Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards?

OBJECTIVES: Literature has shown that some assessors assign passing grades to medical students who, in fact, should not have passed. This inability of the faculty to fail underperforming students can jeopardise the reputation of professional programs, be it in the medical field or beyond. Simultaneously, weak students become incompetent physicians and, thus, endanger the community they serve. The impetus for conducting this systematic review was to identify barriers to faculty in failing struggling medical students.
METHODS: The databases of MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor and Francis, CINAHL, Springer link, ProQuest, and ISI Web of knowledge were searched using Medical Subject Headings (MeSH) terms 'Faculty failure' AND 'Failing students' AND 'Failure to fail' OR 'Assessment'. The data were synthesised, and the results were analysed.
RESULTS: This search showed a wealth of barriers to faculty contributing to a 'failure to fail' such as their concerns about legal action and an appeals process; the stress of failing students; a lack of knowledge about proper documentation; unavailability of support, resources, and offices for faculty; absence of administrative guidelines; and complex dismissal procedures discouraging the faculty from failing students.
CONCLUSION: Institutional faculty development programs and training workshops should facilitate the education of supervisors and assessors for timely evaluation and regular documentation of trainee assessment. The provision of legal advice in cases of appeal and professional support by the resource and support office is emphasised.

Introduction

University academic staff are entrusted with key academic and professional responsibilities to teach, supervise, and evaluate students' performance to guarantee that graduates of the relevant programs are competent. A key role of faculty staff in assessment envisages the assignment of failing grades to students who have not elicited the desired level of competence. However, literature has shown that some instructors and faculty members struggle in identifying underperforming students and in making decisions to fail students who exhibit incompetent or indecent professional practice. Although educators and field experts have studied and recommended solutions for such issues,2, 3 inconsistent reports with no significant improvements towards fair and just assessments exist. One major reason for this ‘failure to fail’ is the barrier that prevents faculty from making a fair and objective assessment of students. An array of factors contribute to this barrier and prevent some faculty members from fair and objective assessments such as their lack of feedback skills, insufficient knowledge of regulations about professional behaviour and a perceived fear in facing a legal complaint from a failing student. On a serious note, the faculty member can be sued by the institution for passing an unsafe or incompetent student that will be a threat to their clients and the community.

All academic institutions acknowledge a legal and ethical obligation to fail underperforming learners. However, a significant number of clinical educators agree that a small fraction of faculty fails to report the unsatisfactory performance of medical students,5, 6, 7 jeopardising honest and fair assessment. Although unprofessional behaviour is observed in 20% of students, it is reported in only 3–5%.8, 9 Furthermore, research has convincingly demonstrated that underperforming medical students go on to become incompetent physicians with potential malpractice potentially contributing to poor patient care,9, 10 thus underpinning the importance of the early identification of the struggling learners. Early identification of lapses in professional behaviour is crucial to achieving remediation before said behaviour has become resistant to treatment.

Some empirical studies have suggested some possible reasons for the failure of faculty to report negative performances, such as a fear of facing a legal petition if their evaluation is challenged and a possibility of legal repercussions.12, 13 However, there is insufficient research exploring the reasons for a faculty's inability to fail underperforming students. This review draws upon the academic, social, psychological, and administrative barriers preventing educators and supervisors from failing dysfunctional students. A framework of suggestions is offered for institutions to identify students' unprofessional behaviour and to provide support to faculty in making upright and fair assessments.

Search design and process of article selection

In 2017, a literature search was conducted for English-language original and review articles published from 2002 to 2007 by connecting the Medical Subject Headings (MeSH) terms ‘Faculty failure’ AND ‘Failing students’ AND ‘Failure to fail’ OR ‘Assessment’ using the databases MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor & Francis Online, CINAHL, Springer link, ProQuest, and ISI Web of knowledge. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for the systematic selection of studies. Systematic reviews, meta-analysis, and original research, including longitudinal and cross-sectional studies using quantitative/qualitative/mixed method studies, were included in this search. Letters to editors, personal opinions, brief communications, editorials, and conference proceedings were excluded. Two independent reviewers scrutinised the selected studies and reached a consensus by comparing and verifying the inclusion criteria and keywords. They discussed any differences in coding until consensus was reached and concerns were resolved. The barriers and challenges faced by faculty and identified in the published articles were coded and ultimately grouped into categories about faculty barriers to fail students.

An initial search retrieved 470 articles, but this set of studies included 134 that were published before 2002. These studies were excluded. During the data synthesis and analysis of abstracts and titles, another 265 irrelevant studies were excluded (Figure 1). Finally, 56 further publications were excluded as these studies were letters to editors, editorials, and personal views. The following final list of 15 articles was included in this systematic review for a detailed literature review.

Figure 1

Flow diagram showing the selection of studies through the different phases of this systematic review.

The barriers and suggested remedies that can help educators in overcoming identified barriers will be discussed in the sections and subsections hereunder.

Barriers to failing students

Some constraints on educators in failing underperforming undergraduate and postgraduate medical students, particularly during their clinical assessments, have been elaborated in the literature. Based on the literature search, we have defined the barriers to faculty to fail students in irresponsible behaviour and incomplete administrative work, the threat of complicated litigation process in cases of appeals by failing students and its unpleasant consequences and the issue of perceived faculty stress in failing a student. A summary of all constraints on the faculty is outlined in Table 1.

Table 1

Barriers to fail the underperforming students.

1	Lack of appropriate documentary evidence showing communication to the student of academic concerns of the administration
2	Personal relationship with the student
3	Worried about students' financial issues
4	Concerned over students in general
5	Sympathetic for student's professional future
6	Higher administration overturns the decision
7	Not enough remediation options
8	Afraid of a lengthy litigation procedure

Lack of faculty knowledge

Van Mook et al. investigated the combined formative and summative assessment of problem-based learning in a Dutch medical school and revealed that a lack of faculty knowledge of how to fail an underperforming student could potentially hamper the process of identification of students with lapses in professional behaviour. This underscores the importance of the early identification of underperforming students and the initiation of the remediation process. Dudek et al. proposed that preceptors need to be prepared to assign failing and passing grades and urged them to report their concerns about a student as early as possible, particularly in writing, to faculty members. Nevertheless, the varying standards of assessing clinical competence and defining the ‘minimum’ standards of practice across institutions and agencies account for a major share of variations in grades and ratings in subjective evaluation. The perceived barriers to the professional development of faculty in dealing with such situations also play a vital role in executing just actions at the right time.

Incomplete documentation

Dudek et al. explored the clinical supervisors' perceptions of barriers to fair judgment and found that educator failures in keeping a record of the trainee's day-to-day performance resulted in insufficient documentary evidence for failing struggling students. The absence of appropriate documentation was a major constraint to reporting underperformance. Educators believed that the time taken for the completion of the documents was onerous and exceptionally labour-intensive. Furthermore, the authors reported that faculty were not adequately trained on what needed to be documented to support their judgment about underperforming learners. Also, the faculty failed to document the specific behaviours of the struggling students that led to their impression that the student was failing.

Faculty's reluctance and system failure to fail students with unprofessional behaviour

Many educators are reluctant to fail a student solely due to his or her unprofessional behaviour.18, 19 A multicentre qualitative interview-based study explored the perceptions of six heads of UK medical schools in developing and assessing the behaviour of undergraduate medical students. The respondents believed that some students could still qualify and pass the assessment modalities despite having unprofessional attitudes or behaviour. They suggested that few domains of the hidden curriculum, particularly the negative role modelling witnessed during clinical practice, undermine the attitudinal jest of the agreed curriculum. Teaching and training educators to evaluate students' professional behaviour and involving them in students’ remediation appears to reduce their reluctance to fail students demonstrating unprofessional behaviour.21, 22, 23 Interestingly, a standard code of conduct for dealing with established lapses of ethical integrity by university students is not available, though institutions have their policies and procedures that take varying disciplinary and punitive actions.

Primary determinants of behavioural intention

Cleland et al. conducted a qualitative focus group study to probe the perceptions of general practitioners, hospital doctors, and non-clinical tutors from two different UK medical schools about the potential factors that determine the impact on failure to fail. The respondents proposed that failing underperforming students would result in unfavourable outcomes for the educator and learner. In their opinion, each assessment can be considered as merely a pixel contributing to a complete picture, although some extreme behaviour may be a reason for the dismissal of individual students, even after one report. Furthermore, pressure from peers to pass underperforming students would also influence the preceptor's final rating of the candidate. Supervisors find it more difficult to report an underperforming favourite or popular student whom they liked or who was liked by other colleagues.26, 27 Although the development of preceptor-student relationships is frequently stressed, faculty are urged to maintain professional boundaries and ethical silos that will secure their position during assessment and feedback.

Complexity of the dismissal process

The legal requirements for expulsion or dismissal of a university student depend on whether the institution is public or private and whether a disciplinary reason or unsatisfactory academic performance is the basis for dismissal. A clear definition with associated rules and regulations should be formulated and communicated to students and staff. The contract between student and institution lays down the recommended guidelines of the entire dismissal process that needs to be followed before a student is dismissed. Documentation before dismissal should adhere to these local and national (if available) guidelines and serve as a strong defence to a lawsuit by the student. As the documentation is time-consuming and demands uninterrupted follow-up, educators often find it much easier to pass failing students than going through the legal challenges and stress of failing them. Even after rigorously following these complex procedures, at some places, dismissed students can reapply and re-enter the program. Furthermore, courts have repeatedly upheld dismissal verdicts by higher-education faculty.

Lack of resources and support office for the faculty

Institutional support offices for the faculty can sufficiently educate and guide the teaching staff about the organisational structure and action plans for dealing with dismissals and expulsions of underperforming students. In case of an appeal and legal recourse, these offices can also provide legal support to the supervisors and faculty administration. A lack of such faculty support is considered by teaching staff to be a constraint to fail underperforming students. The majority of institutions do not have the resources and support offices required to provide guidance on the necessary measures and steps to be taken in dealing with struggling learners. Unfortunately, despite the availability of several sets of disciplinary frameworks for dealing with students' unprofessional behaviour, guidance on how to deal with dysfunctional residents is limited. Van Mook et al. proposed that the threshold for documenting professional lapses by medical students should be kept low and, rather, a formal framework for dealing with lapses and/or unprofessional behaviour be developed. The dysfunctional individuals ‘do not meet the expectations of their programs because of problems with knowledge, skills and/or attitude’ and they ‘demonstrate problem behaviours significant enough to require intervention by program leadership’.

Fear of legal actions and appeals

To determine institutional barriers to placing failing students on probation or dismissing students, Guerrasio et al. conducted an online survey among the deans of student affairs across the United States. Nineteen of the 48 (40%) schools responded that a fear of litigation was the greatest barrier to probation and dismissal of underperforming students. The majority of respondents (79%) agreed that their institutions granted degrees to undergraduate students who should not have graduated. The appeal process is also considered as a stigma to the supervisor's credibility, in addition to being time-consuming and demoralising. It is also worth mentioning that legal frameworks vary across regions and even across institutions in the same country. Furthermore, the time involved in the appeal process has been reported to be threatening enough to consider passing an unsafe student.

Emotional constraints

Examiners report that failing a student is stressful. Bogo et al. discussed the significant emotional concerns experienced by assessors when facing the task of providing negative feedback in assessing a range of competencies. In a similar vein, Samec reported the guilt, emotional pain, anger, and shame felt by the clinical supervisors of psychotherapy students in failing their assessments.

Internalising failures

The frustration, anger, disappointment, and role strain experienced by some assessors in failing medical students appears to obligate the assessors to internalise the student's failings as their own.38, 39 Any subsequent failure on the student's part then becomes heavily internalised to the same assessor, and the ‘error’ is personalised as his or her own.

Fear of breach of confidentiality

On several occasions, faculty members were reluctant to seek the help of peers when failing a student, for fear of breaching the confidentiality of assessment procedure.

Suggestions to overcome faculty barriers to fail students

Concerted efforts should be in place to improve the assessment, and remedial intervention of a failing student by constructive feedback, rigorous follow-up, adequate documentation, better communication and support. Pro-active signalling, surveillance, and reporting of dysfunctional learners as indicated by professional lapses should be performed, with active surveillance during both the formative and summative assessments. A blend of both the summative and formative forms of assessment in the same procedural approach seems to be more feasible.15, 42 This will help identify the underperforming student at an early stage. The interventions should be proportional to the problem severity, and follow a stepwise, graded approach from a ‘cup of tea conversation’, through ‘awareness interventions’, and ‘authority interventions’ to ‘disciplinary interventions’ in a model adopted and adapted from Hickson. Supervisors and educators should be informed about the type of documentation required to support their judgments. In the same context, user-friendly electronic appraisals and evaluations need to be developed by the institutions that will facilitate the reporting process and minimise the time taken for manual documentation. The use of a web-based instrument for the assessment of professional behaviour can yield a significantly higher number of comments compared to classic paper-based assessment. However, despite a higher volume of feedback, web-based assessment does not offer any qualitative improvement in the feedback. Faculty development programs and training workshops promise to educate supervisors about how to provide timely and authentic evaluations on a day-to-day basis. We also recommend the provision of resources and support offices for the faculty.

Conclusions

Judging fitness to practice in the health care professions includes students satisfactorily passing the theoretical and clinical criteria of assessments as defined by the professional institution and the governing medical council. Literature has identified the unprofessional behaviour of faculty in not failing students. Unacknowledged emotional difficulties faced by educators indicate that students are being passed as competent when evidence regarding their professional competence may strongly suggest otherwise. By passing underperforming students, the faculty produces incompetent doctors, thus posing a serious threat to the community. An array of social and emotional factors, such as uncertainty about reporting the struggling student, incomplete documentation, complexity of the dismissal process, and the faculty's fear of facing litigation are the key barriers to failing underperforming students. This review reiterates the need for institutional support to all assessors and supervisors in the early identification of dysfunctional students and in dealing with struggling or failing students. Calling upon the expertise of trained assessors in multi-dimensional contexts with background knowledge of problem-based educational strategy can enrich the feedback and communication skills and, in a way, overcome some of the identified barriers for the faculty. Faculty development programs and educators' training in coping with failing students can help enhance the credibility of assessment in medical schools.

Source of funding

No funding was provided for this research

Conflict of interest

The authors have no conflict of interest to declare.

Ethical approval

Not applicable.

Consent

Not applicable for data and materials used in this research. However, the authors agree to transfer the copyrights to the publisher if this paper is accepted for publication.

Authors contributions

SYG conceived the concept of this research and did literature review with data synthesis. He also prepared first draft of the article. WNKM and KIK conducted literature review and revised all drafts of the article. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Availability of data and materials

Not applicable, as this is a systematic review.