The authors comment
Every spring at U.S. medical school commencements, deans of student affairs and curriculum stand on stage, pledge along with the graduating class to do no harm and hood their students, shake their hands, and confer their medical doctorate degrees. All the while, they know in their hearts that there are one or two (or possibly more) of these new doctors whom they would not allow to care for their family. Aware of these students’ academic limitations or unprofessional behavior, the deans nonetheless allow them to graduate. We believe that allowing inadequate or inappropriate candidates to become doctors is unacceptable, and we cannot continue to neglect our responsibility in this way.
It’s natural, of course, for some students to struggle and for medical schools to work with them to overcome their difficulties with academics or professionalism. Though there are no data on students, there is evidence that some unprofessional behavior on the part of practicing physicians can be remediated. In rare cases, however, students who are permitted to graduate despite unprofessional behavior go on to become disruptive or incompetent clinicians.
It is our responsibility as physicians to care for our patients, and our duty as leaders in medical education to develop a competent workforce that will provide safe and compassionate care. Medical errors continue to be committed and to cause harm, and though most are attributable primarily to systemic problems, some result from a physician’s difficulty working in the system, inability to communicate, lack of knowledge, or unprofessional actions.
In addition, a few physicians commit criminal or malicious acts; such incidents occur in medicine at a rate similar to that in other white-collar fields. Could we predict sooner that these doctors will behave unprofessionally? Evidence suggests that we could; physicians who are sanctioned by state medical boards are more likely than other physicians to have had their professionalism questioned previously, to have been identified as problematic by promotions committees, and to have performed poorly on tests. Yet medical schools continue to graduate students who should not be physicians. What are the incentives for promoting — and the barriers to dismissing — problematic students? ...
Associate deans of education don’t always believe that the leadership of their medical school will support them in decisions to dismiss students. Such decisions are generally made by an academic review committee and managed by associate deans; they are often appealed to the dean, an executive committee, the university president, or other leaders, who may confirm or reverse them. These leaders may be rather removed from the details of student issues and, having their own pressures to contend with, may not endorse dismissal. They may also fear that dismissal will be perceived as a sign of the school’s failure to support its students.
The medical school accreditation process requires reporting student attrition rates. Overall, the U.S. medical school attrition rate is low, with only about 3% of students failing to graduate for any reason, whether academic, professional, personal, or medical (see the Supplementary Appendix, available at NEJM.org). A higher-than-average rate of attrition or dismissal might raise red flags, affecting accreditation and recruitment. In medical schools outside the United States, a somewhat higher proportion of students (9% on average, internationally) do not finish their degrees, and attrition in other professional schools is quite a bit higher; students, faculty, and administrators of law schools (20% attrition, on average), nursing schools (10 to 50%), pharmacy schools (10 to 14%), and Ph.D. programs (up to 50%) seem to recognize that selection of candidates for professional schools is an imperfect process (see the Supplementary Appendix). Still, in light of the traditionally low attrition in U.S. medical schools, higher rates at a given school could well threaten its reputation.
An additional strong disincentive to dismissal is the question of legal liability. It is rare for a medical school to lose a lawsuit related to dismissal; in general, the courts have decided that professions have the right and responsibility to sanction their own members, including students. The cases in which courts have not upheld dismissal decisions have involved schools’ deviation from their own due-process, recusal, and appeals policies. Nevertheless, each time a school considers dismissing a student, the risk of a lawsuit triggers involvement by the institution’s legal counsel, since students and their advocates may explore their legal options. Any litigation can take a protracted personal toll on faculty members and administrators, in addition to costing the school money for legal defense.
Finally, we are inevitably uncomfortable about the degree of uncertainty in measurement. One of the most difficult problems with dismissing students is a lack of detailed data on which to base such decisions and the debatable accuracy and validity of the data that do exist. Often, faculty do not want to document unprofessional behavior that might hurt a student’s career. They rationalize that a single instance of unprofessional behavior is just a single instance. They may not know that the student has exhibited a pattern of such behavior elsewhere. Out of compassion, educators may choose to believe that the behavior merely reflects immaturity or a student’s slower-than-average growth trajectory. When faculty members refrain from documenting the problems that arise, it is difficult to amass adequate input for academic review committees to make decisions.
The vast majority of U.S. medical students succeed, including those who struggle and undergo remediation. But when students clearly should not become doctors, shuttling them through to graduation has consequences. Some residency program directors have lost their trust in medical schools, knowing that their Medical Student Performance Evaluations and academic transcripts don’t accurately reflect students’ performance because negative comments may not be included, professionalism issues may be hidden, and a course failure may be replaced with a “pass” when the student receives remediation or retakes the course.
We believe that medical schools will need to partner with accreditation bodies, create degree-granting off-ramps, and make some tough decisions. If medical educators examine their consciences, they will recognize the need to ensure that every student we graduate is someone we would allow to care for patients and our own families.
