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#KeyLIMEPodcast 68: Failure to fail – The institutional perspective

This week the Key Literature in Medical Education post examines one of the biggest threats to the profession of medicine.  If the autonomy of medicine builds from our social contract with society (i.e. the commitment of the profession to the public to altruistically serve the common good and act in the best interest of our patients), then allowing dyscompetent physicians to advance through training and into practice, breaks our commitment and threatens external measures of accountability (e.g. governmental bureaucratic oversight).

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– Jonathan (@sherbino)


KeyLIME Session 68 – Article under review:

Listen to the podcast

View/download the abstract here.

Guerrasio J, Furfari KA, Rosenthal LD, Nogar CL, Wray KW, Aagaard EM. Failure to fail: The institutional perspective. Medical Teacher 2014. [ePub ahead of print]: 1-5


Linda Snell (@LindaSMedEd)

Faculty members fail to fail for many reasons, including lack of willingness to document negative evaluations, lack of knowledge as to what to document, anticipation of the grade or evaluation appeals process, and lack of remediation options. However, institutions bear ethical responsibility for failing underperforming learners, and institutional barriers are obstacles in identifying and dismissing failing learners. Institutional resistance was defined as ‘policies, procedures, committee responses, and appeals processes, that failed to remediate, delay or dismiss students who did not meet standards’. US medical schools have a reputation for dismissing very few students relative to other graduate programs or international medical schools.

To determine institutional barriers to placing failing students on probation, dismissing students.

Type of paper
Research: Survey

Key Points on the Methods
Online survey of regionally-based random sample of “the most appropriate person” in MD, DO, PA, NP schools.

Open ended questions: define the terms probation and dismissal, describe barriers to probation and dismissal, and to comment on whether under-qualified students were permitted to graduate and to indicate the likelihood of using probation and dismissal for underperforming students.

Key Outcomes
• 40% of 48 schools responded.
• Definitions of the terms ‘probation’ and ‘dismissal’ inconsistent & varied widely.
• A wide range of barriers were identified, greatest emphasis on legal concerns. Others include:
• Barriers (% responses)
• Limited availability of remediation options (36%)
• Personal relationship with the learner (29%)
• Concern for students financial investment (21%)
• Concern for students future professional career (21%)
• Dean or other administrate faculty overturn decision (21%)
• Quotations supported themes – ‘easier to pass than fail’, ‘hard to dismiss when issues of professionalism’ …
• 79% felt that students were graduating who should not be allowed to graduate and only half thought an incompetent student would be placed on probation or terminated.

Key Conclusions
The authors conclude that if barriers that lead to promoting failing students are not addressed, institutions will continue to concede that students are graduating without the necessary skills or competence.

Proposed solutions included clear accreditation guidelines for failure; increasing understanding of legal aspects; development of remediation teams and strategies that work; reinforcement and support of faculty and documentation; publicize studies of long term outcomes of failing students to understand risk of not failing.

Spare Keys – other take home points for clinician educators
An important yet underexplored area: often in med ed we look at the individual or program, yet systems perspectives are also important and may explain unexpected findings or lack of response to interventions.

Access KeyLIME podcast archives here

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