The Dean's Letter
The MSPE, which is still sometimes referred to as the Dean's Letter, is an attempt to capture the overall performance of a medical student during his or her undergraduate career in medical school. The Group on Student Affairs-the AAMC's body consisting of associate Deans of Student Affairs throughout the country-has attempted to make the MSPE uniform, shorter, and more standardized. Despite the hundreds of hours of work at each medical school devoted to these letters, many residency training directors admit they read only the final paragraph including the last sentence, which is coded to rank the student in his or her class. Although the changes in MSPE have resulted in greater standardization, several factors limit their usefulness. First, the MSPE is supposed to include quotes, free of redaction, from the third year clerkships. However, schools may include informal comments for internal evaluation purposes that are not judged to be important enough for inclusion in the MSPE but may nonetheless show a pattern of problematic behavior. Second, the Liaison Committee on Medical Education rules state that a student has the right to review his or her MSPE before it is sent out from the student's school.7 These rules tend to blunt any criticism or render information vague to the point of loss of meaning. Last, the MSPE introductory paragraphs often distinguish the student based on the level of enthusiasm in tone of the letter itself. Only a careful evaluation of the letter can detect these nuances.
The MSPE is required to include comments about professionalism and any problems in the continuity of education. Although these goals are laudable, they have yet to be fully implemented because of the difficulty in the measurement of a variety of components of the category of behavior known as professionalism. Considering the aforementioned forces leading to uncritical acceptance of student performance, any problems noted in the MSPE are notable, at least to the level of further investigation. An increasing amount of literature shows that professionalism problems of a medical student likely predict more professionalism problems in the future. Therefore, any hint of problematic behavior should be followed up within the applicant interview or through telephone contact with the referring institution. Anecdotal reports among Associate Deans reveal the MSPE often does contain major concerns that are ignored by residency directors. Most startling is to see members of a profession pore over radiographs, laboratory data, and physical findings looking for minute subtleties, but not apply the same rigor to the review of an MSPE. Although not all interviewers within a residency program have the time for thorough review, each program should identify two individuals who will go over each MSPE with a fine toothed comb looking for changes in tone and enthusiasm that may signal larger difficulties. Clerkships where a student, otherwise described as superior, completes all requirements should raise an eyebrow. A description that appears apologetic about some aspect of student performance should, likewise, signal potential trouble. Uneven performance may indicate that a student has problems with motivation. More troubling is two or more clerkships reporting even subtle difficulties. Students are entitled to some benefit of doubt on a rotation given the wide range of residents and faculty who will evaluate them. However, a pattern of such things as lateness, brusqueness, or defensiveness no matter how understated in the MSPE is cause for concern.
