Providing Compassionate Off-Ramps for Medical Students Is a Moral Imperative

Stepping Back: How Should Pass/Fail Scoring Influence Step 1 Timing?

ABSTRACT

Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students' individual needs and goals.

The experiences and support needs of applicants who go unmatched to genetic counseling graduate programs: An exploratory qualitative study

As interest in the profession of genetic counseling continues to grow, the number of applications received by accredited genetic counseling graduate programs far outweighs the number of available training positions. In the 2023 application cycle, 46% of applicants who participated in the genetic counseling match went unmatched. There is limited research surrounding the experiences of unmatched candidates. The aims of this qualitative study were to highlight the experience of not matching and reapplying and to identify support resources for the genetic counseling admissions process. We conducted 15 semi-structured interviews with individuals who had previously applied to genetic counseling graduate programs, not matched, and were in the process of reapplying. Through reflexive thematic analysis, five major themes were conceptualized: (1) Emotional navigation through the stages of the match process; (2) external perceptions surrounding going unmatched and disclosure of results; (3) experiencing stagnancy throughout applying and reapplying; (4) advances in knowledge and personal growth; (5) areas for increased supports and resources. This study has shed light on emotional and practical challenges faced by individuals who did not match with genetic counseling graduate programs and chose to reapply. The participants' experiences highlighted the need for enhanced support, especially in terms of emotional assistance and program feedback. They also underscored the importance of standardization and transparency in the application process. This research offers valuable insights for genetic counseling programs and organizations seeking to enhance the reapplicant experience and address the evolving needs of prospective candidates in the genetic counseling profession.

Transforming remediation for competency-based medical education

We care about the future experiences of all health professions trainees as competency-based medical education evolves. It is an exciting new era with many possibilities for progress in learning and competency development. Yet we are concerned that remediation remains a troubled and stigmatized detour from routine learning that can persist as a feared off-ramp from competency development rather than a central avenue for improvement and competency achievement. We believe that it is time to acknowledge that all trainees struggle and to recognize that remediation is an essential aspect of individualized learning. Decisive steps are possible to revitalize remediation and to launch its transformation towards growth-oriented pathways for change.

Revisiting Feed Forward: Promoting a Student-Centered Approach to Education Handoffs, Remediation, and Clerkship Success

Issue: Throughout medical school, and especially during clerkships, students experience changing work and learning environments and are exposed to new academic, interpersonal, and professional challenges unique to clinical learning. Given the siloed nature of clinical rotations, students often "fall through the cracks" and may repeatedly struggle through clerkships without support and coaching from which they would otherwise benefit. Many institutions have grappled with creating feed forward processes, that is, educational handoffs in which information is shared among faculty about struggling students with the intention of providing longitudinal support to ensure their success, while protecting students from negative bias that may follow them throughout the remainder of their medical school tenure. Evidence: Here, the authors describe the feed forward processes of four medical schools. Each school's process relies on close collaboration between course directors and deans to identify students and develop intervention plans. Course leadership and administration are typically the primary drivers for long-term follow-up with students. The number of participants in the process varies, with only one school directly involving students. Two schools hold larger, regularly scheduled meetings with up to 12 faculty present in their institution's feed forward process. Across these institutions, students can "graduate" from the feed forward process once they achieve competency in the areas of concern. Implications: The authors believe the most important outcome achieved is the formalization and adherence to a feed forward process. Thus, risk to students in the form of negative bias is mitigated by the flow of information, the extent to which information is available, and permitting students to be part of the process. These exemplars give insight into variable approaches to feed forward systems adopted by medical schools and demonstrate highly visible methodologies by which educational leadership empower students and educators toward a shared goal of student progress and achievement.

The role of feedback in supporting trainees who underperform in clinical environments

Introduction

Underperformance in clinical environments can be costly and emotional for all stakeholders. Feedback is an important pedagogical strategy for working with underperformance - both formal and informal strategies can make a difference. Feedback is a typical feature of remediation programs, and yet there is little consensus on how feedback should unfold in the context of underperformance.

Methods

This narrative review synthesises literature at the intersections of feedback and underperformance in clinical environments where service, learning and safety need to be considered. We do so with a critical eye towards generating insights for working with underperformance in the clinical environment.

Synthesis and discussion

There are compounding and multi-level factors that contribute to underperformance and subsequent failure. This complexity overwrites simplistic notions of 'earned' failure through individual traits and deficit. Working with such complexity requires feedback that goes beyond educator input or 'telling'. When we shift beyond feedback as input to process, we recognise that these processes are fundamentally relational, where trust and safety are necessary for trainees to share their weaknesses and doubts. Emotions are always present and they signal action. Feedback literacy might help us consider how to engage trainees with feedback so that they take an active (autonomous) role in developing their evaluative judgements. Finally, feedback cultures can be influential and take effort to shift if at all. A key mechanism running through all these considerations of feedback is enabling internal motivation, and creating conditions for trainees to feel relatedness, competence and autonomy. Broadening our perceptions of feedback, beyond telling, might help create environments for learning to flourish.

"Dismantling Fixed Time, Variable Outcome Education: Abandoning 'Ready or Not, Here they Come' is Overdue"

Two decades after competency-based medical education appeared in the lexicon of medical educators, the community continues to struggle with realizing its full potential. The implementation of the time variable, fixed outcome component has languished based on complexity compounded by resistance to change. Learners continue to transition from medical school to residency, and then practice, primarily based on time rather than having achieved the ability to meet the needs of the patient populations they will serve. Only those few who demonstrate glaring deficiencies do not graduate. The authors urge the medical education community to move from the current fixed time path of medical education toward the implementation of a true continuum of time variable, fixed outcome education, training, and deliberate practice. The latter is defined by purposeful learning, coaching, feedback, and repetition on the path to achieving and maintaining expertise. The opportunities afforded by such a time-variable, fixed outcome approach include: 1) development of a career long growth mindset, 2) ability to address evolving population health needs and careers within the context of one's practice, and 3) continual improvement of care quality and outcomes for patients on the journey towards expertise for providers.

Compassionate Off-Ramps: The Availability of Terminal Master's Degrees in US Medical Schools

Medical students who underperform or find they are not a "good fit" for medicine have limited options. A terminal master's degree represents an exit alternative that recognizes students' completed coursework and acknowledges their commitment to the medical sciences. Although medical educators have called for the creation of such programs, termed "compassionate off-ramps," the prevalence of degree offerings in US programs is unknown. In the fall of 2020, a survey was sent to Student Affairs Deans at 141 LCME-accredited MD programs; 73 institutions responded (52%). Terminal master's degrees were offered by 19% of respondent institutions (n = 13). While 85% of those without a terminal master's (n = 48) endorsed degree benefits, only 36% (n = 21) had plans to create the degree. This study demonstrates that few US medical schools offer a terminal master's degree, leaving students who exit medicine with high levels of debt without an avenue for a degree to support employment or future academic pursuits. The authors identify implications for students, particularly those who are at a higher risk of failing Step 1, such as students who are underrepresented in medicine, socioeconomically disadvantaged, or who have a disability and are unaccommodated. Potential barriers to terminal master's program creation are identified and mitigating strategies are recommended.

Competency frameworks, nursing perspectives, and interdisciplinary collaborations for good patient care: Delineating boundaries

To enhance patient care in the inevitable conditions of complexity that exist in contemporary healthcare, collaboration among healthcare professions is critical. While each profession necessarily has its own primary focus and perspective on the nature of human healthcare needs, these alone are insufficient for meeting the complex needs of patients (and potential patients). Persons are inevitably contextual entities, inseparable from their environments, and are subject to institutional and social barriers that can detract from good care or from accessing healthcare. These are some of the reasons behind current movements to develop competency frameworks that can enhance cross-disciplinary communication and collaboration. No single profession can claim the big picture. Effective teamwork is essential and requires members of diverse professions to understand the nature of each other's knowledge, skills, roles, perspectives, and perceived responsibilities so that they are optimally utilized on behalf of patients and their families. Interdisciplinary approaches to care permit different aspects of a person's needs to be addressed seamlessly and facilitate the removal of obstacles by engaging the range of resources exemplified by the different professions. Additionally, collaborative efforts are needed to influence policy changes on behalf of individual and social good and to address root causes of poor health especially as these impact society's most vulnerable. Here, we explore both the benefits and the risks of an uncritical acceptance of competency frameworks as a way to enhance interdisciplinary communication. We highlight the importance of anchoring proposed competency domains in the reason for being of a given profession and exemplify one way this has been accomplished for advanced practice nursing. Additionally, we argue that having this mooring, permits integration of the various competencies that both enhances professional moral agency and facilitates interdisciplinary collaboration to further the mutual goals of the healthcare professions on behalf of quality patient care.

Considerations for remediation policy and procedures in pharmacy education

INTRODUCTION

Despite the heterogeneous nature of remediation definitions, processes, and impact on learning, it is commonly understood as a process for identifying student deficiencies in knowledge, skills, and attitudes that need to be corrected prior to student progression in the program.

COMMENTARY

Current issues related to remediation in pharmacy education include inconsistencies in practices and types within and among institutions, a lack of correlation to student academic success, effects on attrition both positive (student staying on-time for graduation) and negative (students sitting back one year), increase in faculty workload, and negativity or stigma associated with the student.

IMPLICATIONS

Key considerations in developing and implementing remediation policies and procedures include being student-focused, providing a positive frame for remediation, implementing a clear process, and early identification of students who need help.

The appeal process and beyond (part 3 of 3). When residents shouldn't become clinicians: getting a grip on fair and defensible processes for termination of training

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone's best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (Part Three in the series of three) will focus on the formal appeals and what to do after the appeal.

Competency-based time-variable training internationally: Ensuring practical next steps in the wake of the COVID-19 pandemic

Competency-based medical education has been advocated as the future of medical education for nearly a half-century. Inherent to this is the promise that advancement and transitions in training would be defined by readiness to practice rather than by time. Of the logistical problems facing competency-based, time-variable (CBTV) training, enacting time variability may be the largest hurdle to clear. Although it is true that an 'all or nothing' approach to CBTV training would require massive overhauls of both medical education and health care systems, the authors propose that training institutions should gradually evolve within their current environments to incrementally move toward the best version of CBTV training for learners, supervisors, and patients. In support of this evolution, the authors seek to demonstrate the feasibility of advancing toward the goal of realistic CBTV training by detailing examples of successful CBTV training and describing key features of initial steps toward CBTV training implementation.

Growth mindset in competency-based medical education

The ongoing adoption of competency-based medical education (CBME) across health professions training draws focus to learner-centred educational design and the importance of fostering a growth mindset in learners, teachers, and educational programs. An emerging body of literature addresses the instructional practices and features of learning environments that foster the skills and strategies necessary for trainees to be partners in their own learning and progression to competence and to develop skills for lifelong learning. Aligned with this emerging area is an interest in Dweck's self theory and the concept of the growth mindset. The growth mindset is an implicit belief held by an individual that intelligence and abilities are changeable, rather than fixed and immutable. In this paper, we present an overview of the growth mindset and how it aligns with the goals of CBME. We describe the challenges associated with shifting away from the fixed mindset of most traditional medical education assumptions and practices and discuss potential solutions and strategies at the individual, relational, and systems levels. Finally, we present future directions for research to better understand the growth mindset in the context of CBME.

Twelve tips on guiding preparation for both high-stakes exams and long-term learning

High-stakes exams including admissions, licensing, and maintenance of certification examinations are commonplace in health professions education. Although exam scores and performance can often serve gate-keeping purposes, the broader goal of health professions education is to foster deep, self-directed, meaningful, motivated learning. Establishing strong support structures that emphasize deep learning and understanding rather than exam scores can be beneficial to preparing learners who have the knowledge base to be excellent practitioners. This article offers guidance that can be used by academic support centres, medical educators, learning specialists, and faculty advisors, or even test-takers, to help learners to balance score achievement and knowledge development, while simultaneously cultivating more efficient and motivated studying and increasingly self-regulated learning. This series of tips details considerations for building academic success supports, fostering a growth mindset, planning efficient and effective studying efforts, utilizing test-enhanced learning strategies, exam-taking skills practice, and other support structures that can help strengthen learning experiences overall.

A Snapshot of Current US Medical School Off-Ramp Programs-a Way to Leave Medical School with Another Degree

Although most students finish medical school, those who do not frequently have no obvious programmatic alternatives. In recent years, a growing number of medical schools have been developing "off-ramp" programs to help such learners. We surveyed 12 medical schools with off-ramp programs to understand their characteristics and challenges. Differences existed between programs but most were deemed helpful to the students and institutions they served. Advantages included the opportunity to acknowledge the students' hard work, increase career opportunities, and reduce debt. Understanding and promoting such programs will assist students for whom medical school does not represent the optimal career path.

Remediation and reassessment methods in pharmacy education: A systematic review

BACKGROUND

Colleges of pharmacy are currently required to implement a remediation program within their curricula, but no specifications are provided on the ideal methodology. While the need for successful remediation strategies continues to grow, literature describing positive or negative outcomes of different approaches is significantly lacking. The objective of this literature review was to describe and evaluate remediation methodologies in pharmacy education.

METHODS

This literature review was completed following PRISMA criteria. A search of the PubMed, Cochrane Library, Cumulative Index of Nursing and Allied Health, Academic Search Complete, PsycInfo, Scopus, and ProQuest Central databases was conducted in July 2019. Studies were included if they involved pharmacy student education and described either remediation or reassessment.

RESULTS

The evaluated studies discussed a range of course types being remediated, a large variety of remediation strategies and timeframes, and differing overall outcomes. No studies provided comparison of remediation techniques or provided details on the implementation of their chosen approaches. A consistent finding within the evaluated studies was the inclusion of prevention strategies to attempt to avoid the need for remediation preemptively. Overall outcomes for each remedial program were inconsistent and no clear patterns were evident other than an improvement in student performance following remediation.

IMPLICATIONS

Remediation strategies included course repetition, summer restudy, reassessment, and individualized plans. Outcomes varied significantly between studies, making methodology comparisons difficult. Future studies that include more detail and consistency in the reported outcomes would be beneficial to students and help clarify remediation for colleges of pharmacy.

Identifying and Supporting Students to Prevent USMLE Step 1 Failures When Testing Follows Clerkships: Insights From 9 Schools

Several schools have moved the United States Medical Licensing Examination Step 1 exam after core clerkships, and others are considering this change. Delaying Step 1 may improve Step 1 performance and lower Step 1 failure rates. Schools considering moving Step 1 are particularly concerned about late identification of struggling students and late Step failures, which can be particularly problematic due to reduced time to remediate and accumulated debt if remediation is ultimately unsuccessful. In the literature published to date, little attention has been given to these students. In this article, authors from 9 medical schools with a postclerkship Step 1 exam share their experiences. The authors describe curricular policies, early warning and identification strategies, and interventions to enhance success for all students and struggling students in particular. Such learners can be identified by understanding challenges that place them "at risk" and by tracking performance outcomes, particularly on other standardized assessments. All learners can benefit from early coaching and advising, mechanisms to ensure early feedback on performance, commercial study tools, learning specialists or resources to enhance learning skills, and wellness programs. Some students may need intensive tutoring, neuropsychological testing and exam accommodations, board preparation courses, deceleration pathways, and options to postpone Step 1. In rare instances, a student may need a compassionate off-ramp from medical school. With the National Board of Medical Examiner's announcement that Step 1 scoring will change to pass/fail as early as January 2022, residency program directors might use failing Step 1 scores to screen out candidates. Institutions altering the timing of Step 1 can benefit from practical guidance by those who have made the change, to both prevent Step 1 failures and minimize adverse effects on those who fail.

Guidelines: The dos, don'ts and don't knows of remediation in medical education

INTRODUCTION

Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies.

METHODS

Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus.

RESULTS

We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline.

CONCLUSIONS

Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

Practical Implications of Compassionate Off-Ramps for Medical Students

Attrition from medical school remains uncommon even when a medical student performs poorly, has a change in interests, or experiences an unexpected life event that alters his/her ability to succeed as a physician. In this issue, Bellini and colleagues describe the scope of this problem and make recommendations to support the implementation of compassionate off-ramps for students. These recommendations include enabling ongoing assessment of commitment to career path via a professional identity formation curriculum; implementing competency-based education and training to identify struggling learners; using career advisors and coaches who understand alternative career pathways; providing credit or credentials for competencies already achieved; requiring financial counseling and supporting debt forgiveness; and requiring schools to report on their remediation programs and handling of debt. In this Invited Commentary, the authors describe a representative student-a composite of several students they have counseled whose medical school paths have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues-who may have benefited from these recommendations. The authors elaborate on Bellini and colleagues' recommendations and describe what they think would be necessary to ensure that the recommendations effectively meet the goal of providing compassionate off-ramps for students in need. The authors describe the potential impact of the recommendations on the representative and similar students. Although this impacts a small proportion of students, the recommendations would help schools achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.