Remarkable changes have occurred during the past few decades in medical education as faculties more clearly articulate what it means to be a physician.1 The evolving definition includes knowledge and skills as well as habits of mind and character. Within this analytic model of growing competence, a minority of students struggle during medical school. These students represent a continuing concern for faculty, who must correctly identify them and make appropriate decisions, weighing concerns about future patient care and our obligation to society.
Students struggle during medical school for a variety of reasons. Such students have been described in the literature as “strugglers,” “marginal students,” and “problem learners.”2–4 They include students presented to an academic progress committee who have not met expectations in a course or clerkship, students who meet some but not all requirements of a clinical evaluation, as well as students with characteristics such as poor interpersonal skills, excessive shyness, poor integration skills,5 and a lack of personal responsibility.6
We sought to characterize the policies of U.S. and Canadian medical schools regarding struggling medical students during the core internal medicine clerkship and fourth-year internal medicine rotations. More specifically, we surveyed a national cohort of educators and inquired about how they handle grading and sharing of information about struggling students, as well as how their institutions develop and use remediation plans for struggling students. We defined struggling students as those students at risk of receiving a grade of less than “pass” because of problems with knowledge, clinical skills, professionalism, or a combination of these items, and we included marginal and problem students under our definition.
We conducted a systematic literature search on struggling medical students. We cross-referenced the following key words with medical students in MEDLINE: clinical competence, problem student, struggling student, marginal student, marginal performance, marginally performing, poorly performing, suboptimal student, grading, remediation, knowledge deficiency, skills deficiency, failing, failure, dismissal, problem resident, and struggling resident.
Identification of the struggling student
Prior work has shown that up to 10% to 15% of medical students have been identified as struggling.3 Students may be identified as struggling through written examinations,7,8 clinical performance evaluations,9 clinical evaluations,10 formal evaluations of professionalism,11–15 peer assessments,16 during group review and grading sessions,17–19 or using combinations of methods such as a clerkship pretest combined with a marginal clinical indicator.20 Struggling preclinical and clinical students have both been identified as the result of failure in a course and subsequent presentation to an academic progress committee.2,21 We found no studies describing the grades assigned to struggling medical students who did not fail a course or clerkship.
There is concern that some struggling students are not identified. Publications describe common types of learner difficulties and barriers to their identification and remediation.2,22 It has been noted that students with unsatisfactory clinical performances are often not given failing clinical evaluations. In structured interviews with 21 clinical teachers at McMaster University, Dudek et al10 report reasons for not identifying unsatisfactory students. These include a lack of documentation and knowledge about what to document, and a lack of remediation options. Additional barriers cited include the concern that failing a student will result in negative consequences for the student or the evaluator, and fear of making an erroneous judgment based on limited contact. Fear of litigation may be another reason for the reluctance of faculty to give a failing evaluation.23,24
Failure of students to accurately identify their own deficiencies adds to the difficulty of their identification by faculty. Cleland and colleagues6 found that medical students failing a high-stakes OSCE were unlikely to identify their deficiencies without feedback and were unlikely to ask for help. Finally, the lack of comprehensive policies and procedures to deal with struggling students is cited as a barrier to the dismissal of failing students.25
Accurately identifying struggling medical students is important if we are to have the opportunity to remediate deficiencies and to ensure that inadequately performing students do not advance to the next stage of training. To our knowledge, our survey is the first to attempt to measure the prevalence of struggling students in internal medicine clerkships nationally, and it is the only study to examine how these students are graded.
Sharing information about struggling students
Sharing information about struggling medical students has been proposed as a method to improve their identification and remediation. The advantages and disadvantages of sharing information about struggling students have been debated since at least 1979, when faculty from the Association of American Medical Colleges’ Clinical Evaluation Program5 expressed concern about the lack of information shared about students between one rotation and the next and the lack of an early warning system for problem students. The 45 participants of the 1989 Generalists in Medical Education meeting unanimously agreed that there should be some information shared in some circumstances.25 In 1998, Gold et al26 surveyed medical school deans about struggling students and found that 56% of responding deans had written policies permitting sharing assessment information about students, though only 35% had policies permitting sharing information about academic performance or professional conduct. The authors recommended the development of criterion-based evaluations to reduce bias, as well as the implementation of policies permitting some sharing of information. We found no citations subsequent to 1998 describing the sharing of information and its effect on the identification and/or remediation of struggling medical students. One of our aims, therefore, was to determine current opinions and policies regarding the sharing of information about struggling students among clerkship directors in internal medicine.
The literature includes few descriptions of remediation plans. Successful remediation plans for students who fail the National Board of Medical Examiners internal medicine subject exam include self-directed study,7 faculty-led tutorials with directed reading, attendance at teaching conferences, and problem-based discussion sessions.27 Successful remediation of inadequate clinical performance has been demonstrated for students failing a Clinical Performance Examination.9 Lin et al28 published a case report of the successful remediation of a student with communication skills deficiencies. Programs have been described that offer multiple options for remediation of clinical and knowledge deficiencies.29,30 Our survey adds to this literature because it is the first to ask teaching faculty nationally about how their institutions design and use remediation plans for struggling students.
In April 2006, the Clerkship Directors in Internal Medicine (CDIM) conducted its annual, voluntary, and confidential survey of its U.S. and Canadian membership, consisting of 110 of 143 medical schools in North America.* All 110 institutional members (typically clerkship directors of internal medicine, one per institution) were invited to complete the survey. The first section of the survey elicited demographic information.
All survey items were reviewed and modified by members of the CDIM Research Committee. Questions were then presented to the CDIM Council and, after additional revisions, accepted by the CDIM Council for inclusion on the 2006 survey. The survey was then pilot tested with members of the CDIM Research Committee, and additional modifications were made. The survey was mailed in April 2006, and nonresponders were contacted up to three additional times through e-mail, regular mail, and/or telephone contact. Approval for this study was sought by the CDIM Research Committee chair’s (S.J.D.'s) institutional review board. This study was approved by the IRB of the Uniformed Services University of the Health Sciences.
The section on struggling students contained 19 items, comprising 14 structured questions and five items requiring short-answer, free-text responses. The items explored core as well as fourth-year clerkship perspectives. Respondents were asked what percentage of students in the core clerkship receive a less than passing grade, the percentage of students in the core internal medicine clerkship or an elective fourth-year internal medicine rotation (subinternship, clinic, or consult rotations) who are identified as struggling each year, the typical final-grade options assigned for struggling students each year, and how often the clerkship director used those grades. Respondents could choose High Pass/B, Pass/C, Low or Marginal Pass/D, Incomplete, Fail/F, or “other,” with a space for written comments. Respondents were also asked the percentage of students who received a less than passing grade and who were presented to a medical school promotion or evaluation committee.
Items also asked clerkship directors whether they routinely shared or should share information about struggling students with other course directors or clerkship directors outside of formal medical school committees, or with current teachers on the internal medicine clerkship. Free-text items were analyzed using a grounded theory approach. One of the authors (E.A.B.) identified themes. All authors reviewed and concurred with the final coding scheme. Further, we asked whether the respondents’ school has or should have a formal written policy about sharing struggling students’ information. Finally, we asked who designs remediation plans for struggling medical students in the internal medicine clerkship and what types of remediation are available to students after performing unsatisfactorily on the internal medicine clerkship.
Respondents were instructed to discuss items with the responsible faculty to gather accurate data about their institution. We did not include unanswered items in the analysis. Descriptive statistics were performed on all responses. We used SPSS version 12 (SPSS Inc., Chicago, Illinois) to calculate descriptive statistics.
Identification of the struggling student
Eighty-three of the 110 (76%) institutional members responded to the survey. Between 0% and 15% of students were identified as struggling each year during the core internal medicine clerkship. A smaller number of fourth-year students (0%–11%) were identified as struggling, with 45 clerkship directors (55%) reporting a frequency of 0% to 2%. Table 1 shows the distribution of responses about how many students were identified as struggling. Struggling students received a variety of grades for the internal medicine clerkship. The typical final-grade options for struggling students, and ranges used, are listed in Table 2.
When struggling students received unsatisfactory grades, 77% of respondents reported that those students were always presented to a medical school promotions committee. Fourteen respondents (19%) reported that students receiving an unsatisfactory grade were presented to a medical school committee at their schools 50% of the time or less.
Sharing information about struggling students
More than half (64%) of respondents agreed that they should share information about struggling students with other clerkship directors outside of formal medical school committees, and 40 (51%) respondents did routinely share such information. Within the internal medicine clerkship, 36 (48%) respondents thought they should share information about struggling students with students’ current teachers, but only 27 (36%) actually did share information. Only 11 (14%) institutions had formal written policies about sharing information. Nine (12%) were specifically prohibited from discussing students with academic difficulty with current teachers or other clerkship directors.
Many respondents (42, or 51%) provided free-text responses about sharing information. Several themes emerged. Among those in favor of sharing information, there were three themes identified: the need to provide a supportive educational environment and to provide guidance and mentorship, the need to identify students early, and the importance of viewing medical education as a continuum and not focusing solely on a single clerkship (see List 1).
Two themes emerged in comments made by those not in favor of sharing information or whose institutions did not allow the sharing of information: fear of creating bias or prejudice against students, and lack of trust that clerkship directors will use such information appropriately (see List 1).
Only 11 (14%) institutions had formal written policies about sharing information. Nine (12%) schools were specifically prohibited from discussing students with academic difficulty with current teachers or other clerkship directors. Reasons for prohibiting or precluding the discussion of students included fear of litigation (1, or 1%), fear that students would not be treated fairly (6, or 7%), fear that faculty would not be able to render a fair evaluation (5, or 6%), and fear of violating student confidentiality (4, or 5%). Importantly, 41 institutional member respondents (53%) were in favor of having formal written policies about sharing information on struggling students.
Remediation plans for struggling students varied. The types of plans available to students and the faculty who design those plans are listed in Table 3. Plans were designed by multiple faculty. The types of remediation plans available varied, and there were multiple sources for remediation plans in some institutions. Numerous respondents offered write-in responses (54, or 69%), which ran the gamut from additional clerkship experience to elective rotations, clinical special remediation months, and paper case studies.
Identification of the struggling student
Our findings regarding the prevalence of struggling medical students are consistent with previous reports in the literature, which adds to the validity of our findings. The wide range (0%–15%) of struggling students identified in our study is striking. Identifying and characterizing struggling students is a topic of national interest; allowing students to advance without successful remediation could, ultimately, compromise patient care.
Grading options were not uniform for struggling students, and more than two thirds receive nonfailing grades. We believe that a significant portion of this variance reflects individual students’ unique circumstances. However, the high percentage of satisfactory or above-satisfactory grades does raise concern regarding grade inflation and the need for agreed-on criteria to describe medical student performance. Giving struggling students satisfactory grades may lessen the chances of those students being identified as struggling, thus reducing the potential for remediation. We believe that students should receive grades that accurately and honestly describe their performance. Synthetic, portable evaluation frameworks such as RIME (Reporter, Interpreter, Manager, Educator) have been shown to improve educators’ identification of marginally performing students.31 We believe that a national discussion of consistency in student grading is needed, with the goal of reaching national consensus. This would allow important, multiinstitutional studies to be conducted to determine the reliability and predictive validity of evaluation standards; the latter would help ensure that educators are fulfilling the societal obligation of graduating trainees who are fit for practice.
Most institutions reported that students who received nonpassing grades were presented to a medical school committee, but a significant proportion were not. In the absence of measurements with proven reliability and validity, we believe that discussion of student performance with a group of local experts (i.e., a student promotions committee) is needed, to ensure fairness to the student and to society. Studies are needed that describe the outcomes of student promotion committee deliberations.
Sharing information about struggling students
Most clerkship directors agreed that they should share information about struggling students in some manner, but there was disagreement about how this should happen and whether institutions should have written policies about sharing information. The high number of write-in responses confirms that clerkship directors have strong feelings on the subject, and the variability of these responses illustrates the lack of consensus on the best approach. Until reliable and valid evaluation systems are in place that are understood and consistently applied by teachers, it will be difficult to overcome the perception of bias. Until that time, it will also be difficult to uniformly embrace the concept of education as a continuum and the importance of sharing information as part of this continuum.
We believe that the benefit of focused attention and remediation from teachers who understand students’ issues outweighs the risk of bias in grading by future evaluators and that specific information about a student such as “frequently tardy” or “difficulty obtaining a relevant history” should be shared with a limited number of faculty. We support previously published statements advocating that institutions develop formal written policies on sharing information about medical students. National discussion is needed if we are to attempt to reach consensus on the best policies for the sharing of information.
We found that clerkship directors commonly design remediation plans for struggling students and that the types of remediation plans, as well as the resources available, vary widely between institutions. Consistency between types of remediation plans described by survey respondents and those described in the literature lends support to our results. We found no descriptions of multiinstitutional studies on the effectiveness of remediation plans in our review of the literature. Future discussion and research should focus on the effectiveness and generalizability of remediation plans, with the goal of building consensus on the types of remediation plans that are most effective, and on how these remediation plans are best used.
Our study has several limitations. We did not confirm the perceptions of our institutional member respondents with objective data from their respective institutions. There is the possibility of nonresponse bias, though this is unlikely, given our high survey-response rate. It is also possible that survey fatigue affected responses. However, the high percentage of free-text, write-in responses makes this less likely. As with all surveys, recall bias may have affected responses. Our survey did not include questions about whether clerkship directors believe their schools accurately identify all struggling students or what barriers might prevent the identification of struggling students. A more detailed study of current barriers for clerkship directors in identifying struggling students is needed so that solutions can be proposed to overcome those barriers. We did not ask about whether or how successful completion of a remediation plan might affect students’ final grades. Finally, our findings suggest the need for the longitudinal assessment of struggling students. There is some evidence that struggling students continue to have difficulty during internship32 and that lapses in professionalism in medical school predict future professionalism lapses.33,34 Future studies are needed to more accurately differentiate students likely to continue struggling and those who will acquire the knowledge and skills needed without additional intervention.
Students struggle during medical school for a variety of reasons, and the reported prevalence varies from institution to institution. We need to accurately identify and remediate struggling students in medical school to fulfill our societal obligation for patient care. Agreeing on terminology to describe struggling students is needed as a first step toward a consistent approach between medical schools. We prefer the term “struggling students” because it is descriptive rather than judgmental and because it suggests an ongoing process rather than an end result.
We advocate for the development of national standards to promote grading uniformity, using agreed-on grading categories and criteria for each category. We support sharing limited information about struggling students to enhance their educational experiences and potential for successful remediation, and we also support the concept of medical education as a continuum. We believe that institutions should develop policies on sharing information about struggling medical students. Finally, many clerkship directors are currently responsible for the design of remediation plans for students, and remediation plans vary widely between institutions. National discussion and a research agenda are needed to facilitate the development of effective, generalizable remediation plans for struggling medical students. Ensuring the accurate identification of struggling medical students through improved assessment and communication systems, and developing effective remediation plans for struggling students, are necessary steps whose time has come.
The data used in this survey are the property of the Clerkship Directors in Internal Medicine (CDIM) and are used with permission. The authors gratefully acknowledge the assistance of the CDIM Research Committee in the preparation, distribution, and management of the survey.
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*All authors are members of the CDIM. Authors E.A.B., S.J.D., and K.K.P. participated in the construction and revision of the survey items as members of the CDIM Research Committee Survey Writing Team. The data are used with permission. Cited Here...
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