Diagnose - Assessing the Difficulty


You have identified a learner in difficulty. Documentation and creating a plan are key to avoiding further difficulties for the learner, the program, and ultimately patient care. Acting earlier increases the chances of positive outcomes and decreases potential for harm.

Red Flags
If there are red flags such as gross incompetence, violent behavior, patient safety issues, or substance abuse, remove the learner from the work environment: consult the policy here. Thereafter, you may want to return here to diagnose the underlying reasons for the difficulty. In the absence of red flags, whether you are going on a hunch or on documented learner behaviors that interfere with the learner achieving competencies, understanding why the difficulties arise is key to supporting learners to achieving their best outcomes.

Using SOAP to Diagnose Difficulty
Using the SOAP (subjective, objective, assessment, plan) note format for thinking about your approach, consider the subjective and objective information on the learner to make your diagnosis. What have you or others said and noticed that made you think there might be difficulty?

Subjective:  For example, has this learner been labelled as “slow, aggressive, unprofessional” by preceptors, others on the team including other learners? Does the learner think there is a problem?
Objective: For example, Takes twice as long compared with peers to complete dictation; Interrupted patients three times during history taking; When gathering data, multiple sources will provide a fuller picture, but make sure one source is direct observation from faculty.
Assessment: When diagnosing the reasons for difficulty, look at knowledge, skills, attitudes, interpersonal, and structural areas. It’s helpful to use a framework to think about possible factors.

The CanMEDS competencies are a very useful and familiar structure to help describe what the performance deficits are for your learner.  However, they do little to assess why these are occurring. Cross referencing the CanMEDS competencies or  objectives with the following categories can be helpful in seeing where symptoms are and how underlying issues manifest. The categories include cognitive, affective, valuative, environmental and medical.


Factors Contributing to Learner Difficulties


  • Knowledge base weak/gaps

  • Clinical skills less than expected

  • Dyslexia? Learning Disabilities?

  • Critical Thinking: Problem Solving or Clinical Reasoning


  • Related to emotion

  • Anxiety, depression, - slow down learning/performance

  • Anger, fear, - can arise from previous learning experiences or deeply held beliefs

  • Difficulties with social interaction



  • Based on values

  • Often seen when mismatched with program/preceptor expectations


  • Changes in learning environment

  • Learned hasn't adjusted


  • Mental Health - e.g. diagnosed anxiety/depression, illness such as schizophrenia

  • Temporary Illness - e.g. pneumonia, mono

  • Pre-existing Illness now poorly controlled due to change/stress


A Second Approach to Diagnose Difficulty

Another way to diagnose learner difficulty is analogous to the medical history and physical exam approach. Based on their review of the literature, Lacasse, Théorêt, Skalanda, and Lee’s (2012) approach examines past educational history, history of the present difficulties, objective examination, and identification of personal situation, habits, and review of systems (See Figure 1).

Figure 1: Assessing the Difficulty
Based on Lacasse, Théorêt, Saklenda, & Lee (2012)



There is good overlap between the two approaches, but this second one isolates the teacher as a factor in a way the previous one did not. Teacher related issues may include personal or family health as well as practice, relationship, or staffing issues. Teacher factors, like some environmental or structural factors, are not always considered in forming a remediation or learning plan. However, it may help to consider these when reflecting on learning environment.

UofM Respectful Work and Learning Environment Policies

WRHA Respectful Workplace Policy

Teachers may also benefit from learning more about teaching e.g. providing feedback (coaching). For a list of faculty development workshop topics and opportunities, see the resources tab.


SOAP approach is based on a presentation developed by the Mountain Area Health Education Center in Asheville, North Carolina, with a grant from the federal Health Research and Services Administration.

Lacasse, M., Théorêt, J., Skalenda, P., & Lee, S. (2012). Challenging learning situations in medical education: Innovative and structured tools for assessment, educational diagnosis, and intervention. Part 1: history or data gathering. Canadian Family Physician, 58(2). 481-484.