Describing Failure in a Clinical Clerkship: Implications for Identification, Assessment and Remediation for Struggling Learners.

Background: In addition to training future members of the profession, medical schools perform the critical role of identifying students who are failing to meet minimum standards in core competencies.

Objective: To better understand reasons for failure in an internal medicine clerkship.

Design: A qualitative content analysis of letters describing reasons for students' failure.

Participants: Forty-three students (31 men) who failed the internal medicine clerkship at the University of Minnesota Medical School, 2002-2013.

Approach: We conducted a qualitative content analysis of the 43 letters describing reasons for students' failure. We coded critical deficiencies and mapped them to the Physician Competency Reference Set (PCRS) competency domains and classified them into two categories: conduct (unprofessional behaviors) and knowledge and skills specific to the practice of medicine. We then calculated the frequency of each critical deficiency. We statistically tested for relationships between gender and critical deficiencies in each of the competency domains.

Key Results: We coded 50 critical deficiencies with all codes mapping to a PCRS competency domain. The most frequently cited deficiencies were "insufficient knowledge" (79 % of students) and "inadequate patient presentation skills" (74 %). Students exhibited critical deficiencies in all eight competency domains, with the highest concentrations in Knowledge for Practice (98 %) and Interpersonal and Communication Skills (91 %). All students demonstrated deficiencies in multiple competencies, with 98 % having deficiencies in three or more. All 43 students demonstrated deficits in the knowledge and skills category, and 81 % had concurrent conduct issues. There were no statistically significant relationships between gender and critical deficiencies in any competency domain.

Conclusions: This study highlights both the diversity and commonality of reasons that students fail a clinical clerkship. Knowing the range of areas where students struggle, as well as the most likely areas of difficulty, may aid faculty in identifying students who are failing and in developing remediation strategies.