Frellsen and colleagues1 use the term “struggling students” to refer to those at risk of receiving a grade of less than “pass” because of problems with knowledge, clinical skills, professionalism, or a combination of these items, including marginal and problem students. I believe there are a number of reasons that information regarding such students should not be shared; namely, the unlikelihood of confidentiality, the introduction of bias and unmerited stigmatization, the creation of unfair advantage, the unproven benefits, and the related legal issues.
Privacy, and therefore confidentiality, is an overriding value in medicine. Although clerkship directors might intend to limit information about struggling students to only a small and select group, it is naïve for one to assume that the information that is fed forward will be kept confidential. In this day of hackers, e-mail, text messaging, YouTube, Instant Messaging, and MySpace, information about individuals is liable to be open to everyone's scrutiny. We would do students a disservice by labeling one as “struggling” and putting that information out for discovery.
Sharing information regarding struggling students has the potential for creating both negative and positive biases toward the student identified as such. In the negative sense, attending physicians/teachers (and therefore residents) may develop a preconceived view of the student as “weak” and will expect less. They may well “write the student off” without observing the behavior that caused the student to be initially identified. Also, attendings and residents may exaggerate personality traits in a student identified as struggling and, thus, bring about a “self-fulfilling prophecy” (e.g., a shy student intimidated by a previous attending and characterized as “hiding” may find every instance of slight shyness overemphasized during a subsequent rotation).
Positive bias may cause the clerkship director to change the assignment of the student to a faculty member considered a “better fit” or easier for the student—thus eliminating the opportunity for an educational experience for the student to learn and demonstrate his or her ability to get along with a wide variety of personalities.
Identifying a student as “struggling” is a form of stigmatization, defined as “labeling as socially undesirable,” which can unfairly brand a student from one class or rotation to the next. For example, Ainsworth and Szauter2 found that the vast majority of students (87%) who received early concern notes (ECN) reflecting an incident of unprofessional behavior only received one ECN. Such students could have been identified as “struggling” and unfairly labeled throughout their training.
In some situations, identifying a student as “struggling” and forward feeding that information could lead to the creation of an unfair advantage for that student, because it may lead to tutoring or other remediation actions to which all students do not have the same access or opportunity. Two examples:
* A student who has been identified as struggling because of “lack of medical knowledge” is required to sign up for special tutoring in a subsequent rotation and has an advantage in the examinations from being taught to the exam.
* A student who has been identified as struggling because of “not fulfilling responsibilities” is assigned by the subsequent clerkship director to residents and attendings who engage the student more actively.
There is no evidence of value or proven benefit to forward feeding information regarding struggling students that would justify the risks. Further, remediation plans vary widely and exhibit little standardization. Frellsen and colleagues1 suggest that between 5% and 10% of students in third-year clerkships and about 2% to 3% of fourth-year students are identified as struggling. Although assessment is a very important part of medical education, forward feeding of assessment information for struggling students may create new costly and complicated systems to ensure that privacy and legal concerns are met.
Finally, in today's litigious environment, it can be expected that a number of lawsuits will be filed, alleging that forward feeding led to irreparable harm to medical careers and claiming damages. Although it is likely that the courts will uphold the general right of the educational system to assess students, these lawsuits will be very costly to defend—costs that are not justified by evidence proving benefits of forward feeding.
There is no evidence from educational research to justify assessment information on struggling students being forward fed or shared outside of grades or promotion committees, which have been established for specific purposes. If there are difficulties with insufficiently integrated curricula, inadequate systems of assessment and remediation, unevenly applied grading criteria, scarce feedback, little mentoring, or poor teaching, then attention should be focused on correcting these systemic difficulties and not on developing intrusive, costly, and risky arrangements of little or no proven value.
Susan M. Cox, MD
Dr. Cox is associate dean for medical education and professor and clerkship director, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; (Susan.Cox@UTSouthwestern.edu).
1 Frellsen SL, Baker EA, Papp KK, Durning SJ. Medical school policies regarding struggling medical students during the internal medicine clerkships: Results of a national survey. Acad Med. 2008;83:876–881.
2 Ainsworth MA, Szauter KM. Medical student professionalism: Are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Acad Med. 2006;81(10 suppl):S83–S86.