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Volume III, Number 10, November, 2005

From Classroom
to Emergency Room:
Educational Triage
in American Schools

By Jennifer Booher-Jennings

About the author

These findings were initially reported in:
“Below the Bubble:

'Educational Triage' and the Texas Accountability System,”
Jennifer Booher-Jennings,
American Educational Research Journal
vol. 42, 2005, pp. 231-268.

© Jason Booher-Jennings

Just to be clear from the beginning, this is not a story about a few rotten apples. In a society seduced by the individual, our cultural referees often conclude that “bad people” make bad choices. The proffered solution is to sack the bad people or to enlist sanctions so these amoral calculators decide that the ends do not justify the means.

Rather, this is a story of how systemic incentives in the No Child Left Behind Act (NCLB) lead educators to adopt a series of educational triage practices, practices that in many ways undermine equity.1 By educational triage, I refer to the process through which teachers divide students into three groups - safe cases, suitable cases for treatment, and hopeless cases - and ration resources to those students most likely to improve the school's scores.

The metaphor of triage, a practice usually employed in dire circumstances like the battlefield or the emergency room, poignantly captures the dynamics of many schools' responses to NCLB. In the name of improving schools' scores, some students must inevitably be sacrificed. The stakes are high for schools, which face serious sanctions for failing to meet adequate yearly progress targets; for students, who increasingly face retention if they do not pass state tests; and for teachers, who are judged by the number of students they “save.”

A Hopeless Case

While this is a story about the broader consequences of NCLB on day-to-day life in schools, it is also a story about Javier, age eight and three-quarters, who has been deemed a “hopeless case” by his teacher.

“Please! The one about the jumping spiders!” Javier squeals with an excitement typically reserved for kickball and Jolly Ranchers and a miniature girl named Esmeralda. Having traded in his fascination with Ralph S. Mouse for spiders, particularly those of the jumping variety, no other book will do. The educational platitude of our times - “no child left behind” - seems strangely irrelevant in moments like these, where nothing could be more important than what spiders eat, and if they have teeth, and whether they bite, and, if so, how hard.

Yet every contour of Javier's third grade year was shaped by his elementary school's attempt to succeed within the confines of the Texas Accountability System. At the beginning of the school year, students were given a practice test of the Texas Assessment of Knowledge and Skills (TAKS). Teachers then divided their students into three groups: those who would pass, those close to passing (the “bubble kids”), and those requiring significant remediation. Javier's reading score placed him in the remedial category. While the bubble kids in his class received extra attention in class, tutoring from the reading specialist, and tutoring after school and on Saturdays, Javier did not.

Two other benchmark tests were given during the school year. Javier still scored below the bubble. So it was little surprise that Javier failed the third grade reading test, which Texas students must pass to be promoted to the fourth grade.

And so began Javier's downward spiral. Though he was earning Bs and Cs until he failed the reading test, he now pulled Ds and Fs. His teacher lamented that he developed confidence issues that were impeding his performance. In a lunchtime conversation, Javier confided that he worried about staying in the third grade. I asked, “When you worry about it, what do you think about?” Javier, eying his sneakers, softly replied, “That I'm gonna stay there forever.”

Javier's Teachers: Living with Educational Triage

The teachers at Javier's school had worries of their own. Every teacher interviewed talked about the intense pressure she felt to increase her students' scores. The majority of teachers, in discussing this pressure, spoke emotionally about an annual faculty meeting at which a chart was revealed that listed each teacher's pass rate next to her name. In other words, a competitive economy where the sole currency was test scores was established within the confines of the school. It was a competition of which teachers were painstakingly aware. In these interviews, some teachers focused their comments on the negative self-valuations that resulted from their students' poor scores. As one teacher said:

[Last year] I was so upset when their scores came back. They did real good on reading, but only 55% of my kids passed the math. And we went to this faculty meeting and they put every teacher's scores and pass rates up on the transparency, and I just wanted to cry. I felt so bad, like I had done something wrong, like I was a bad teacher.

Other teachers emphasized that their colleagues make judgments about their professional competence based on these scores. According to this teacher:

Everything rides on it [the test]….You can't be a teacher who deviates from the average-you know, the average for the school. They pass out this paper with everyone's scores and they put your scores up on a transparency, so if you're on the lower side, people think you're a terrible teacher and you're doing something wrong, and if you're on the higher side, everyone says, “Oooo, he's doing something right.” The thing is, even if you are a terrible teacher and you get high scores, that's all that matters.

Finally, other teachers simply expressed outrage that this practice occurred. As this teacher related:

I guess they're trying to humiliate us into getting their scores up….It's all accountability, accountability, accountability. Why don't they just strip you naked and make you stand on a table? That's the same thing as putting your scores up there.

Yet this is the favorable outcome proponents of high-stakes accountability desired, not a malfunction of the system. A teacher's professional competence is now showcased by her students' test scores. If these teachers don't want to be labeled as “bad teachers,” it is argued, then they should work harder to become “good ones.” But the only measure of good teaching in this system is the percentage of students in a teacher's class who pass the test. Any other notion of good teaching has been displaced. To the detriment of the students below the bubble, teachers, using a series of educational triage practices, strive to become “better teachers.”

The Bubble Kids

Administrators in this school district often credited improvements in test scores to recently instituted systems of data-driven decision making. But rather than being used to address the individual needs of every student, data were employed to target some students at the expense of others. The district required teachers to use each benchmark test to set a passing target for the next text. The formula for setting this target assumed that bubble kids would become passers. Focusing on the bubble kids was official district policy, and teachers thus felt persistent pressure to focus disproportionate attention on these students.

Teachers did not describe the bubble kids in technical terms, but in a vocabulary of triage. The following were teachers' typical responses to the question, “Who are the bubble kids?”:

The ones that will pass with a little more help. With the [the remedial kids], it's really a lost cause. They must have fallen through the cracks somehow.

Those are the ones that you can count on to pass if you move them up a little bit. They're the ones we do one-to-one with and small group instruction in class.

The ones who miss by one or two points-they just needed a little extra help to pass so we concentrate our attention on that group. The bubbles are the ones who could make it.

They are your first priority, the ones whose folders you move to the top of your pile.

Theoretically, the bubble keeps moving down, and teachers eventually get to everyone. However, a kid like Javier can stay below the bubble for two-thirds of the year before he is deemed a suitable case for treatment (if he ever is at all). Ironically, the lowest-scoring children are given the least attention during the course of the school year. At this school, the number of students languishing below the bubble was sizeable. By the final benchmark test, 35% were still below the bubble.

Teachers often spoke of the need to focus on those students for whom we can have hope. Given the imperative of annual improvement, hope can be kept alive only for those students close to passing the test this year. As one teacher summed up:

If you have a kid who is getting a 22, even if they improve to a 40, they won't be close-but if you have a kid with a 60, well, they're in shooting range. Bush says that no child should be left behind, but…the reality in American public schools is that some kids are always going to be left behind. Especially in this district, when we have the emphasis on the bubble kids. Some are…they're just too low.

There is something profoundly troubling about a law that leads dedicated educators to discard hope for children who have yet to turn nine years old in the service of saving those who have a better shot at passing this year's test.

Perverse Incentives

How did educational triage affect Javier? Javier hovered below the bubble throughout the entire year. As a result, he was denied access to the scarce educational resources reserved for the bubble kids. He failed both the first and second TAKS reading tests. Undeterred, he agreed to go to summer school to prepare to take the third and final test. He passed. But his grades had plummeted after he failed the first test, and his teacher decided not to promote him. His mother, who spoke only halting English, did not contest his teacher's decision.

In the period between the first and second tests, I once asked Javier what the worst thing about staying in the third grade would be. Javier, never one to waste words, did not hesitate.

“You got to take the test all overs again.”

It would be simple to blame educational triage on teachers. But sanctimonious exhortations that teachers are behaving badly will not stop educational triage. Nor will anemic defenses predicated on the notion that NCLB does not formally require teachers to triage their students. Perverse incentives to focus on those closest to passing are woven throughout NCLB. It is these incentives, not ethically-challenged educators, that are the problem.

When I concluded this study in 2003, NCLB was not yet fully implemented. I hoped that NCLB would not impel the diffusion of educational triage beyond state boundaries. Unfortunately, I have since received letters and emails from educators in more than 20 states lamenting that educational triage is occurring in their schools. Educational triage is not an isolated problem, but a widespread response to systemic pressures.

Without exposing the lived realities of schools grappling with the demands of NCLB, its narrow conception of accountability emerges unscathed, if only because test scores continue to rise. A closer examination of these trends reveals that the cost of these increases is the unequal treatment of children unlucky enough to find themselves below the bubble. These students, as young as eight years old, are the casualties of NCLB.


[1] My use of the metaphor of educational triage draws on the work of David Gillborn and Deborah Youdell, Rationing Education: Policy, Practice, Reform, and Equity. (Buckingham: Open University Press, 2000).

Jennifer Booher-Jennings is a doctoral candidate in the Department of Sociology at Columbia University. Her research focuses on accountability, school organization, and school choice. She can be contacted by email at or by mail at 1180 Amsterdam Avenue, 413 Fayerweather Hall, New York, NY, 10027.
© 2005, Jennifer Booher-Jennings, all rights reserved. This article may be e-mailed to individuals by individuals, but all other duplication, distribution, publication and use is prohibited without first receiving explicit permission. Contact for information.