Using the detailed data by Frellsen1 et al as a jumping-off point, Drs. Cleary2 and Cox3 have provided insightful, independent perspectives on the issue of sharing information about students in the clinical setting (“forward feeding”). Underlying the comments of both is a principle of fairness that should embrace the interests and rights of patients, students, and teachers. Each articulates possible consequences to that fairness—to patients if information about students is not shared, and to students if it is. The pragmatic reality of litigation by students might prompt a school's attorneys to discourage any forward feeding among clerkship directors and teachers. From another perspective, there are practical difficulties in achieving consistency in the application of forward feeding for all students that could argue against the practice. Yet the majority of clerkship directors in medicine feel the practice is in the interest of students and patients, and many do share information about students.
One hallmark of fairness in assessment is consistency in when and how students are evaluated. Important barriers to consistency remain in most schools: the time given to teachers to get enough observations, such as at the bedside; the time for clerkship directors to do the ongoing faculty development needed to train teachers to use a single frame of reference, that is, to get everyone “playing from the same sheet of music”4; and the willingness of teachers, including housestaff, to be honest in their evaluations. Differences in the vocabulary and complexity of assessment frameworks may contribute to the difficulties that clerkship directors and teachers have in sharing information about students,5 and it is not clear yet that multiple disciplines can or will effectively use the same tools across clerkships.
Clinicians are regularly trusted to make high-stakes decisions from complicated and incomplete information about the health of individual patients, and they can probably be trained to do so, minimizing diagnostic errors and bias, about their students. Yet, there is a lot we do not know about the preconditions and barriers to doing this consistently. Here are some questions which, if answered, might help schools decide on their own policies about forward feeding:
1. Are there particular types of behaviors that are more likely to be “true positives” and that, therefore, merit forward feeding, so that a pattern can be established and documented? In their case–control study, Papadakis et al6 found that examples during medical school of unreliability (such as poor follow-up in patient care) or of diminished capacity for self-improvement (such as failure to accept constructive criticism) were associated with subsequent discipline by state medical-licensing boards.
2. Is the natural history of a “first” problem in a clinical course or clerkship different for the professionalism domain than for cognitive issues? Which problems, and for which students, resolve on their own with the usual curriculum, and which need further feedback and deliberate practice? Would there be a different response to problems in the “preclinical years”?
3. What preconditions are in the educational system and culture for consistent evaluation of students? Can qualitative studies reveal more about barriers to honest assessment of students by teachers and provide the basis for a more comprehensive systems approach to consistent evaluation?
4. What is the empiric support for the notion that a framework for educational goals (such as the Accreditation Council for Graduate Medical Education competencies) can be used consistently across teachers and across clerkships? The Research in Medical Education (RIME) Section of the Group on Educational Affairs (GEA) has proposed that we define learning outcomes and competencies at progressive developmental levels and collapse isolate competencies into a growth chart defined by level of training.7 Can this be a prerequisite to forward feeding?
5. Can clerkship directors themselves be trained to avoid “diagnostic biases” from having forwardly fed information about students? If biases persist, how might they be recognized, or mitigated by the assessment system, such as having a departmental review of grades? Can individual teachers be trained or coached to avoid diagnostic biases,8 or should forward feeding be limited to the clerkship directors?
6. What evidence exists that forward feeding has been successful in remediating struggling students' problems or that it has been detrimental to how such students are perceived?
Clerkship directors' organizations could lead by sponsoring interschool symposia to determine any “best practices” available. Using a common format, each could prepare a systematic summary to be circulated and presented. The Alliance for Clinical Education (ACE) can host these on its Web site. The GEA of the Association of American Medical Colleges can work with ACE on a project to understand what works in what circumstances, and why. Then, with the collaboration of the RIME section of the GEA and the Generalists in Medical Education, a multiinstitution, interclerkship project to determine the efficacy and safety of forward feeding could be done. Struggling students are a small percentage of all students and are not the biggest problem facing clerkship directors. Yet, fairness to society and to these students means they should get the attention they need. So, although forward feeding is not the only or the most salient issue in improving assessment and grading in clerkships, it might be a problem focused enough to lead to the exploration needed to solve the larger issues.
Louis Pangaro, MD
Dr. Pangaro is professor and chair, Department of Medicine, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. He is a member of the editorial board of Academic Medicine; (email@example.com).
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 Cleary L. Point–counterpoint: “Forward feeding” about students' progress: The case for longitudinal, progressive, and shared assessment of medical students. Acad Med. 2008;83:800.
3 Cox SM. Point–counterpoint: “Forward feeding” about students' progress: Information on struggling medical students should not be shared among clerkship directors or with students' current teachers. Acad Med. 2008;83:801.
4 Pangaro L, Holmboe ES. Evaluation forms and global rating scales. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, Pa: Mosby Elsevier; 2008:24–41
5 Pangaro LN. A shared professional framework for anatomy and clinical clerkships. Clin Anat. 2006;19:419–428.
6 Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353:2673–2682.
7 Implementing the Vision: Group on Educational Affairs Responds to the IIME Deans' Committee Report. Washington, DC: Association of American Medical Colleges; 2006:8.