On this episode of the Academic Medicine Podcast, Lynnea Mills, MD, joins host Toni Gallo to discuss her new study of medical students’ experiences of failure and remediation in the United States and the Netherlands, which is part of this year’s Research in Medical Education (RIME) collection. Also joining the conversation are RIME Committee member Mike Ryan, MD, MEHP, and AAMC MedEdSCHOLAR Anna-kay Thomas, EdD.
This episode is the second in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field. Check out last month’s episode on perceptions of disability inclusion in medical education among students with disabilities. And tune in next month for the final episode in the series on the transformative potential of the arts and humanities in residency training.
This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.
A transcript is below.
Read the article discussed in this episode:
Transcript
Toni Gallo:
Welcome to the Academic Medicine Podcast. I’m Toni Gallo. Every year, Academic Medicine publishes the proceedings of the annual Research in Medical Education or RIME sessions that take place at the AAMC’s Learn Serve Lead Meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the Learn Serve Lead Meeting, which is taking place in Atlanta in November. The RIME papers are all available now to read for free on academicmedicine.org.
As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research and its implications for the field. On last month’s episode, I spoke to the authors of a qualitative study on disabled student perspectives on disability inclusion in US medical education, and you can find that episode in our archive. Today for the second of this year’s RIME conversations, I’m joined by Dr. Lynnea Mills, one of the authors of “‘When You’re in It, It Feels like Everything’: Medical Students’ Experience of Failure and Remediation in the US and the Netherlands.”
Joining us for our conversation are RIME committee member, Dr. Mike Ryan and MedEdSCHOLAR, Dr. Anna-kay Thomas. We’ll talk about decreasing the stigma associated with failure and remediation and how we can support students’ well-being during this difficult time. And then we’ll get into some of the differences between the medical education systems in the United States and the Netherlands and how that affected students’ perceptions of the impact of remediation on their career long-term.
So before we get into our conversation, I’d like to ask each of you to please introduce yourselves for our listeners. Mike, you want to go first?
Mike Ryan:
Hi. First of all, congratulations, Dr. Mills in your paper. It was wonderful reading it. I’m very happy to be here. So my name’s Mike Ryan. I’m a professor of pediatrics and associate dean for assessment, evaluation, and scholarship at the University of Virginia, and I’m also a RIME committee member as Toni mentioned.
Anna-kay Thomas:
Hi. Congrats on your paper, Dr. Mills. Anna-kay Thomas. I’m the director of medical education at Cooper Medical School of Rowan University. My doctorate is in education with a focus of leadership, mentoring, and coaching, and I am a MedEdSCHOLAR.
Lynnea Mills:
Thank you so much for this opportunity to come and talk about my paper and my work. I’m really excited to be here. I’m Lynnea Mills. I’m an associate professor in the Department of Medicine at UCSF and I have a few different academic roles, but what’s most relevant to our discussion today is that I direct programs to coach struggling learners primarily on the GME level but also with medical students as well. And the paper we’ll talk about today looks at students’ experience of that process.
Toni Gallo:
Thanks very much to all of you for being on the podcast today. I’m looking forward to our conversation. Lynnea, can you get us started? Just tell us a little bit about your paper, what you did for your study, and maybe highlight some key findings.
Lynnea Mills:
Yes, absolutely. Thank you. So just a moment on the background of why we decided to do this study. If you were to look at the remediation literature, you’d see a fair amount of publications by faculty talking about what they think works in this space, and relatively less from the learners themselves about their experience of going through the remediation process. And some papers look at logistical pieces of, for example, students saying, “Yeah, we really like simulation. We feel it’s helpful.”
But there’s not much about students’ emotional experience of being told they failed something and then going through a process of trying to address it. And to me that felt like a really important gap. We talk about emotion a lot in health professions education as it relates to well-being, but there’s also this whole other area of study, particularly in neurosciences and psychology around the impact of emotion on learning, on the learning process, on the mechanics of that.
And so I felt like if we’d spent more time paying attention to what happens for the learners emotionally during this process, we actually could identify some ways that we could improve their learning, which in this context is really crucial. They have to learn to be able to improve and meet those milestones.
So that was the goal of this study, to look at learners’ emotional experience of going through this process. And in the study, we interviewed students at four different medical schools, two from different regions in the US and two from the Netherlands. And these were students who had self-identified as not having met expectations on any assessment throughout any phase of medical school. And we asked them questions that were specifically targeted toward their emotional experience.
The reason that we picked those two countries, the US and the Netherlands, was because they’re quite different in how their curricula are structured and how students are expected to progress, the US being pretty fixed with the med school curriculum being four years pretty much everywhere, and the Netherlands being much more flexible in how students can progress through the curriculum with many students taking quite a bit longer or figuring it out as they go in terms of how long they want to take. And we can talk more about that later, but we thought, my co-authors and I, that that could have an impact on students’ emotional experience.
So our findings were several. We realized that students have a lot of the emotions that probably most of us wouldn’t be surprised by. So many of them felt shame. A lot of them felt like, “Hey, I’m worse than my classmates. Everybody else must have passed this exam and I failed. There’s something wrong with me.” A lot of those kinds of emotions.
We had expected to hear about those. What we hadn’t expected was how significant those emotions would feel for the students and how much they would impact the student’s sense of their professional identity. So a lot of students really felt like the fact that they had failed something was very significant in commenting on their suitability for the profession. So a lot of students said, “How can I even be a doctor if I can’t pass a test on pathophysiology?” or that kind of feeling about themselves as future clinicians.
We noted that over time the students did feel a decreasing sense of that and many started to feel like, “Hey, it’s normal to fail. I shouldn’t be beating myself up.” But it did take them a while to get there and it didn’t completely dissipate for most of our students.
And the last thing I’ll say right now is that we found that to be a common experience for students in both the US and the Netherlands, but what we noticed to be different between the two countries was that the students in the Netherlands seemed to be significantly less worried about the impact this would have on their long-term careers. Most of them sort of felt like, “Yeah, this isn’t really going to set me back in applying for or getting a job. It’s frustrating, but it’s not the end of the world in terms of how my career will unfold.” Whereas for students in the US, it felt like a significant detractor in their ability to get started on their career paths.
Toni Gallo:
Thank you. And for listeners, there’s a link in the notes for today’s episode to find Lynnea’s paper. So definitely go check out the full text after you finish listening today.
One of the things that stood out for me in reading some of the quotes from the participants was this idea of normalizing failure, that you mentioned students feeling alone like they didn’t belong, that meant maybe medicine wasn’t for them, and they were really frustrated by how much stigma is still associated with needing remediation or with failure. And so I wonder if we can all dig into that a little bit more and talk about what are some of the ways that we can think about normalizing failure for students and decreasing the stigma that was across your paper, a lot of different students mentioned it?
Mike Ryan:
Well, Dr. Mills, I’ll be curious your take on this. So I think one of the questions that I would pose to the group and the audience is about the terminology we use here. So failure and remediation. I worry that we label certain students as having failed when we should really expect that everyone is learning. That’s after all while you’re in medical school, to learn. If you were ready to practice, you wouldn’t need the training.
And I think about our GME counterparts where, I’ll give you an example, as a pediatric hospitalist, one of the procedures that I do pretty regularly is lumbar puncture. I would never label a resident as a failure or needing remediation if they didn’t get a lumbar puncture on their first attempt. I would simply say that they’re not yet competent in that and that’s actually the expectation, that you have to do a certain number with supervision and then gradually you get better and better until you finally are competent.
So I think that the term normalizing failure, I would actually kind of reverse it and say normalize the development towards competent practice and say that we are all developing at our own trajectory and we need to think about how to share with our trainees that we expect them to have hurdles and have certain areas where they’re strong and certain that they’re weak in, and that we’re helping them as their mentors and coaches and advisors and faculty to get them to that point.
Lynnea Mills:
Yeah, it’s such an important comment and I’ll say we purposely designed our interview guide not to include those words, and then the students all used those words. I think every single student used words like failure and remediation in their spontaneous speech in answering our questions.
And I think this really gets at what you’re talking about here, Mike, which is there’s a sense for medical students probably more than for residents and fellows that a lot of their assessments are very summative. So they sit down and they take an exam and the exam is very binary. You pass or you fail. Maybe there are grades in there too, but that binary feels really important to them. Whereas I think more commonly in graduate medical education, learners do see their progression as sort of being along trajectory, where they have developmental phases that are considered really appropriate.
Of course, we feel that way about medical students too, and I think that’s a lot less visible to them when they have these graded experiences. So part of the question around reducing stigma is around shifting that to focus more on formative assessments, which I know is a whole other really important discussion in the literature. And I think there are smaller ways that we can do it too in the meantime.
So one student talked about a leader at their school getting up in front of the school during orientation and saying, “I failed.” I forget what that leader failed, but it was a dean or an associate dean or somebody saying, “I failed something in medical school.” And the student remembered hearing that and going like, “Whoa, that person is really doing well in their career and they failed something. So actually it must be okay to fail something.”
I think some of those little pieces, those little actions around normalizing failure can help us. But in the long run, moving toward this space where we don’t make assessment feel so summative, I agree, is definitely the answer.
Anna-kay Thomas:
I love that. I love that the leader got up and said that. I think when you start to normalize or how you start to normalize that conversation is doing exactly that.
The other thing to remember is that students come in feeling like they’re academics too. So a huge part of their identities is they’re carrying this, “I am an academic, I’m in medical school now.” And that first failure or dealing with adversity on an exam is really difficult for them. And I’m talking about the medical … the undergraduate piece. So reminding them too that they have other identities that are salient as well, like although they’re in medical school, there are other things happening in their life because I think medical school overshadows them … all the other identities that they come in with. And so when one thing is impacted, it feels like now they’re drowning because that is such a big part of who they are right now in their career.
So just reminding them of all the other identities that they came into medical school with and re-grounded them, from my experience as a medical learning … education learning specialist, that was really important for us to do in our work.
Toni Gallo:
Mike, I wanted to come back to you were talking about residency and learners progressing towards being competent practitioners. And one of the themes that Lynnea mentioned was this difference between the US context and the medical education context in the Netherlands, where the medical education system is set up a little differently. And in the US, we have a pretty rigid system in terms of medical school has a set length, and then you go to residency and it’s a set length and there’s been a lot of discussion about time variability and competency-based education and the Netherlands has a different system than we have here in the US.
So Lynnea, could you maybe give us some background context for how those two systems are different? And then I’d like to talk about learners in your study in the Netherlands were not as concerned about remediation having long-term career effects for them because they could progress to the next level at different times. Whereas in the US, the students were very concerned about, “If I have to repeat a course or something like that, this is going to push back my entire education, my residency, when I can get a job.” And so there was a very different reaction there to the long-term consequences.
Lynnea Mills:
Yes, absolutely. Thank you. So if you were to ask a medical student in the US how long medical school is supposed to take, they would say four years right away. And many of those students take time to complete PhDs or maybe they’ll take a leave of absence for personal reasons, other reasons that they might extend that time. But four years is how long it takes to complete medical school. That’s very well known in the US.
If you were to go to the Netherlands and ask a medical student how long it takes to complete med school, it would take them a while to give you an answer most likely, because there’s no set number, and a lot of students will take different amounts of time. So many students are completing the curriculum in six, seven, eight years. It’s really different for every individual and they don’t come into medical school with an expectation that they’re going to finish at a specific point.
So in the US, there’s a white coat ceremony that will coat the individuals and say, “Welcome, class of 2028.” That doesn’t happen in the Netherlands. They don’t get cohorted based on their expected graduation date. It’s very much this sense that they will progress through the curriculum and whatever amount of time it takes to meet these different milestones and the different competencies is however long they take, and that that’s not a problem.
They still do have assessments, they have summative assessments that they can pass or fail, but they’re expected to be able to take a flexible amount of time to complete different requirements, particularly a lot of those clinical rotations which they call internships. So there’s not this fixed sense that you finish in a certain amount of time. And I think the impact for the students is that they feel a lot less abnormal if they take time out for any reason because that’s sort of the expectation, that they’ll have different amounts of time that they need to get through.
So I was really curious what that would mean for students who take time out because of a need to repeat something. Maybe they have to repeat a course or they repeat one of those clinical rotations, the internships, and wondering what would be their sense of the stigma or the isolation, the self-doubt that we observed in the students in the US.
And it was really interesting to me to note that they did have a lot of those same feelings and they did really question themselves and a lot of them said, “I really want to do right by my patients and if I can’t do well in this clinical rotation, am I equipped to serve my patients down the road? Maybe not.” So they had a lot of those same feelings, but what they didn’t have was this sense of urgency that the students in the US had of, “I need to finish this. I have to be able to enter the Match at this specific time of year, because the match only comes around once a year.” They didn’t have any of that feeling because they know that whenever they finish medical school, there will be jobs available to them whatever time of year it is.
So they apply for these jobs rather than applying to enter this sort of rigid process, the Match, and they get to progress no matter when they finish. So for them, there’s not nearly so much pressure to be able to be on a particular schedule or “on time” as we might think about it here in the US.
And for that reason, a lot of the students that we interviewed from the Netherlands said things like, “Oh yeah, it wasn’t a big deal that I repeated that rotation.” And one student said, “Oh, I would far rather feel really prepared than finish a couple months earlier.” And I think that really comes down to the fact that the implications for them were so much different and the ability to transition into the next career phase was a lot easier for the students in the Netherlands because of that time variability.
Mike Ryan:
I would argue that the US system kind of has two tensions as far as what the purpose of medical school is. So tension one is to train us to be good doctors, much like the system is in the Netherlands. But then the other is this implied and sometimes explicit desire to match as well as you humanly can. And because we have a meritocracy of sorts in how we set things up, there is this devastating blow that a failure of any kind takes to your ability to match. And I’m wondering if the stigma that you saw in the students in your study, was it related to an internal struggle of what it means for me to become a doctor? Or was it this notion of like a single failure is now this red flag on my application that I’ve heard from students who’ve preceded me that now my chances of going into surgical subspecialty X or match at this particular place are now off the table? And what does that mean to my identity as I thought of myself as this aspirational doctor in that specialty?
Lynnea Mills:
Yeah. Well, this raises a really interesting question. So all of the students who participated from the US had not passed exams. There were no students from the US who had needed to repeat clinical clerkships, which is really interesting and that contrasts with our participants from the Netherlands.
So all of these students were aware that the way their schools had designed the system was that a single failure on an exam was not going to show up on their transcripts or on their residency applications. And they were incredibly grateful for that. I will say in the US, there are certain failures that do show up on transcripts that do get passed along to residency programs. And I suspect if we had been able to interview any of those students who had been in that situation, they would’ve felt all these same emotions and probably a whole lot more too.
So the concern was there very much, and a lot of our students said they worried that it wasn’t true, that it wouldn’t show up on their transcript or they worried if they failed again, it would show up on their transcript, something like that. They really had a lot of stress around. And so I can imagine that would be so much greater in cases where it is understood that it would be a red flag for them in the residency application process.
Anna-kay Thomas:
I’m also curious to know what was the implication for them, the financial implication for those students as well? Because Mike talked about the two tensions, but the third tension I would add is the financial component of spending that extra year in medical school, if you have to repeat a course or if you have to repeat a clerkship, how that impacts the students’ finances in the US versus in the Netherlands.
Lynnea Mills:
Yeah, the finances are another really important consideration. So medical school is significantly less expensive in the Netherlands, and that was actually something none of the participants from the Netherlands mentioned, whereas students from the US did mention that they were thinking about the cost of staying in medical school longer, and they were also thinking about the financial impact of waiting an extra year to start getting an attending level salary. So for them, the financial impact felt really significant. For the students in the Netherlands, there is some delay in their being able to garner that higher salary, but for most of them, that didn’t feel like a big consideration, most likely because the cost of medical education is so much lower in the Netherlands.
Toni Gallo:
Anna-kay, earlier you mentioned helping students think about all of the identities that they bring to medical school, not just their academic backgrounds. And I want us to all get into thinking about well-being and students’ well-being, and some of what we’ve talked about has sort of been reactionary when somebody does need remediation, how do you help them through it? But are there things that we can also do proactively to help students?
Lynnea, you mentioned the administrator getting up and saying, “Hey, I failed during medical school too,” and students being able to see like, “Oh, it happens, but look, this person is where they are today,” and obviously they were able to get there too. So how might we help students before they’re in the situation where they need remediation to understand what that means for them personally, for their career, to maybe stave off some of that shame and self-doubt and sense of that they don’t belong in medical school?
Anna-kay Thomas:
I think that’s great question. One of the things is normalizing academic difficulty, like Lynnea said earlier, but also across the board. So not just the leader normalizing academic difficulty, but also the folks in academic support, normalizing students seeking help, so help seeking behavior, right? Saying to students during maybe an orientation platform that everybody uses academic support, everybody uses tutoring, and of course I’m talking mostly to the undergraduate level here, but normalizing the culture of utilizing these services is one way, partnering with well-being, partnering with student affairs, partnering with academic affairs once a student fails for example, or have academic difficulty and sending them to the different departments for that emotional component that Lynnea’s research really talks about.
So not just meeting with academic support, which is going to help them kind of create a plan and get some structure around, figure out how they’re learning, but also sending that student to well-being folks too, to really talk about any imposter feeling that they’re feeling or how their academic identity is being impacted, I think is very useful to make sure that they have a safe space where they can have these conversation, if they can’t have them with their family.
I think in your paper, you talked about that, students feeling like they didn’t really want to share out with folks who didn’t understand that process. And sometimes once you… I’ve heard from students once they got into medical school, really it’s almost like the shame of, “Now I’ve failed. You thought that I was doing this amazing thing and I’m on this journey and now I’ve disappointed you.” And so creating these safe spaces, whether small group, so groups of students who’ve also had the same experiences, sharing with each other or sharing, creating these platforms where students share across the board about what their experience has been in medical school.
Mike Ryan:
I would build upon what Anna-kay is saying and probably make two points about what we as educational leaders can do. So point number one is to use an analogy, if you ever played video games where it’s a sports video game and you have different players and then they show you that each player has various strengths. Somebody is really fast and somebody is very good at, let’s say it’s basketball, shooting three pointers and someone’s very good at passing, et cetera, every single player on the team has different things that they’re strong at and different things that they’re weaker at. And I think we have to accept the fact that physicians all have similar strengths and weaknesses. If you use competencies, some are going to be better interpersonal communication skills, others are going to be better at knowledge, others are going to be better at systems-based practice, et cetera.
So I think it helps if we say on the front end, “All of you will struggle in one way or another. And our job here is to help you in the areas that you’re not so great at, and then also to recognize you for your accomplishments in the areas that you are really great at and try to help everybody along the way.” So I think that’s number one, is recognizing that we all have strengths and weaknesses and we can all support each other in those areas that are not as strong.
And then the other one is I think we have to look critically at what we value in medical education and we place such a high value, speaking of competencies, on the medical knowledge domain. I thought it was really interesting in your study, and you mentioned this earlier, Lynnea, how all the failures in the US were on tests. And I think tests are only one small part of what we do as physicians, and I suspect there’s students in your study who had failures in communication skills or failures in professionalism, but we have a hard time recognizing those things. And I think we have to kind of think critically about how we design our assessment programs so that they are appropriately judging relative strengths and weaknesses of every student and not just weighting medical knowledge above all else and only labeling those who struggle in medical knowledge as those who are failures in our system and require remediation.
Lynnea Mills:
I love all those comments and have been thinking a lot about all of these pieces. And I absolutely think we need to normalize this process of getting help, of getting support around areas where we all need help. I mean everybody has these areas of weakness and to sort of pretend that we can’t get better at them is ridiculous. So to convey to students right up front, “We all need coaches, we all need support people, we all need resources. And if you think you don’t, you’re wrong. And if you think you’re alone because you do, you’re also wrong.” Really sort of making that clear up front that that is the case for everybody, and that it’s a little bit of a fluke whether your weakness ends up being something that is demonstrated on a summative exam.
In residency, I was really, really bad at procedures, but there’s no assessment of procedures. There’s no sort of like, “You failed procedures.” And so that didn’t sort of count against me in any summative assessment. And yet, other people might have similar areas where they struggle and it does count against them in some sort of assessment or on their file. We really need to be talking about that more and sort of making clear that there are these areas where people are going to struggle and that’s okay and we can support them. And yes, there’s a tension with how we assess individuals. That doesn’t mean we should stop assessing them, but it means we should be thoughtful about how we’re doing it and we should be honest with the learners about recognizing the impacts that our assessment systems have on them.
Anna-kay Thomas:
To your point, at one of my prior institutions, the very first test the first year students took weighed 25% of that block because they knew it was the first test students were taking and they knew the pressure they felt, so they lowered the weight of that particular exam just so students could transition a little bit more easier. I think that’s what you’re saying, like let’s really be more thoughtful in how we’re creating our assessment pieces so students can run transitioning a little bit easier. They’re dealing with all these different things and really celebrate in places that they’re doing well.
Lynnea Mills:
What I will just add that feels important to note is there was a decent amount of frustration about assessments being unfair or things like that in our study, but ultimately the students came to a point of feeling like they had learned something valuable about themselves in going through the process. Some of them felt like they developed better study skills, things like that. And at the end of the day, they want to be assessed. They think it’s important, they think it’s necessary for patient care. So they really felt like there was room for improvement in how the assessment happens, but particularly in how the support happens and how the news gets conveyed to them and all of those pieces.
So none of the students we talked to sort of said, “It’s unfair that you grade us or that we have exams or those kinds of pieces.” So I think there’s nuance to what they’re asking for in terms of how we can change our assessment system to meet their needs a little bit better and to reduce the stigma around needing extra time or extra support to achieve those competencies.
Anna-kay Thomas:
I think in your paper, you talked about the student receiving an email that they failed versus someone just calling them and having a conversation that they failed, and the difference between the two. Having someone who, and it depends on the caller of course, but having someone really convey that information in a compassionate way feels very differently for that learner than just reading how they performed in an email, also depending on how that is crafted too. So I can see the difference in how students would interpret the two different experiences from how that failure is conveyed.
Lynnea Mills:
Yes, we definitely heard that from multiple participants. If they found out by email or if they found out by sort of looking on some class list where grades are posted, that was really challenging for them because they wanted a more personal conversation, which I think helps with two pieces. One is the connection and empathy piece that they might get from the person delivering the news. And two is the ability to ask questions and to get questions answered about next steps, because a lot of students worried what’s going to be next? What’s the timeline? How do I manage all of these things? And that wasn’t always clear in the email or the grade posting.
And I think they’re spending a lot of their cognitive and emotional bandwidth worrying about those pieces. And if we could provide more of a structure to help them get those pieces addressed right up front, they would have more of that bandwidth for actually thinking about how to improve.
Toni Gallo:
What about for students from different backgrounds, whether it’s coming from an underrepresented background or students from different contexts? Did this come up in your study or maybe for all of you, what other considerations or things should we be thinking about when we’re considering students from different backgrounds?
Lynnea Mills:
Well, in this study we did not ask for demographics and it actually did not come up that frequently, spontaneously for our participants. I will say in some other work that I’m doing, I’m looking at this question because it’s definitely anecdotally known that people who are referred for remediation are more likely to be underrepresented in some way. And there’s a lot of question about what are the driving forces behind that.
So that’s certainly been my experience on the GME level and the coaching that I do. There’s a lot of question about what’s going on for those learners and what does the process of going through the remediation experience look like that might be different for underrepresented learners compared to learners who are not underrepresented. I think that’s still an open question, and I’m really eager to learn more about that. But I think at the end of the day, the pieces that we already mentioned around really normalizing, really affirming, “This doesn’t mean you’re a bad doctor, this means you have an area where you could use support like the rest of us,” is going to be so crucial for all of those individuals.
Mike Ryan:
I would just add. I mean I think there’s pretty good literature at this point that shows that there’s differences in terms of medical school outcomes when you look at those from socioeconomic disadvantage or underrepresented groups in general. And there’s a multitude of reasons for that which include biases in evaluation, biases in assessment, and then also burden, especially when we see that in the clinical environment.
And so I think it’s not surprising in systems we set up that we see more performance deficits in medical knowledge especially, where we know that Step 1 scores are predicted by MCAT scores, which are predicted by prior sorts of attributes that are largely related to social determinants of education, et cetera. And so I think that that is one reason why we see disproportionate representation in remediation programs. And then I think it’s compounded by the fact that our schools are not as diverse as they can be. And so there’s this isolation that likely happens because there’s just differences in proportions of students from different backgrounds that I think it can all compound itself and really be a significant challenge.
Anna-kay Thomas:
I would just add isolations and microaggressions. So while other students are just thinking about their coursework, you have students from specific backgrounds that are also thinking about their coursework and how are they performing on these rotations. How are they performing in class? And that carries its own weight, that they have to work through individually, so they’re not focused just solely on doing their academic work as well. So that’s a pretty big component within the US environment that we have our underrepresented students dealing with as well.
Toni Gallo:
One final question then for you all, this was not part of the study that Lynnea and her co-authors did, but something that we’re seeing more and more in the literature is the idea of compassionate off-ramps for students for whom medical school might just not be the right place for them. And I wonder if there’s anything we can take away from your study to help us think about this and advising students, helping students figure out is medical school where they should be and how do we help them transition out if it’s not?
Lynnea Mills:
Yeah, it’s a great question, and I think the literature around compassionate off-ramps is just really starting to give us a sense of how to do this. I think what I learned from this study was that students need some time before they’re able to put a failure in the context of their trajectory and be able to rightsize it and sort of say, “Yes, I’m still suited for this profession even though I failed this one exam or this one rotation, or whatever it might be.”
So the idea of really sort of being able to assess whether something is the right fit for them probably is going to take some time for the learners. It’s also going to take time for us to be able really to do significant assessment, to be able to have a good enough perspective on how the learner is doing is going to take a while.
Ultimately, when I’m in the setting of coaching learners, I’m thinking less about what are their competencies, what have they achieved. Because I do really believe if you can get to this point, you can do this. The question is do they want to. Are they in love with this career path? Do they feel really passionate about it? And to me, I think the compassionate off-ramp place that is probably going to end up being the biggest is a place around helping learners who may not really feel like this is the right choice for them, go in that direction.
For learners who do feel really excited about this but are struggling so much with their competencies, I think there’s a different path that we can follow with more intensive remediation than so far we’ve been able to offer most students based on just resources, and I suspect a lot of those learners, we could get to a point where we don’t need off-ramps for them.
There will be a small number and to figure out who really meets those criteria for needing to be removed from that space, I think is going to take a lot of different individuals, a lot of different perspectives thinking about what’s going on for that learner because it’s of course a very high stakes decision, but it’s also important to consider in the context of all the biases that go into our assessments.
So I know that doesn’t answer your question at all, but I think what I’m coming away from the study with is the students don’t know for quite some time how really to put this in context, and we don’t know either, which means we really need to be thoughtful and careful.
Mike Ryan:
I was going to go back to Dr. Thomas’s comment about financial consideration, and I think that compassionate off-ramps should happen as early as humanly possible because of the financial burden. But it’s tough because you’ve made an investment to admit a student into your school, and so they struggle on an exam in the first year. That doesn’t necessarily mean they need an off-ramp instantaneously, but if you wait till third year, now they’re in debt $150 plus thousand dollars and now it feels like it’s even more challenging to have that off-ramp, unless there’s an alternative such as a master’s degree or something like that. And so I think that’s one of the keys, is what is the alternative for the students.
The other point I just would make quickly is that I think having worked in the medical school and residency space at different levels, I think that the real hard students are not the ones who need off-ramps because of knowledge. Those students, we know they’re at risk for potentially failing Step exams and In-Training exams and ultimately boards, but there’s not much evidence related to those sorts of things and their actual patient care skills. The harder ones are the students who struggle due to professionalism, communication skills, et cetera, which are a lot harder to wrap your head around and a lot tougher in my experience than trying to remediate.
So I think there’s a couple of challenges, which is how quickly do you have the off-ramp? And then also, how do we support off-ramps and students that struggle in these non-medical knowledge areas that are really tough to work through and also are, I would argue, more significant in terms of their detriment for the patients that they ultimately serve?
Toni Gallo:
I want to give you each a chance, if you have any final thoughts you want to share with listeners, maybe a key takeaway from the paper we’ve been talking about or even a next step, Lynnea, where are you going with this research? Mike, Anna-kay, is there anything that you’re taking away for your own practice, thinking about differently? So I’ll give you each a chance. Mike, you want to go first?
Mike Ryan:
Sure. I mean, I think this is a great paper. Dr. Mills, I love that you explored the student perspective in all of this, and I think it’s really critical that those of us who work in the educational programs are really considered about what the impact is when we place students into remediation or failure. I think, like you said, mistakes here were not terribly high because these were not transcript-related failures in the US at least, but they still had major impacts on the student’s identity formation and all that sort of thing.
So as somebody who works in assessment, I’m very worried about how we develop our programs of assessment so that they both support the greater need for the patients we serve, but also do not cause harm where we’re characterizing students as having failed something when really they just need more time to grow or develop. So I think that’s just a point of reflection that your paper furthers for me. Thank you.
Anna-kay Thomas:
I really enjoyed reading your paper, Dr. Mills. I love the narrative pieces that you included in your work. Sometimes, we really don’t hear those voices. One of the things that I am looking forward to is just seeing how, when you expand your work, because you mentioned that you were expanding your work earlier, when you’re including race, the racial demographic of these students, to see how they may be similar or different from others and what we decide to do in the next steps to really address individual learners or individual bodies of learners. But great work, and I look forward to reading more of it.
Lynnea Mills:
Thank you so much, and thanks for spending this time talking with me about the paper. There are a lot of research directions I’m really interested in. I do want to think more about demographics and about impacts on underrepresented learners. I’m also right now thinking about ways that emotions might be associated with other pieces that we can measure around the learning process for some of these individuals, and might be related to feedback because that’s such an important part of helping learners grow.
So there’s a lot of projects I’m thinking about and a couple underway that I hope to be able to publish in the next several months. In the meantime, I’ve really tried to take to heart what I heard from the students about their experiences and have really been thinking about how we could reduce some of that extraneous load that comes from some of these pieces, maybe not giving them full enough information or not helping them realize they’re not the only student who failed, whatever it might be to help them be able to transition, focusing that energy on improving as opposed to focusing the energy on feeling stressed and worried and wondering if they’re still a good fit for this career.
So I’ve made some small changes in the programs and the work that I do to try to get at those pieces, and I hope to be able to continue hearing more from the learners so I can keep doing that.
Toni Gallo:
Thank you all so much for being on the podcast today. I appreciate your time, and I want to encourage our listeners to check out the paper that we discussed today, as well as all of the RIME articles. They’re available to read for free on academicmedicine.org. And make sure to check back next month on the podcast. Our third and final RIME episode will be coming out, and I’m talking to the authors of a study that looked at the transformative potential of the arts and humanities in residency training. So that’ll be here next month. Thanks very much.
From Academic Medicine’s website, you can access the latest articles and our archive dating back to 1926, as well as additional content including free eBooks and article collections. Subscribe to Academic Medicine through the Subscription Services link under the Journal Info tab or visit shop.lww.com and enter Academic Medicine in the search bar.
Be sure to follow us and interact with the journal staff on X or Twitter at @AcadMedJournal and on LinkedIn at Academic Medicine Journal. Subscribe to this podcast anywhere podcasts are available. Leave us a rating and a review when you do. Let us know how we’re doing. Thanks so much for listening.