Ethics Roundtable: When a Student Fails to Make the Grade

Response By Marcy Rosenbaum

Marcy Rosenbaum, Ph.D.
Assistant Professor, Department of Family Medicine and Office of Consultation and Research in Medical Education
University of Iowa College of Medicine
Iowa City, Iowa

The case of a student who is due for graduation and displays less than satisfactory clinical and/or professional behavior during clinical rotations is not a new one in clinical educational settings. Recently, we faced a very similar situation with a fourth year medical student. I queried many colleagues for advice on how to approach this issue and most suggested that some form of remediation would be most appropriate and was commonly used. In our case, we required that the student participate in intensive remediation focused specifically on her weak areas during a one-month rotation. Her graduation was made contingent upon successful completion of this program. This effort was labor intensive and tailored specifically for the student. Other institutions have well-established structured remediation programs for just this sort of situation. These remediation efforts give the message to students that clinical weaknesses are not to be taken lightly and may significantly delay graduation or require a change in the student's life circumstances.

This case points to much more critical issues regarding the ability of evaluation systems to catch and correct student behaviors and weaknesses of application before it is almost too late to take any action. The rigor of evaluation is especially important when students receive much of their training in clinical sites. If clinical and professional skills are important areas to master as part of the training program, these aspects of clinical practice need to be given as much importance as other issues in the evaluation system.

If the university coordinator noted others also having had problems with Sarah, what actions were taken to correct these problems earlier? It is the responsibility of the university coordinator to make sure both student and preceptor know what is expected of students and the recourse available if students do not meet these expectations. If Sarah was able to "pass" previous rotations in which she had problems, she has no reason to believe this current rotation should be any different. Thus during each of Sarah's previous rotation expectations should have been laid out clearly and enforced through the provision of a non-passing grade or the recommendation for remediation.

This case also raises questions about the reasons for Sarah's inconsistent behaviors and her seeming inability to reproduce the basic skills required of her. Certainly further explanation for the causes of these behaviors is warranted. I think our first reaction is that Sarah has not applied herself and does not care about such things as time or professionalism. A second reaction could be that she "just doesn't get it", perhaps Sarah is "not too bright." However, behaviors such as these can be red flags that point to more complex explanations for these behaviors. Mark Quirk, Assistant Dean for Academic Achievement at University of Massachusetts Medical Center, might argue that Sarah may have a learning disability that explains her performance difficulties. He writes eloquently about his experiences in discovering learning disabilities as being at the root of many "difficult student" encounters in his 1994 book, "How to Learn and Teach in Medical School." Or perhaps Sarah has an unstable home environment that contributes to her tardiness and seeming lack of attentiveness during her work.

In sum, this case raises several issues and suggests several potential actions. First, the potential causes of Sarah's behavior should be thoroughly explored. Second, both supervisor and university coordinator should make sure that behavioral expectations are clear to students, as well as the consequences of not meeting those expectations. Finally, institutions should have remediation opportunities available to students so they can learn to correct their behaviors and proudly go out into the world as new professionals, in a timely manner.

To submit cases or to be added to the list of respondents please contact: Helen Sharp Department of Speech Pathology and Audiology, 307 WJSHC University of Iowa, Iowa City, IA 52242. Phone: 319-335-6596, fax 319-335-8851, e-mail: [email protected]

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