Why Failing Med Students Don't Get Failing Grades ...

4 Interesting discussion re difficulty failing medical students compared to how nursing educators view need for safe practitioners.

Why Failing Med Students Don't Get Failing Grades ... - Well

NY Times
February 28, 2013
By Pauline W. Chen, M.D.

...I first noticed her when I overheard her quarreling with a nurse. A few months later I heard her accuse another student of sabotaging her work. And then one morning, I saw her storm off the wards after a senior doctor corrected a presentation she had just given. “The patient never told me that!” she cried. The nurses and I stood agape as we watched her stamp her foot and walk away.

“Why don’t you just fail her?” one of the nurses asked the doctor.
“I can’t,” she sighed, explaining that the student did extremely well on all her tests and worked harder than almost anyone in her class. “The problem,” she said, “is that we have no multiple choice exams when it comes to things like clinical intuition, communication skills and bedside manner.”

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

A student’s performance at this early stage, the traditional thinking went, would be predictive of how good a doctor she or he would eventually become.
But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course. ...

...But for many of these educators, the real issue was not flunking the flagrantly unprofessional student, but rather evaluating and helping the student who only needed a little extra help in transitioning from classroom problem sets to real world patients. Most faculty received little or no training or support in evaluating students, few came from institutions that had remediation programs to which they could direct students, and all worked under grading systems that were subjective and not standardized.

Despite the disheartening findings, Dr. Fazio and her co-investigators believe that several continuing initiatives may address the evaluation issues. For example, residency training programs across the country will soon be assessing all doctors-in-training with a national standards list, a series of defined skills, or “competencies,” in areas like interpersonal communication, professional behavior and specialty-specific procedures. Over the next few years, medical schools will likely be adopting a similar system for medical students, creating a national standard for all institutions....

Very interesting. Especially the last paragraph in your quote. I can think of a few residents I've worked with who would go into remediation based on that grading standard.

I've personally seen one medical student get failed out of a clerkship for poor interpersonal skills in the clinical area (after multiple counselings and opportunities to improve). One of the reasons clerkships are reluctant to fail people is that, unlike nursing, no other medical school will touch you if you flunk out. Failing someone is essentially ending that person's medical career permanently, which is a big step to take.

Quote from elkparkI've personally seen one medical student get failed out of a clerkship for poor interpersonal skills in the clinical area (after multiple counselings and opportunities to improve). One of the reasons clerkships are reluctant to fail people is that, unlike nursing, no other medical school will touch you if you flunk out. Failing someone is essentially ending that person's medical career permanently, which is a big step to take.

I'm not so sure how I compare nurse educators view on graduating safe nurse practioners.

Quote from elkparkOne of the reasons clerkships are reluctant to fail people is that, unlike nursing, no other medical school will touch you if you flunk out.

Quote from TheCommuterThe lower-tier medical schools in Mexico or the Caribbean will accept candidates who have previously flunked out. In fact, many of the Caribbean colleges have reputations as 'second chance' medical schools.

Quote from Libby1987I'm not so sure how I compare nurse educators view on graduating safe nurse practioners.

Quote from Jules AIn my experience going through two NP programs is they are kind of oblivious and ambivalent to whether or not the person will be a skilled practitioner. I don't think anyone flunks out of NP school. The exams are easy, there are more than enough fluffy nurse theory classes, the preceptors are reluctant to give harsh feedback and the schools won't fail anyone due to fear of legal ramifications. While I can't say I felt there are a large amount who will be overtly unsafe but I definitely feel and have seen the results in practice of more than a few psych-NPs who are not good prescribers.

Having talked to a few doctor friends -- they won't flunk you but you can still get a bad review which will make it harder to match into certain competitive residencies.

Quote from elkparkThat depends on the school. In my graduate program, there were students on the verge of flunking out all the way through the program, right up to graduation. The grading was v. tough. The clinical (and academic) standards and expectations were v. high. Not all programs are diploma mills.

Quote from Jules AGood point but did any of them actually flunk out? I went to two very reputable schools which I would in no way consider diploma mills but I don't remember anyone not graduating-eventually. Because everyone is already a nurse it raises the bar as compared to undergrads but I bet it is very difficult if not near impossible to be kicked out of a NP program. Heck even in undergrad it was difficult for them to kick out the truly incompetent students.

I agree that it is very difficult to fail a nursing student in clinical, unless they do something clearly unsafe and in direct violation of a policy. Most assessment in nursing clinical is subjective. Where people fail nursing is obviously in didactic content, and I will assume the same of med students. So the nightmare for an instructor is the rare student that is an excellent didactic student and is clueless in clinical. I think the days of the cut-throat nursing instructor are behind us. Colleges simply are not backing students being failed out without clear cut documentation. They want to retain students and avoid appeals or litigation.I will also add I do not know of anyone who has failed the clinical portion of an NP program. I do know those that have failed out before they reach clinical. I do feel graduate nursing education relies too heavily on RN experience and again, subjective evaluations.