In this issue, Brenner and colleagues report a correlation between the frequency of negative comments in the "dean's letter" and future problems during a psychiatry residency program. Their study makes an important contribution to the body of literature on factors that predict professionalismrelated performance issues during residency and suggests the importance of dependable data that can be used to predict and hopefully intervene early in the training of future physicians across all

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... s. As we think about the implications of this study, important issues involving the standardization of medical student performance evaluations (MSPEs) and the assessment of professionalism are raised. Despite the Association of American Medical Colleges' 2002 guidelines for MSPEs, subsequent studies have revealed that considerable inconsistencies among the evaluations still remain. To enhance the accuracy and usefulness of the MSPEs in predicting "problem residents," improved standardization is necessary. Moreover, Brenner's findings call for the development of more vigorous assessment of professionalism in undergraduate medical education, as well as more accurate reporting of these assessments to residency programs. Longitudinal assessment of professionalism with robust tools allows for the identification and possible remediation of students early in their undergraduate training. Insofar as unprofessional behavior in medical school is predictive not only of problems during residency but also of later disciplinary action against the practicing physician by state medical boards, it is the obligation of the medical school to the residency program and to society to identify and report these behaviors. Inthisissueofthejournal,thearticleby Brenner and colleagues 1 studies predictors of residency performance. The authors report a correlation between the number of negative comments in the "dean's letter" and future problems during residency in a psychiatry training program. Failed courses, letters of recommendation, and ratings from interviewers were not predictors of future problems. In this study, "problems" included "acute psychiatric illness, character pathology, boundary violations with patients, recurrent conflicts with peers and faculty, and situational losses and stresses" that directly affected residents' performance, causing them to drop beneath the minimum standards of the program. These problem areas clearly fall under the domain of professionalism. Although the authors refer to the impact of "problem residents" on the operational aspects of the graduate program as well as the morale and reputation of the program, the implications for patient care are even more concerning. In our opinion, this report is a very important contribution to the extant literature on factors that predict performance during residency and has clear implications for practice beyond residency. Unfortunately, part of the problem with this body of literature is the lack of standardization of the predictive factors and their definitions. Indeed, studies examining the dean's letter or medical student performance evaluation (MSPE) come to different conclusions regarding its usefulness. [2] [3] [4] The MSPE is a complex document that comprises several categories. To compare studies about the MSPE, the category in question must be clearly specified in all cases. Understanding and capturing the factors that are prognostic of future performance is extremely important at all levels of training. Although the study by Brenner and colleagues focuses on a single psychiatry residency program, it suggests the importance of dependable data that can be used to predict performance problems and hopefully intervene to prevent such problems early in the development of future physicians in all specialties. Brenner and colleagues raise specific issues which need to be addressed, including the composition and integrity of the MSPE and the need for robust assessment and reporting of professionalism in undergraduate medical education programs.