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 professionalism-related 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 specialties. 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.
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