Council on Medical Student Education in Pediatrics


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Failure IS an option

The failure to fail underperforming trainees in health professions education: A BEME systemic review:  BEME Guide No. 42.  Yepes-Rios R., Dudek N, Duboyce R, Curtis J, Allard R, and Varpio L:  Medical Teacher, 206, 38:1092-1099.

Reviewed by Janet Meller

Tags:  faculty development, failing underperforming trainees, systematic review

What was the study question?  What are the factors related to assessors' ability and willingness to report poor clinical, academic and professional performance?

How was the study done?  The authors conducted a systematic review of the literature relating to the failure to fail phenomenon across medicine, nursing and dentistry. They identified 28 articles—most were qualitative studies (focus groups, individual interviews or reviews). The authors then conducted thematic analysis of the article content.  They identified 6 themes related to barriers assessors face when failing a student and 3 themes related to factors enabling assessors to fail underperforming students.

What were the results? The barriers identified were 1: professional considerations –workload involved in recording a failing grade, insufficient information to do so and fear of litigation; 2:  personal considerations--sense of personal failure, strain of conflicting emotions- support vs. assessment, failure of teaching, anticipation of conflict. 3:  trainee related considerations-effect on trainee's future, emotional reaction. 4: Unsatisfactory assessor faculty development, 5: Institutional culture--lack of support for decision to fail, 6: lack of available remediation for trainees.

The enablers identified were:  1:  duty to patients, to society and to the profession, 2:  support from the institution, colleagues and assessor faculty development, 3:  opportunities for support and guidance to trainees after failing.

What are the implications? Institutions play an important role in creating a climate to support faculty members who are involved in failing trainees.  In many cases there is insufficient faculty development in terms of the tools required to identify and assess a failing performance.  In addition to institutional support including improved faculty development, measures to strengthen ethical competence, development of more explicit expectations for trainees and opportunities for trainee remediation are needed.

Editor’s Note: It’s not surprising, given how many barriers there are to receiving a failing grade in a clinical setting, that many students spend their time on more “objective” assessments like multiple choice exams rather than improving their clinical performance. (JG)

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