Sharing Information About 'Struggling' Med Students

August 28, 2008

As colleges have begun paying increasing attention to retaining their current students, they have embraced a range of strategies for identifying and helping those who struggle. Virtually all of those strategies -- such as "early warning" systems and "intrusive advising" -- depend on a "it takes a village" approach, in which the more people working together to help the student, the better.

Those and other tactics, though, more or less depend on widespread sharing of information about how students are faring -- particularly if they are struggling. But a series of articles released Wednesday -- while relegated to the sphere of medical education, which has some unusual characteristics -- suggests significant reluctance on the part of some educators to share information about at-risk students with some colleagues who might be in a position to help the students later.

The articles, published in the September issue of Academic Medicine, the journal of the Association of American Medical Colleges, include a report on a survey and three editorials about medical schools' policies regarding the sharing of information about students who struggle during required "clerkships" in internal medicine in their third and fourth years of medical school.

The study, which was conducted by researchers at Rush Medical College in Chicago, Cleveland's Case Western Reserve University, and the Uniformed Services University of the Health Sciences, in Maryland, first asked the directors of internal medicine clerkship programs how many of the students were identified as "struggling" through performance on written exams, evaluations of their clinical performance, peer assessments, and other measures, including formal evaluations of "professionalism." Individual respondents identified between 0 and 15 percent of students in their programs as struggling. This figure includes only those students who were deemed to be struggling at the end of their clerkships, excluding those who had struggled during the clerkship but improved their performance (through remediation or otherwise) by the time it ended.

To the surprise of the researchers, more than two-thirds of the students the directors identified as "struggling" received non-failing grades, and significant numbers received grades high enough that they probably would not have shown up on the radar screens of the "promotions committees" or other officials at their medical schools who are charged with assessing the academic status of students. While those higher-than-expected grades may reflect "individual students' unique circumstances," the authors write, "the high percentage of satisfactory or above-average grades does raise concern regarding grade inflation.... Giving struggling students satisfactory grades may lessen the chances of those students being identified as struggling, thus reducing the potential for remediation."

Students who did receive failing or otherwise unsatisfactory grades were commonly referred to a "promotions" committee at their institution. But while nearly two-thirds of the clerkship directors said they believed that they should share information about struggling students with other clerkship directors at the institution, and nearly half thought they should share such information with students' medical school instructors, far fewer actually did so (51 percent shared this information with other clerkship directors; 36 percent shared it with medical school instructors).

Those who favored sharing information with instructors and others who might work with the students down the road said they did so because they wanted to provide a supportive educational environment and to identify students' problems early, and because they "viewed medical education as a continuum," the report says. (Two commentaries in the same issue of Academic Medicine -- by academics at the State University of New York's Upstate Medical University and the Uniformed Services University -- endorsed the idea of such information sharing for those and other reasons.)

Those who opposed sharing information about students' failings cited a "fear of creating bias or prejudice against students, and lack of trust that clerkship directors will use such information appropriately." Some also said they feared litigation from students. (One commentary in the issue of Academic Medicine -- by a dean at the University of Texas Southwestern Medical Center at Dallas -- discouraged the sharing of such information, expressing concerns about stigmatization of struggling students.)

Only 14 percent of institutions had formal policies on sharing information, and most of them "were specifically prohibited from discussing students with academic difficulty with current teachers or other clerkship directors," the report says.

Sandra L. Frellsen, assistant professor of medicine and co-clerkship director at Rush Medical College and the study's lead author, said the degree of grade inflation created numerous potential problems. First, "if students are never given a grade that identifies them as struggling, then they're missing out on an opportunity to get remediation," she said. Perhaps more seriously, given that these are students nearing the end of their medical school careers, there's a possibility that significant flaws might not get corrected until the soon-to-be doctors are treating patients, if ever. "We do have an obligation to say, when we graduate students, that they're ready and that they're not going to be a danger," she said.

Frellsen said she and her colleagues endorse the sharing of "limited information" about struggling students to help ensure that they get the help they needed from their instructors. "If a student had a difficult time representing a patient's medical history in an organized, succinct way in the clerkship, that would be useful information for the director of the next rotation to know, so attention can be paid to that," she said. Frellsen and her fellow authors call for a national standard that at least permits, if not openly encourages, the sharing of such information. "It would be easier if this were dealt with at the national level," she said.

Although the study in Academic Medicine focuses on medical education, its findings resonate with issues in undergraduate education, too, said George D. Kuh, Chancellor's Professor of Higher Education and director of the Center for Postsecondary Research at Indiana University at Bloomington. Kuh noted that there is great variation among colleges in how they approach student performance, with certain institutions -- he singled out many historically black colleges -- adopting a "talent development" orientation in which all hands work together to help students improve the most.

The competitiveness of medical schools, which are typically "creaming the cream off the top" of undergraduate student bodies, may lead faculty members and officials there to see information about students' academic troubles leading to "bias" against them. But it's hard to see, Kuh said, how such a view results in helping institutions help their students. Kuh said he was troubled by the suggestion of some medical school officials that "we don't trust others in our setting to have this information.... We have to be confident that others having this information will somehow make a positive difference in the students' performance."

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