One size doesn’t fit all: framework and resources for individualized interventions for struggling medical students [version 1; peer review: awaiting peer review]

When helping struggling medical students, a “one size fits all” approach is often ineffective, as many different factors affect academic success. In our experience, these factors may overlap or be distinct for each student, and thus require individualized interventions based on student needs. We recommend an individualized model of academic support includes an intake interview, assessment, individualized interventions, and follow up to assess progress. This paper provides a recommended framework of resources for medical school faculty and staff who work with struggling students. Different issues that lead students to struggle are categorized in the main domains of Bloom’s taxonomy: cognitive, affective, and psychomotor. A discussion of the impact of the factors in each domain includes detailed tables with corresponding manifestations, assessments, and support strategies literature for each issue. An application of a proposed framework is presented on a case example. Individualized approaches to improving medical student success are presented to address the complex and interrelated areas of academic success, wellbeing, quality of life, career potential, and satisfaction with medical school.


Why one size doesn't fit all for interventions for struggling medical students
It is often unclear why some students do not thrive in medical school. Medical schools have sought to address many of these negative outcomes at the school or program level with interventions such as curricular changes and academic support services. Support services are frequently similar resources offered to any struggling medical student, e.g., board exam preparation programs, time management seminars, study skills workshops, and bolstering wellness program offerings. Additionally, a standard set of resources is offered to a struggling student, such as discussing problems with a Course Director, studying better/more, attending peer tutoring, or other standardized remediation offerings.
The problem with this "one-size-fits-all" approach to resources is two-fold. First, failure to thrive academically is caused by a variety of specific and sometimes overlapping factors that are distinct for each student, and thus need distinct interventions. Second, limited systematic monitoring of progress for struggling students leaves many questions. Have students availed themselves of academic success resources?
If not, what barriers exist? Have resources proven effective as evidenced by outcomes? Are other assessments needed to identify issues that may be preventing success?

How to best individualize help?
Medical education programs teach medical students how to propose a differential diagnosis based on an individual patient's presentation and history, assessment, diagnosis, intervention, and follow-up evidence. In contrast, academic support for struggling medical students is frequently offered with a one-size-fits-all approach for any struggling student. Based on our experiences implementing and leading academic success efforts at our medical school, we propose that academic support strategies for medical students should follow a similar process as a differential diagnosis, starting with an intake interview with the struggling student, followed by assessment, appropriate interventions, monitored outcomes, and re-assessment.

Bloom's Taxonomy as a framework for individualized student support
This paper provides a framework for medical school faculty and staff (student affairs, instructional coaches, learning specialists, academic advisors, etc.) working with struggling students. Table 1, Table 2, and Table 3 provide specific areas  The 16 Personality Factor Questionnaire (16 PF) 41 The California Psychological Inventory (CPI) 41 The Myers Briggs Type Indicator (MBTI) 41 Identify personalities with academic performance and non-cognitive factors 41,42 Maladaptive perfectionism

Inflexibly high standards
Negative perception of performance Test accommodations 35,36 Lecture capturing [37][38][39] Self-efficacy Low self-confidence about academic performance Motivated Strategies for Learning Questionnaire 6 Improving achievement, motivation and overall well-being 40 in which students may struggle. These areas, which can overlap and affect each other, and cause students to experience low academic performance, are grouped into domains cognitive, affective, and psychomotor based on Bloom's Taxonomy 70 . These varied resources across domains can help faculty and staff differentially identify various problems of struggling medical students, provide available assessment tools, and possible interventions based on the literature. An application of the framework is presented on an example of a case in the Table 4.

Cognitive domain
Students come to medical school with various strengths and backgrounds depending on their previous education and professional experience. With the increased amount of information that medical students need to process and learn in medical school, many may need to change study strategies and learning habits that were previously effective (see Table 1). When helping medical students to improve their study strategies, faculty and learning specialists should assist students with developing active learning strategies, strong metacognitive skills, critical thinking and regulation of their own learning. Effective time management is beneficial to medical students during medical school but also during their residency training and later in their careers. Students need to apply a different approach to test taking that includes strategies for long-stem clinical scenarios and monitor their reading 34,35 and concentration 21 .
Students can start medical school with previously diagnosed learning disorders and Attention Deficit Hyperactivity Disorder (ADHD) 30 . Before coming to medical school, these students have compensated for their difficulties without interference in their academic success 31, 34 . For other students, academic difficulties may begin for the first time in medical school. Various reading disorders like dyslexia can cause students to struggle with academic requirements in medical school 30, 34 . ADHD can also be barrier to academic success in medical school. Students with ADHD might lack organizational skills and the ability to focus and complete assignments and tests on time. This consequently affects not only their academic performance, but also quality of life 32 . Learning disorders and ADHD can also interfere with passing United States Medical Licensure Exams (USMLE) 35 . The presence of these conditions requires the evaluation of a licensed neuropsychologist 33 . For students with learning disorders and ADHD, test accommodations can be considered such as supplementary educational material and reduced distraction and extended time for exams 35,36 .
Additionally, physical disabilities, injuries, acute or chronic physical illness can also affect a learner in medical school, and students can benefit from academic support and test accommodations 36,37,39 . Overall, by helping students to improve their learning skills and support transition to medical school, student academic self-efficacy, or confidence and beliefs in their own ability to succeed academically, may increase. Self-efficacy can consequently have a positive effect on academic performance, motivation, stress reduction, emotional reactions and overall wellbeing 40 .

Affective domain
Academic support services often neglect to identify and address issues in the affective domain, yet the affective domain is very important for the overall wellbeing of students and their success and motivation in medical school (see Table 2). For the purpose of this paper, several personality traits such as conscientiousness and introversion and extroversion are categorized in the affective domain, which can also affect academic performance 40 . For example, conscientious students develop habits that lead to high academic performance. Personality differences may cause students to experience different stress levels when presented with the same stressor. Other issues include maladaptive perfectionism, which leads to negative self-perception and burnout.
Adjustment to medical school, situational stress, and life changes can negatively affect academic performance. Examples of situational stress include financial difficulties, long commute time, moving a household, child care arrangements, unsupportive personal relationships, and domestic violence.
Examples of life changes include childbirth, divorce, and illness or death of a loved one. Medical schools should provide support to help students who experience situational stress and life changes, as these stressors may lead to poor academic performance, burnout, and mental health concerns.
Common mental health concerns include mood disorders such as depression, generalized or specific anxiety disorders, and substance misuse. For those issues, it is important to make referrals to mental health professionals.

Psychomotor domain
Several self-care strategies that support student academic success and wellbeing are classified in the psychomotor domain (see Table 3). Self-care includes activities that improve physical and psychological health such as healthy diet, regular exercise, quality time spent with loved ones, spiritual care, relaxation and stress management, hobbies, outdoor activities, and medical appointments 58 . Students may de-prioritize many of these self-care practices, perhaps believing that all available time should be used exclusively for academic pursuits. Students may feel they don't have time for a healthy diet, exercise, and adequate sleep; but these healthy habits support concentration, energy levels, and memory 67 . Medical schools should teach self-care habits to students from the beginning of medical school, allowing students to Student A is a nontraditional student who was out of school for seven years before starting medical school. She performs poorly on exams in class. Even though she tries to work on her schedule and time management, she falls behind with her class materials and studies all night before each exam. She describes herself as perfectionist. She feels stressed and burned out at the end of semester. Her motivation to succeed in medical school is strong.

Intake interview framework and individualized intervention examples.
learn and value healthy habits to support their success and wellbeing. Self-care positively affects academic performance and well-being, and is likely to decrease stress and improve work-life balance later in their careers.

The importance of individualized interventions for struggling medical students
Because medical students may struggle for a variety of reasons, and for varying lengths of time, medical educators and academic support staff should use an individualized intervention approach to helping struggling students. The framework and resources provided in this paper include many issues from the cognitive, affective, and psychomotor domains that may interact and cause disbalance, resulting in lower academic achievement and poor well-being of medical students. An application of the proposed approach using a fictional student example is available in the Table 4. Individualized approaches to improving medical student success should address the complex and interrelated areas of academic success, wellbeing, quality of life, career potential, and satisfaction with medical school. Interventions should be followed by monitored outcomes, re-assessment, and continued individualized interventions to support the student's success and well-being.

Take-aways
• The reasons medical students struggle may be individual and complex, thus a one-size-fits-all approach to helping struggling medical students is often ineffective.
• Medical educators and academic support staff should consider an individualized intervention approach to helping struggling students.
• A framework based on Bloom's Taxonomy and existing literature is recommended to help medical school faculty and staff individualize interventions when working with struggling students.

Data availability
No data are associated with this article.