Editor’s Note: An Invited Commentary by E.M. Aagaard and L. Moscoso appears on pages 619–622.
It is highly unusual for learners to leave medical training in the United States even though some individuals’ goals may change and others may not achieve expected competence. One possible explanation for the former is that once students progress to a certain point in their careers and have amassed a certain amount of debt, they feel they have no choice but to finish their medical training. Possible explanations for the latter are that students are allowed to graduate despite marginal performance and that some students entered medical school with risk factors for poor performance (such as poor undergraduate performance or preparation and/or cultural or socioeconomic disadvantages) that were not addressed.
Regardless of the reason, there is a problem. Allowing a student to progress through training who does not want to be there or who does not have the skills to be successful is wrong. The time, energy, and resources required to practice medicine effectively and safely are significant. As stewards of the educational process, medical educators have an ethical obligation to students and the public to create off-ramps, or points along the educational continuum at which learners can reassess their goals and educators can assess competence, that allow for students to leave medicine. For such a concept to work, the ability to assess students must move beyond completing the four-year curriculum to competencies that can be robustly assessed across multiple domains. Competency-based education and training would allow for earlier identification of struggling students, which, in turn, would enable earlier remediation or counseling out of the profession if remediation is ineffective or the student’s goals have changed.
Failure to Fail
In undergraduate medical education (UME), the attrition rate for students in U.S. MD-only programs who have not taken leaves of absence has been stable at 4% since 1990; this percentage is below that of other graduate degree programs and international medical schools.1,2 It is possible that this low attrition rate is related to the “failure to fail” phenomenon highlighted in a study reporting on a cohort of 43 struggling medical students that were followed through residency.3 These learners consistently scored lower than their randomly matched peers in 10 of 12 performance areas, including medical knowledge, clinical decision making, clinical skills, interaction with patients, independent learning, and collaboration. Of the 7 students in this cohort who were recommended for dismissal but allowed to graduate, 4 completed residency, 1 withdrew, 1 was dismissed, and 1 changed specialties.3
Prior studies have suggested that low rates of failure reflect that faculty are underreporting struggling learners because they are unprepared or unwilling to do so.4 An online survey of leaders from 19 MD, DO, PA, and NP programs revealed that 79% felt that their institution or other institutions that grant the same degree had graduated students who should not have graduated.2 The authors concluded that although struggling learners should be provided opportunities for remediating their deficits, this is not always successful.2 A recent systematic review of the literature on failure to fail underperforming medical, nursing, and dental trainees showed common factors across the professions and educational continuums over 10 years of data.5 Particularly inadequate was evaluator development and remediation programs. Factors that enabled systems to fail underperforming trainees, on the other hand, included a sense of duty to the profession, strong assessment systems and faculty development programs, and opportunities for trainees after leaving training.5
This culture of failing to fail persists in graduate medical education (GME) as well. A national survey of program directors in 2000 revealed that 10% of learners were on probation or restricted practice, had transferred to another training program and failed to graduate from that program, or had withdrawn from their training program.6 Yet, no learners were dismissed. Interestingly, there was also no general agreement on how long a learner should be remediated or how many remediation attempts should be made before dismissal.6 In 2016, Guerrasio and colleagues7 reported data collected from 2002 to 2012 on the characteristics, deficits, and outcomes of 102 (3% of 3,091) residents placed on probation from all 142 of the University of Colorado’s GME programs. They found that those on probation were more likely to be international medical graduates, married, not Caucasian, older, male, to have transferred from another GME program, or to have taken time off between medical school and residency. They concluded that placement on probation was associated with failure to graduate and lack of board certification.7
We propose that off-ramps could be distributed across the medical education continuum, but effective use of these would require the early identification of struggling learners and appropriate counseling and education about alternative careers. As GME and UME implement competency-based education, assessment has become more robust and can identify individuals who are struggling more readily than in the past.8 This early identification of struggling learners has led to the development of more proactive and structured remediation programs. One national model for remediation is the program at the University of Colorado School of Medicine.9 Created in 2006, this remediation program is based on the principles of deliberate practice, feedback, and reflection. In the report on their experiences after six years of the program it was noted that somewhere between 7% and 28% of medical trainees, regardless of their level of training or specialty, required remediation in the form of an individualized learning plan to achieve competence. Among medical students, reported deficits included the inability to integrate large amounts of material, poor time and stress management, and poor test-taking skills, while among residents, they included insufficient medical knowledge, poor clinical judgment, inefficient use of time, inappropriate interactions with patients and colleagues, and “unacceptable moral behaviors.”9
Another use of off-ramps is to promote learner reflection and give them the opportunity to reaffirm their commitment to a career in medicine. We suspect that if given the option, many current students would reconsider their career choice. In a survey of students’ attitudes toward educational debt, one author’s (R.E.’s) school asked students, “If we could return your tuition and forgive your debt, would you take the money and leave the field of medicine?”10 Just about 15% of second-year students said yes!10 This number is likely bloated by the fact that the school asked students about this at the end of their second year, which is before the clinical immersion experience and as they were studying for the United States Medical Licensing Examination Step 1. Nonetheless, why would students choose not to complete their medical education after already investing a great deal of time and money into the process? For some, the choice to leave medicine is based on their evolving self-realization, changes in values and priorities, and the recognition that they no longer want to join the profession of medicine. For others, it could be related to debt, familial expectations, illness, or caretaking responsibilities. Finally, a few others will have demonstrated that they cannot or do not want to do the work. In fact, some experienced medical educators believe that many students who underperform academically or behave unprofessionally, particularly those who feel familial pressure to become physicians, are likely, to some extent, engaging in “self-sabotaging” behaviors.11
The Moral Imperative
Given the nationwide focus on physician health and wellness, we believe that the creation of options to leave medical training without compromising one’s self-esteem or incurring unmanageable debt (i.e., compassionate off-ramps) is a moral imperative. The attrition rate for students in MD-only programs who take a leave of absence is 30%.1 We would hypothesize that a leave of absence offered these students time for reflection, and for a significant percentage of them it led to the decision to leave medicine. This level of reflection must be incorporated into the general curriculum and normalized so that every student has the opportunity to reaffirm their career goals. The practice of medicine should not be an exercise in survival; it should allow people to develop and thrive over the course of their careers. Offering students options to make use of the medical competencies they have accumulated in other attractive careers would enable medical educators to behave compassionately toward individual students and fulfill their societal obligation to graduate competent and committed physicians. To this end, we present the following recommendations for consideration (all of these recommendations would likely benefit from local legal review to ensure that both the student and the institution are protected in the decision-making process).
- Recommendation 1: Explicitly enable the ongoing assessment of students’ commitment to becoming physicians as part of a required professional identity formation curriculum.
- Recommendation 2: Implement competency-based education and training to enable rigorous assessment that would allow early identification of struggling leaners.
- Recommendation 3: Use career advisors and coaches to provide career counseling for those using a compassionate off-ramp. This counseling should include options that enable students to potentially apply some of their acquired competencies toward alternative careers in health care. We recognize that this would require rigorous faculty development and a culture change in our institutions as advisors and coaches would need to become more aware of the training requirements for other health care professionals, health administrators, or researchers.
- Recommendation 4: Give credit or credentials for competencies already achieved at a number of points along the medical education continuum (e.g., master’s degrees in medical science, certificates in clinical competence) to promote the attainment of alternative degrees.
- Recommendation 5: Require financial counseling for students who must or are considering leaving training, and support restructuring of debt (including forgiveness) and other services that would make it easier for students to choose to leave the profession and that incentivize schools to actively ensure career fit.
- Recommendation 6: Require medical schools to specifically report to the Liaison Committee on Medical Education (LCME) on their remediation programs and handling of debt for students that use off-ramps, with the LCME considering debt forgiveness a marker of excellence.
There are likely other career options for students who wish to leave the medical profession that would be better than having them stay and commit to a lifetime of mismatch between their abilities and passions on the one hand and their career in medicine on the other. Off-ramps in medical training should be created and their use encouraged in appropriate circumstances to both demonstrate the same compassion to learners that physicians are expected to show for patients and honor the medical profession’s social contract.
2. Guerrasio J, Furfari KA, Rosenthal LD, Nogar CL, Wray KW, Aagaard EM. Failure to fail: The institutional perspective. Med Teach. 2014;36:799–803.
3. Hunt DD, Scott CS, Phillips TJ, Yergan J, Greig LM. Performance of residents who had academic difficulties in medical school. J Med Educ. 1987;62:170–176.
4. Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of clinical supervisors. Acad Med. 2005;80(10 suppl):S84–S87.
5. Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME guide no. 42. Med Teach. 2016;38:1092–1099.
6. Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000;284:1099–1104.
7. Guerrasio J, Brooks E, Rumack CM, et al. Association of characteristics, deficits, and outcomes of residents placed on probation at one institution, 2002–2012. Acad Med. 2016;91:382–387.
8. Warm EJ, Mathis BR, Held JD, et al. Entrustment and mapping of observable practice activities for resident assessment. J Gen Intern Med. 2014;29:1177–1182.
9. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006–2012. Acad Med. 2014;89:352–358.
10. Englander R; Associate dean for undergraduate medical education, University of Minnesota Medical School. Unpublished data, 2017.
11. Raymond L. Kalet A, Chou CL. Perspectives from a psychiatrist in an office of advising resources. In: Remediation in Medical Education: A Mid-Course Correction. 2014:New York, NY: Springer; 205–219.