilization of additional outside resources (12). If the medical student attempted a formal remediation process at the institution’s direction and has still not achieved competence, it may be necessary to remove the student from the program and guide them to other careers. The student may be directed to work with a learning specialist or career counselor to determine other careers or specialties to consider based on the individual student’s strengths, difficulties, and goals. There are also a portion of resident physicians who do not gain competency from a formal remediation who then may be placed on probation, receive further remediation or potentially withdraw from the program or are dismissed (8). In the consideration of dismissal of a medical student or a resident, it is necessary to review specific institution policies and ensure that the outlined formal process is taken and documented.

A “failure to fail” medical learners is potentially dangerous. Medical educators have a collective duty to create physicians with a standard of care necessary to provide quality medical care and communicate with patients and coworkers in a compassionate and respectful manner. If these standards are not upheld in students, they will have a higher risk of professionalism issues, and their future patients may suffer. Regardless of the outcome, the knowledge that educators implemented effective remediation efforts can improve educator satisfaction (7).

Limitations

While the SOAP-based framework provides a structured and familiar process for physician educators on approaching a struggling learner, there are several real-world challenges that may limit its implementation. Firstly, physician educators manage a wide variety of roles that may make it difficult to implement this process. Clinical educators must manage their core clinical commitments in addition to handling administrative responsibilities, research, mentorship, patient-related concerns, and other competing demands that may leave limited time for structured remediation strategies. Secondly, hospital or institutional policies may limit how and/or when the process of remediation is initiated. Notably, the informal remediation process may differ depending on the educator, due in part to the lack of standardization, which may result in variable learner experiences. However, despite these limitations, adapting and incorporating the SOAP framework in the context of ophthalmology education provides a practical and familiar structure to the remediation process.

Conclusions

The struggling learner is a common challenge in academic settings. Clinicians can apply the SOAP method within the context of a struggling learner, which may allow opportunities to improve academic and clinical outcomes as well as both learner and educator satisfaction. The clinical SOAP format can be applied and expanded in ophthalmology education through tactics for: prevention of struggling students (outlining expectations), screening for competency deficits (frequent assessments), subjective noticing of deficits, objective documentation of unmet expectations, assessment of the deficit and its root causes, collaborative formation of a remediation plan, and reassessment of the competency.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science for the series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology”. The article has undergone external peer review.

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-43/prf

Funding: This work was supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY, USA to A.M.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-43/coif). The series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology” was commissioned by the editorial office without any funding or sponsorship. A.G.L. serves as an unpaid editorial board member of Annals of Eye Science from June 2024 to December 2026 and served as the unpaid Guest Editor of the series. A.G.L. has served as a consultant for the National Aeronautics and Space Administration (NASA), the National Football League (NFL), US Department of Justice, and is a consultant for Amgen, AstraZeneca, Argenx, Bristol-Myers Squibb, Alexion, Celgene, Stoke, Ethyreal, Catalyst, Dompe, and Viridian. A.G.L. received payment from Amgen, Viridian, Alexion and Dompe. He participates on a Data Safety Monitoring Board or Advisory Board of Astrazeneca and Celgene. A.G.L. is also on the editorial board of JNO, CJO, JJO, and JAMA Ophthalmology. A.M. received an unrestricted grant from Research to Prevent Blindness, Inc., New York. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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