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Letters to the Editor

More About Struggling Students

Frellsen, Sandra L. MD; Baker, Elizabeth A. MD, MHPE; Papp, Klara K. PhD; Durning, Steven J. MD

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doi: 10.1097/ACM.0b013e3181939937
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To the Editor:

We are excited that our report1 initiated a lively debate by Drs. Cleary, Cox, and Pangaro in the September 2008 issue of Academic Medicine, which elevated the level of discussion of the topic of struggling students.2–4 We wish to respond to their comments using clinical parallels.

We concur with Dr. Cleary that we need a safety net to identify students whose evaluators do not feel they had sufficient contact time to identify deficiencies or do not feel comfortable giving a failing evaluation. This is like the communication needed between physicians in caring for a patient with hypertension. Appropriate intervention for a single blood pressure reading may be unclear in isolation. Likewise, better communication between teachers regarding struggling students would improve the timing and, hopefully, the accuracy of intervention.

We disagree with Dr. Cox’s concern that sharing information about students will create positive bias. There is no evidence that thoughtful attention to a student’s relative weaknesses would unfairly aid him or her. A clerkship director who is aware that a student has had difficulty could gather information needed to arrange an intervention. Similarly, a physician with access to a patient’s full medical record can act upon or disregard as spurious a patient’s elevated blood pressure. As educators, we strive to tailor the educational experience of each student to his or her needs.

A school’s policy could outline which students’ information should be fed forward; not all students with difficulty would necessarily be “labeled” as struggling. We agree with Dr. Cleary that a comprehensive written policy would help avoid litigation; currently, information may be fed forward informally and without students’ awareness.

A primary concern must be protecting our students’ future patients. The time has come to move towards uniform, written policies and open discussion. As Dr. Pangaro proposes in his thoughtful commentary, we also need more research to move towards a deeper understanding of the effect of forward feeding.

Sandra L. Frellsen, MD

Assistant professor of medicine and co-clerkship director, Rush Medical College, and attending physician, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; ([email protected]).

Elizabeth A. Baker, MD, MHPE

Associate professor of medicine and internal medicine clerkship director, Rush Medical College, Chicago, Illinois.

Klara K. Papp, PhD

Senior research associate, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Steven J. Durning, MD

Associate professor of medicine and course director, Introduction to Clinical Reasoning, Uniformed Services University of the Health Sciences, Bethesda, Maryland.


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. “Forward feeding” about students’ progress: The case for longitudinal, progressive, and shared assessment of medical students. Acad Med. 2008;83:800.
3 Cox SM. “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 LN. “Forward feeding” about students’ progress: More information will enable better policy. Acad Med. 2008;83:802–803.
© 2009 Association of American Medical Colleges