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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.

Background Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting. Methods To obtain data on patient expectations for greetings, we asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. We also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice. Results Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves. Conclusions Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.