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Letters to the Editor

More About Struggling Students

Pangaro, Louis MD; Cleary, Lynne MD; Cox, Susan MD

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doi: 10.1097/ACM.0b013e3181939897
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In Reply:

We strongly endorse the principle underlying the clinical analogy that Frellsen and colleagues draw upon—that clinicians share expectations about goals for patients. Shared criteria and standards allow clinicians to work sequentially with an individual patient over time, and shared expectations are also needed for successful “forward feeding” about students among faculty.

We agree that evidence for the prevalence of unintended “positive bias” is lacking, but Cox has not argued that it “will create positive bias,” simply that it may. Using the clinical analogy, isn’t it reasonable to imagine that a clinician’s desire to help a particular patient may result in some special access or favor not given to all patients?

Neely is certainly right that prognostic information about the success of some struggling students is lacking. We may at times be guilty of offering fraudulent hope that they can ever succeed. But for which students?

Studies on this very question show that while, as a group, these students are at some future risk, the positive predictive value for an individual of failing a clerkship,1 of referral to a student promotions committee,2 or of having documented issues in “professionalism”3 are not very good—certainly not good enough for us to withhold effort. In fact, the “diagnostic specificity” of classifying some students as unlikely to achieve eventual independence would be enhanced if the “repetitive pattern” that Cleary mentions were to persist despite the directed efforts that are part of “forward feeding.” These are the students that Neely is rightfully worried about, but we might not know who they are until a forward feeding mechanism has already been tried.

We emphasize that our perspective, too, remains speculative, pending studies to establish some “standard of care” in feedback, forward feeding, and tailored instruction. We hope to see this kind of experience in print. Until then, prudence is required, and faculty across departments should help plan how such information is to be used to maximize interclerkship consistency and minimize unintended consequences.

Louis Pangaro, MD

Professor and chair, Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and president, The Alliance for Clinical Education; ([email protected]).

Lynne Cleary, MD

Senior associate dean for education, SUNY Upstate Medical University, Syracuse, New York, and chair, Undergraduate Medical Education Section, Group on Educational Affairs, AAMC, Washington, DC.

Susan Cox, MD

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.


1 Lavin B, Pangaro L. Internship ratings as a validity outcome measure for an evaluation system to identify inadequate clerkship performance. Acad Med. 1998;73:998–1002.
2 Durning SJ, Cohen DL, Cruess D, McManigle JM, MacDonald R. Does student promotions committee appearance predict below-average performance during internship? A seven-year study. Teach Learn Med. 2008;20:267–272.
3 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.
© 2009 Association of American Medical Colleges