The Successful Match: Clerkship Grades

[aphistis]

The original article may be found here: http://studentdoctor.net/blog/2007/0...rkship-grades/

Which of the following is the most important academic criterion used by program directors to select residents?

A) USMLE step 1 score
B) USMLE step 2 CK score
C) Pre-clinical course grades
D) Third-year clerkship grades
E) Membership in Alpha Omega Alpha (AOA)

In our own surveys, we have found that students almost always answer this question incorrectly. Students generally base their answer on information gathered from classmates, upperclassmen, residents, and discussion forums, among others. These are all useful sources of information. The ideal way to answer this question, though, would be to discuss it with those individuals directly involved in the residency selection process—in particular, program directors in your chosen field. Ideally, this should be done early in your medical school education. With this knowledge in hand, you can make the most of your opportunities, placing yourself in a position to succeed and match with the specialty or program of your choice.

Fortunately, others have done this work and published their findings. A survey of approximately 800 program directors was performed by Dr. Wagoner, the former dean of students at the University of Chicago Pritzker School of Medicine. These program directors represented 14 specialties, and were surveyed about the importance of various academic criteria used in the selection of residents.1 Dr. Wagoner and her colleagues learned that grades in required clerkships are the most important academic criteria used to select residents.

At most schools, required or core clerkships include internal medicine, pediatrics, psychiatry, surgery, obstetrics/gynecology, and family medicine.Most medical students are surprised to learn that grades in required clerkships are ranked higher in importance than USMLE scores. In our inaugural column, we presented data from a survey showing that 44% of students from three U.S. medical schools perceived required third-year clerkship grades as moderately, mildly, or not at all important in the residency selection process.2

While many reasons exist for this disconnect between the perceived and actual importance of clerkship grades, we know that this can impact students’ efforts and attitudes during rotations.

As this article goes to press, we recognize that thousands of students across the country have begun, or are about to begin, their third year of medical school. Put simply, your performance this academic year can make or break your chances of a successful match.

• Grades in required clerkships are the most important academic criteria used to select residents.
• “Number of honors clerkship grades” was the second most important academic criteria used to select residents in the most competitive specialties.
• Clerkship grades are the major determinant of class rank. The most competitive specialties rate class rank among the three most important selection criteria.
• Clerkship grades are a major factor used by schools in electing students to the Alpha Omega Alpha Honor Medical Society (AOA). Election to AOA is highly valued by many competitive specialties. In some programs, and in some specialties such as dermatology, membership in AOA is used as a screening tool to determine which applicants are even considered for interviews.
• Comments made by attending physicians on the clerkship evaluation form find their way, often verbatim, into the Medical Student Performance Evaluation (MSPE). The MSPE, formerly known as the Dean’s letter, is often scrutinized closely by residency programs.
• Clerkship performance and grades are important in securing strong letters of recommendation. In competitive residencies where many applicants have excelled academically, letters of recommendation take on additional importance.

We present one final question: Which of the following is the most important academic criterion used by ophthalmology program directors to select residents?

A) USMLE step 1 score
B) Alpha Omega Alpha
C) USMLE step 2 CK score
D) Grades in required third-year clerkships
E) Grades in the ophthalmology clerkship

If you selected choice D, congratulations. The correct answer is indeed “grades in required third-year clerkships.” In the Wagoner study, 46 ophthalmology program directors were surveyed. Grades in required clerkships and the number of honors grades were ranked higher in importance than grades from ophthalmology electives.

Is this finding surprising? In our experience, all students recognize the importance of grades in their chosen specialty. However, fewer understand the overall importance of grades in required clerkships. A review of various discussion forums reinforces this finding.

In our next column, we’ll discuss the transition between the basic science and clinical years of medical school: what makes the transition such a challenge, and can be done to excel?

References

1. Wagoner NE, Suriano JR. Program directors’ responses to a survey on variables used to select residents in a time of change. Acad Med 1999; 74(1):51-8.
2. Brandenburg S, Kruzick T, Lin CT, Robinson A, and Adams LJ. Residency selection criteria: what medical students perceive as important. Med Educ Online 2005; 10:17.

[treasurefull2]

Complete nonsense... Is that why optho has the 2nd to highest board scores for their residents?

Residency criteria are definitely not black and white, and it depends on the various programs, but board scores are still by far the most important.... THE REST is just sugar on top....

[domer621]

Originally Posted by aphistis

Bill Johnson, DDS

? I don't get it.

[BlackSails]

Originally Posted by treasurefull2

Complete nonsense... Is that why optho has the 2nd to highest board scores for their residents?

Your logic is faulty.

3rd year clerkships can be more important than Step 1 scores, yet the accepted applicants can have high step 1 scores. Basically, since optho is competitive enough, they can choose students with both honors in required clerkships AND high step 1 scores.

[Pinkertinkle]

And this article says away rotation and USMLE step 1 are most important, and its newer than the wagoner one cited by the authors:
http://www.ejbjs.org/cgi/content/full/84/11/2090/T01

Also:

"# Clerkship grades are the major determinant of class rank. The most competitive specialties rate class rank among the three most important selection criteria.
# Clerkship grades are a major factor used by schools in electing students to the Alpha Omega Alpha Honor Medical Society (AOA). Election to AOA is highly valued by many competitive specialties."

Oh yeah? Where I'm from USMLE step 1 also determines class rank and AOA.

Clerkship performance and grades are important in securing strong letters of recommendation. In competitive residencies where many applicants have excelled academically, letters of recommendation take on additional importance

For ophtho, something like 2/3 of your letters should be from ophthalmologists, a rotation not covered in third year.

[DOCTORSAIB]

Originally Posted by treasurefull2

Complete nonsense... Is that why optho has the 2nd to highest board scores for their residents?

Residency criteria are definitely not black and white, and it depends on the various programs, but board scores are still by far the most important.... THE REST is just sugar on top....

I agree with you 100%.

Anyone who thinks preclinical/clinical grades are more important than board scores has lost touch with reality. It's a simple formula for the competitive residencies:

1) Competitive Step 1 score + HP's/H's in 3rd year rotations = many interviews and will likely get ranked very high (assuming you have research, good LORs, good personality).

2) Competitive Step 1 score + all P's in 3rd year = interviews (although probably a bit less than option #1) and will get ranked high (once again, assuming research, good LORs, good personality.

3) Low Step 1 score + HP/H's in 3rd year rotations = minimal interviews and greatly reduced chance of matching (unless another aspect of the application is outstanding like research, LOR from well-known attending, +/- impressive away rotations).

4) Low Step 1 score + all P's in 3rd year + lackluster LORs with zero research = CHANGE FIELDS ASAP!

Its really not that complicated guys.

[BlackNDecker]

What numerical score equals honors? high pass? pass?

[Roy7]

Originally Posted by DOCTORSAIB

I agree with you 100%.

Anyone who thinks preclinical/clinical grades are more important than board scores has lost touch with reality. It's a simple formula for the competitive residencies:

1) Competitive Step 1 score + HP's/H's in 3rd year rotations = many interviews and will likely get ranked very high (assuming you have research, good LORs, good personality).

2) Competitive Step 1 score + all P's in 3rd year = interviews (although probably a bit less than option #1) and will get ranked high (once again, assuming research, good LORs, good personality.

3) Low Step 1 score + HP/H's in 3rd year rotations = minimal interviews and greatly reduced chance of matching (unless another aspect of the application is outstanding like research, LOR from well-known attending, +/- impressive away rotations).

4) Low Step 1 score + all P's in 3rd year + lackluster LORs with zero research = CHANGE FIELDS ASAP!

Its really not that complicated guys.

The guys wrote a book on the subject. They've obviously researched it waaaaaay more than you have. Why argue? Just crush year three and step 1.

Plus at my school Step 1 has no relation w/ranking.

[arthrodisiac]

Threads like this exist to scare the **** out of medical students from applying to competitive specialties. Look at the raw match statistics on medfriends.org, and make your own conclusions.

[plastikosmd]

"Threads like this exist to scare the **** out of medical students from applying to competitive specialties."

I dunno, eyes wide open is more like it.

It would seem that if there are very few criteria to compare the applicants, then doing well in everything is important. You need to study for Step 1, depending on how you do, Step 2 becomes more/less important. You need to do well on your clerkships, Honors if you can. If you have grades in pre-clerkship..then study. Impress those that are in your future field, get great LOR's. At some point your outlook in med school changes from ....surviving med school...to landing the residency of your choice. Dont close doors you cant open again later.

[Samir Desai]

Originally Posted by treasurefull2

Complete nonsense... Is that why optho has the 2nd to highest board scores for their residents?

Residency criteria are definitely not black and white, and it depends on the various programs, but board scores are still by far the most important.... THE REST is just sugar on top....

Thanks to everyone who has commented on our most recent column. I will try to respond to as many comments as I can, beginning with treasurefull2. I agree with treasurefull2 that board scores are important. In fact, some ophtho programs (along with other highly competitive specialties) will use the board score alone or the board score in combination with other critieria (such as clerkship grades) to screen applicants. Those who meet their threshold criteria or score will be invited for interviews.

Basically, the residency selection process can be divided into two phases. The first phase is the screening phase, the second is the ranking phase. In the screening phase, board scores often do carry great importance. Once applicants get past the screening phase, programs will often place less emphasis on these scores.

Why? Because in the studies that have been done on USMLE scores as a predictor of resident success, scores have not been a good predictor. While scores generally are good predictors of future performance on specialty board exams, being a successful resident requires much more than the ability to take tests.

[Samir Desai]

Originally Posted by Pinkertinkle

And this article says away rotation and USMLE step 1 are most important, and its newer than the wagoner one cited by the authors:
http://www.ejbjs.org/cgi/content/full/84/11/2090/T01

Also:


Oh yeah? Where I'm from USMLE step 1 also determines class rank and AOA.

For ophtho, something like 2/3 of your letters should be from ophthalmologists, a rotation not covered in third year.

Pinkertinkle, thanks for sharing the info on residency selecton criteria for orthopedic surgery. Once you have decided on your specialty, you should search the literature looking for selection criteria specific to the specialty. Having knowledge of how PDs think can help you develop a strategy for success.

The Wagoner study surveyed program directors in 14 specialties, including orthopedics. Since then, several newer surveys of ortho PDs have been published.

As far as class rank, schools will have differing policies on how class rank is determined. At some schools, USMLE scores will be a factor. At others, it may have no bearing. Clearly, every student should know the policy at their own school, given the importance of class rank in the selection process. Thanks for pointing that out.

[Samir Desai]

Originally Posted by arthrodisiac

Threads like this exist to scare the **** out of medical students from applying to competitive specialties. Look at the raw match statistics on medfriends.org, and make your own conclusions.

We didn't write this article to scare anyone. We apologize if we have scared anyone out there. Our goal was to highlight the importance of clerkship grades. Having advised students at different schools, we have seen that many students underestimate the importance of these grades.

Since about 20,000 students have started or are about to start third year, this is a good time to raise the importance of this factor in the residency selection process. Knowing this up front can clear up any misperceptions.

If you look back to our first column of The Successful Match, we are hoping to clear up common misperceptions.

[nykka3]

Originally Posted by Samir Desai

We didn't write this article to scare anyone. We apologize if we have scared anyone out there. Our goal was to highlight the importance of clerkship grades. Having advised students at different schools, we have seen that many students underestimate the importance of these grades.

Since about 20,000 students have started or are about to start third year, this is a good time to raise the importance of this factor in the residency selection process. Knowing this up front can clear up any misperceptions.

If you look back to our first column of The Successful Match, we are hoping to clear up common misperceptions.

How can PD's decide if one applicant is better than another based on clinical clerkship grades if across the country these grades are not standardized like step 1 and step2? It seems like step scores would be more helpful. I do agree good LOR's and comments on the MSPE are also helpful in evaluating clerkship performance, esp. if you attend a school with subjective clerkship grading. What do you think?

[AmoryBlaine]

Originally Posted by arthrodisiac

Threads like this exist to scare the **** out of medical students from applying to competitive specialties. Look at the raw match statistics on medfriends.org, and make your own conclusions.

No, SDN exists to tell students that no matter how badly they did in undergrad/med school they can still get into Harvard or match in Derm if they just try really hard!

[Samir Desai]

Originally Posted by nykka3

How can PD's decide if one applicant is better than another based on clinical clerkship grades if across the country these grades are not standardized like step 1 and step2? It seems like step scores would be more helpful. I do agree good LOR's and comments on the MSPE are also helpful in evaluating clerkship performance, esp. if you attend a school with subjective clerkship grading. What do you think?

You raise an excellent point, nykka3. Clerkship grades are not standardized like board scores. It would be great if they were.

As I mentioned in one of my other posts in this thread, programs/PDs are trying to determine who will succeed as a resident. There have been some studies that have looked at correlating selection criteria with subsequent residency performance. In one study of orthopedic residents, Dirschl found that academic performance in clinical clerkships was most predictive of subsequent overall performance (Dirschl DR, Dahners LE, Adams GL, Crouch JH, Wilson FC. Correlating selection criteria with subsequent performance as residents. Clin Orthop Relat Res. 2002 Jun;(399):265-71).

[nutcancer]

I'd rather have a 240+ on Step 1 with HP/P in 3rd year than a 220 with all H in 3rd year.

What do you guys think? Am I underestimating the importance of 3rd year grades? I don't think so. I think residency directors in the toughest specialties want to know their students will pass their specialty boards (Step 1 is the best indicator) and want to show off their high step average to other programs. But I think the above situation is unlikely as those that do well on step 1 also tend to do well on the wards.

[DOCTORSAIB]

Originally Posted by Roy7

The guys wrote a book on the subject. They've obviously researched it waaaaaay more than you have. Why argue? Just crush year three and step 1.

Plus at my school Step 1 has no relation w/ranking.

At some point in your education, I'm sure someone told you that just b/c something is "published" does NOT make it the 11th Commandment. There are plenty of published material, research articles included, that have major flaws. Some are just plain WRONG. As a physician, you must think critically!

With all due respect to Dr.Desai, I am a bit skeptical of the importance of 3rd year grades over board scores. The top residencies (Derm, Ophtho, Rads, Ortho, Neurosurgery, etc) do NOT screen based on 3rd year grades. There is WAY too much subjectivity in who gets Honors and who doesn't. They screen based on board scores b/c it's a STANDARDIZED test that all of us must take. And we all know that. So why are you guys so swayed in your judgement just b/c some new article came out stating the opposite?

A competitive Step 1 score will land you the INTERVIEW. The rest of your application, especially LORs, research, and your performance during the interview will GET YOU IN. Grades are no where near as important as board scores, LOR, publications, and your interview performance. Having said that, 3rd year grades are more important than preclinical grades.

In short, I'd rather have a 250+/99 and all P's than a 215 with all H's. ALL ELSE BEING EQUAL, the former applicant will do MUCH better in the match.

[Roy7]

Originally Posted by Samir Desai

Basically, the residency selection process can be divided into two phases. The first phase is the screening phase, the second is the ranking phase. In the screening phase, board scores often do carry great importance. Once applicants get past the screening phase, programs will often place less emphasis on these scores.

People should read a thread before giving comments - just my opinion. And yes, I should think critically, but your (or anyones) critical thinking w/no factual support or research is just an opinion (yours). Someone else thinking critically w/10 different publications on the subject, most of which sign clear (at least by the standards of the various journals) carries waaay more weight than any 3rd (or 4th) year medical student saying what they'd rather have when applying.

[DOCTORSAIB]

Originally Posted by Roy7

People should read a thread before giving comments - just my opinion. And yes, I should think critically, but your (or anyones) critical thinking w/no factual support or research is just an opinion (yours). Someone else thinking critically w/10 different publications on the subject, most of which sign clear (at least by the standards of the various journals) carries waaay more weight than any 3rd (or 4th) year medical student saying what they'd rather have when applying.

I did read the thread, actually. What I said is not just my opinion but the opinion of MANY other students, residents, and PD's. Have you looked at the study that Dr.Desai is referring to? Probably not. Do yourself a favor and take a look at it before putting so much weight on what these experts have to say.

Always remember that medical students are an anxious group of people. They make a great target population. It's very easy to market to them, publish a book with the title "Secrets of ____," written by some MD/DO, throw in some "insider" info, and in a few years you've got yourself a "must-have" book (short of First Aid). I work with one of the top medical publishing company so trust me when I tell you this.

Dr. Iserson also published a book, "How to Get into Residency," or some crap like that. A mediocre book at best. In it he rates Emeregency Medicine as MORE competitive than Ophthalmology. Do you believe it? Not sure what study he read, but the published data CLEARLY proves him wrong. The fact that he's an EM doc himself may have something to do with it...

[DocMizzle]

Honestly, I don't see any point in arguing whether board scores or clinical grades are more important. There is so much variation in the weighting each specialty and specific programs within a specialty give to any one factor, that there really is no "right" answer.

If you have a 250+ step 1 but you are a complete a**, you probably will have trouble matching; if you have an average step 1, you can make up for it by honoring 3rd year and getting the great LORs that come with impressing attendings, but you still might have trouble getting past the "screening".

The bottom line is that if you want to be a competitive applicant for a competitive specialty, you should strive to be well-rounded.

[ChildNeuro]

Originally Posted by Samir Desai

We didn't write this article to scare anyone. We apologize if we have scared anyone out there. Our goal was to highlight the importance of clerkship grades. Having advised students at different schools, we have seen that many students underestimate the importance of these grades.

Since about 20,000 students have started or are about to start third year, this is a good time to raise the importance of this factor in the residency selection process. Knowing this up front can clear up any misperceptions.

If you look back to our first column of The Successful Match, we are hoping to clear up common misperceptions.

I think you article *has* scared alot of medical students, in that grading and expectations are ill-defined during third year and that there is alot of heterogenosity in terms of clinical sites and different quality levels of attendings and clerkship directors. Alot of attendings take advantage of third year medical students precarious position and had one attending tell me when I was running around to do work and find some object for him that my "honors was slipping away." Regardless, the focus during third year should be on learning medicine, and taking care of patients, but it turns into a fierce competition for grades and stands in the way of actual learning.

You appear to raise a hysteria about third year grades, but don't offer any solutions, like how to do an excellent job third year, or more importantly how to navigate the pitfalls of third year. Personally, if you show up with a can-do attitude and really jump in and do your reading you will do very well. But alot of the time it may come down to an attending who personally dislikes you or just a very malignant clinical environment. I think all of us are trying to do the best possible on a daily basis, and I don't think your article will make students think, "Oh, yeah, I guess I'd better buckle down", as we already know that. Third year is a very political year, and there are alot attendings with big egos who use evaluations as a sword hanging over students heads rather than objective evaluation or as a means to better ourselves. Having a good work ethics helps alot when honoring, and this should be mentioned, I honored basically all my clinical courses last year because I can run circles around residents and students.

[SmokeyBear]

Medicine is both an art and science. Therefore, a great physician must be able to master BOTH facets of medicine. The reflection of the mastery of the sciences can be indicated by the USMLE I whereas the reflection of the mastery of the art of medicine can be indicated by third year clerkship evaluations. If anything, I believe both the USMLE 1 and third year clerkship evaluations should be weighted the same. I do not agree that the third year clerkship should be more important in determining one's residency. If this indeed is the system that residency programs are using it seems pretty unfair.

[Samir Desai]

Originally Posted by DOCTORSAIB

At some point in your education, I'm sure someone told you that just b/c something is "published" does NOT make it the 11th Commandment. There are plenty of published material, research articles included, that have major flaws. Some are just plain WRONG. As a physician, you must think critically!

With all due respect to Dr.Desai, I am a bit skeptical of the importance of 3rd year grades over board scores. The top residencies (Derm, Ophtho, Rads, Ortho, Neurosurgery, etc) do NOT screen based on 3rd year grades. There is WAY too much subjectivity in who gets Honors and who doesn't. They screen based on board scores b/c it's a STANDARDIZED test that all of us must take. And we all know that. So why are you guys so swayed in your judgement just b/c some new article came out stating the opposite?

A competitive Step 1 score will land you the INTERVIEW. The rest of your application, especially LORs, research, and your performance during the interview will GET YOU IN. Grades are no where near as important as board scores, LOR, publications, and your interview performance. Having said that, 3rd year grades are more important than preclinical grades.

In short, I'd rather have a 250+/99 and all P's than a 215 with all H's. ALL ELSE BEING EQUAL, the former applicant will do MUCH better in the match.

I agree with DOCTORSAIB that, as good physicians, we should be skeptical about the information we are presented with. We definitely need to evaluate the literature with a critical eye.

I agree with you that there is a great deal of subjectivity with regards to clerkship grading. The system is far from perfect. You would be hard pressed to find someone who believes that it doesn't require some fixing.

USMLE scores are important. I have never said otherwise. However, clerkship grades are also important. DOCTORSAIB, you wrote that the most competitive specialties "do NOT screen based on 3rd year grades." In your post, you mentioned that these specialties include radiology, ortho, etc.

Below is a link to the orthopedic residency program at VCU:

http://www.orthopaedics.vcu.edu/resi...nfomation.html

Please note the following paragraph taken word for word from their site:

"The residency program director screens applicants based on the following factors:

USMLE scores.
Transcripts.
Letters of recommendation.
Dean’s letter."

Below is a link to the ophthalmology program at NYU:

http://www.med.nyu.edu/ophthalmology/residency/faq.html

Please note point # 10 regarding the screening of applications.

These are just a few examples of programs that take into account much more than USMLE score at the screening phase. I do agree with you that some programs will screen based solely on the USMLE score but not all will do that.

[ChildNeuro]

Originally Posted by SmokeyBear

Medicine is both an art and science. Therefore, a great physician must be able to master BOTH facets of medicine. The reflection of the mastery of the sciences can be indicated by the USMLE I whereas the reflection of the mastery of the art of medicine can be indicated by third year clerkship evaluations. If anything, I believe both the USMLE 1 and third year clerkship evaluations should be weighted the same. I do not agree that the third year clerkship should be more important in determining one's residency. If this indeed is the system that residency programs are using it seems pretty unfair.

I would agree that having a good knowledge base is very important in medicine, alot of doctors make mistakes based on incorrect clinical knowledge. Third year can be great if you are working with attendings & residents who like what they are doing and don't intellectually bully you. I think third year medical students are infantalized during third year, which includes alot of hazing/abuse, and more than anything you learn the art of being a good clerk or the art of just surviving, not the art of medicine, IMHO. Alot of medicine is a social club or good old boys/girls club, where if your attending likes you then they will give you a good LOR, if not then it really doesn't matter how much work you do. How else does it explain the large number of incompetent and arrogant surgeons and surgery residents who flood hospitals complaining about not having enough money to buy a new BMW?!? Something is rotten with third year evaluations.

How could residency programs screen on rotation grades if schools assign these at different percentages, i.e. 5% here, 25% there, at least the USMLE is standardized, probably smarter PDs would use this . . . if they have to screen. I am very skeptical of any book claiming the almighty importance of having to do spectacularly well on clinical rotations, I think that attendings in medical school love to expound upon the great importance of clinical rotations because it is sort of like saying, "We are the best being in academic medicine and therefore will decide who goes into competitive specialty x or y, and who will automatically not be considered for super-subspecialty surgery z". In the *past* academic docs were the best, but now you have studies showing that some types of pneumonia are treated better at community hospitals instead of big academic centers, there has a been a migration of excellent docs away from academic medicine just because of this attitude that whatever an academic doc like a clerkship director says is golden and perfectly objective, PDs now know how un-objective i.e. politically based evaluations are, and the increased abuse students face on the wards, and they probably should place less emphasis on third year rotation grades. I don't believe that society is best served by overweighting third year clinical grades. . .

[ChildNeuro]

Originally Posted by Samir Desai

I agree with DOCTORSAIB that, as good physicians, we should be skeptical about the information we are presented with. We definitely need to evaluate the literature with a critical eye.

I agree with you that there is a great deal of subjectivity with regards to clerkship grading. The system is far from perfect. You would be hard pressed to find someone who believes that it doesn't require some fixing.

USMLE scores are important. I have never said otherwise. However, clerkship grades are also important. DOCTORSAIB, you wrote that the most competitive specialties "do NOT screen based on 3rd year grades." In your post, you mentioned that these specialties include radiology, ortho, etc.

Below is a link to the orthopedic residency program at VCU:

http://www.orthopaedics.vcu.edu/resi...nfomation.html

Please note the following paragraph taken word for word from their site:

"The residency program director screens applicants based on the following factors:

USMLE scores.
Transcripts.
Letters of recommendation.
Dean’s letter."

Below is a link to the ophthalmology program at NYU:

http://www.med.nyu.edu/ophthalmology/residency/faq.html

Please note point # 10 regarding the screening of applications.

These are just a few examples of programs that take into account much more than USMLE score at the screening phase. I do agree with you that some programs will screen based solely on the USMLE score but not all will do that.

How is this helpful information? Like I stated before, we all try our best to do as well as possible on clinical rotations, but in some of the more competitive environments the students are mean to each other (I know I have had fellow students do some bad/weird things to me). I think that the ones who stand out on rotations are very extroverted, but, sometimes the best students are very introverted and may be attacked for this on a rotation. There is such a high percentage of student abuse on clinical third year rotations, i.e. many figure above 50%, and so much back-stabbing and attendings who have agendas with certain students that there is alot of lack confidence in fairness or objectivity of third year grades amoung students. Your book/post does nothing more than add fuel to the fire that currently is the problem with clinical education that produces a large number of numbed physicians each year who lack any bed side skills and have become disatisfied with health care, and less humanistic than generations past. I think, and forgive me if I am wrong, but you want to sell a book which has magical fixes or supposed secrets of medical education, and do so by trying to show med students how little they know about what you believe to be the real residency application process. I wouldn't buy your book, I am too busy learning medicine than worry about how to smooze up to my next supervising attending.

[DOCTORSAIB]

Thank you for your post Dr. Desai. I certainly understand your point. Third year grades are important. And some programs put more emphasis on those grades than on board scores. This is true not just for ophthalmology but also for other fields like orthopaedics, as clearly stated on the websites you mentioned.

However, it's almost considered poor form for a program to publically announce that they will screen for interviews based on ONLY your Step 1 score, using some cut-off (220 is usually thrown around, but I've heard of 230's and even 240s for certain Derm programs). Once you make that cut-off, then other factors will be considered- LORs, research, grades, and eventually your interview performance.

Do you think any residency program would advertise on their website only ONE criteria for their screening process? Of course not! But in reality, many do just due to the sheer number of applications that they must select from. I've heard this from many, many residents and PD's both in person and on SDN, that if you don't meet the initial screen, your application is tossed. There are just too many applications and too little time to go through each one with a fine tooth comb.

For example, I am friends with the PD of a popular Ophtho program. This program gets 400+ applications per year, of which they interview ~60 to fill FOUR SPOTS! The intial screen is based solely on your Step 1 score. Then they will cut it down to 60 applications based on a number of other factors (LORS, research, big name med school, unique talent, etc). However, once you interview, your Step 1 score is almost irrelevant. Other aspects of your application become important and will be used to rank you.

That has been my experience with many programs and not just in ophthalmology. I've read and talked to people in Derm, Rads, and General Surgery (and one ENT program).

Nevertheless, I like these types of debates as we get to hear different sides of an issue. Thanks again for your efforts in helping us out. We definitely need guidance as we navigate ourselves through the labyrinth of the residency application process...

[Samir Desai]

Originally Posted by ChildNeuro

I think you article *has* scared alot of medical students, in that grading and expectations are ill-defined during third year and that there is alot of heterogenosity in terms of clinical sites and different quality levels of attendings and clerkship directors. Alot of attendings take advantage of third year medical students precarious position and had one attending tell me when I was running around to do work and find some object for him that my "honors was slipping away." Regardless, the focus during third year should be on learning medicine, and taking care of patients, but it turns into a fierce competition for grades and stands in the way of actual learning.

You appear to raise a hysteria about third year grades, but don't offer any solutions, like how to do an excellent job third year, or more importantly how to navigate the pitfalls of third year. Personally, if you show up with a can-do attitude and really jump in and do your reading you will do very well. But alot of the time it may come down to an attending who personally dislikes you or just a very malignant clinical environment. I think all of us are trying to do the best possible on a daily basis, and I don't think your article will make students think, "Oh, yeah, I guess I'd better buckle down", as we already know that. Third year is a very political year, and there are alot attendings with big egos who use evaluations as a sword hanging over students heads rather than objective evaluation or as a means to better ourselves. Having a good work ethics helps alot when honoring, and this should be mentioned, I honored basically all my clinical courses last year because I can run circles around residents and students.

Congratulations on doing so well in your clinical courses! I absolutely agree that the focus of third year is building a foundation and learning as much as you can. I also agree that there is considerable variability among clerkships, different clerkship sites, attendings, etc.

As you noted, there is a lot of subjectivity with clerkship grading. But it is difficult to measure noncognitive skills. How do you measure someone's motivation? Initiative? Integrity? Many attendings struggle with these issues. We do need our institutions to do a better job of educating faculty on the proper way to evaluate students. In my experience, faculty often do not receive this instruction.

I believe it's important for students to be well informed of the criteria used in the residency selection process. In addition to learning as much as you can during clerkships, you also hope to maximize your chances of reaching your professional goals. If you're operating under some misperceptions, then you may not put forth effort where it's needed. For example, if you think clerkships are not important, then you might not work or try as hard in your rotations. That might have an impact on what happens down the road.

[ChildNeuro]

Originally Posted by Samir Desai

Congratulations on doing so well in your clinical courses! I absolutely agree that the focus of third year is building a foundation and learning as much as you can. I also agree that there is considerable variability among clerkships, different clerkship sites, attendings, etc.

As you noted, there is a lot of subjectivity with clerkship grading. But it is difficult to measure noncognitive skills. How do you measure someone's motivation? Initiative? Integrity? Many attendings struggle with these issues. We do need our institutions to do a better job of educating faculty on the proper way to evaluate students. In my experience, faculty often do not receive this instruction.

I believe it's important for students to be well informed of the criteria used in the residency selection process. In addition to learning as much as you can during clerkships, you also hope to maximize your chances of reaching your professional goals. If you're operating under some misperceptions, then you may not put forth effort where it's needed. For example, if you think clerkships are not important, then you might not work or try as hard in your rotations. That might have an impact on what happens down the road.

I think that is almost impossible to measure a student's initiative on a rotation objectively, obviously some students may state aloud that they have no desire to go into internal medicine, but even then they may work very hard on the rotation. I think that is almost slander to write in an evaluation that a student is "unmotivated" or "has no initiative". How does this help the student or society? This so subjective, third year really isn't like college or other educational processes where learning is the main goal, it is more like the business world were who you know matters more than what you know. You can spin a student's performance in third year however you want and come up with an excellent evaluation and a negative evaluation. I really work hard on patient care and keeping up a good foundation of knowledge, but I really fret and try extra hard to laugh at any attendings jokes, and be very receptive to them when other students are staring off into space, does it mean I am a better student? No! I have learned how to play this slimey little game, and after I graduate I need to be de-greased so I can be a more independent resident. I do feel bad for students who don't know how to play this bizarre game, sometimes I'm running around, or looking attentive and answering all the questions on rounds, and I can just tell who will be slammed with a bad evaluation.

I do agree that attendings need more education in terms of evaluation and overall teaching, the flip side of evaluating students is that you are actually trying to teach them versus just lording over the next generation of doctors. Most attendings, IMHO, are extremely independent, make extreme judgments about students, and themselves may not be model doctors, and teaching medical students, residents and patients about their health problems was not a major motivating factor in their decision to pursue an MD, which may or may not be bad. That is why so many attendings don't like medical students, because they feel it is a waste of their time to teach us, I had an attending who calculated how much they school was paying him to teach, it was low based on whatever he was using like $3/hr or something, and he brought it up alot and when he felt he taught enough he became upset and left. I love explaining something obvious, but not well understood by a third year like some renal process, CVP, MI or something clinically important that they have no idea about, they would say "wow, they didn't us that in medicine" or something like that, and its because attendings feel it is just their job to be sitting on a golden throne judging students, but don't have real clinical discussions with students. Alot of attendings feel that their only job is to ask impossible questions, and then fill out evaluations.

Medical school tuition does not pay for or get a student excellent education, it gets you access to patients in a hospital so you can read their chart and so you can eavesdrop on rounds. You learn more reading books and journals. With attendings who feel so unmotivated to teach I would not trust their evaluations. Your article should include also how to honor a fourth year sub-I for those students who can't wiggle their way to honors during the debacle that is the third year of medical education, which I think is a poor yard stick.

[plastikosmd]

posted by Child...
"Alot of medicine is a social club or good old boys/girls club, where if your attending likes you then they will give you a good LOR, if not then it really doesn't matter how much work you do. How else does it explain the large number of incompetent and arrogant surgeons and surgery residents who flood hospitals complaining about not having enough money to buy a new BMW?!? Something is rotten with third year evaluations"

Funny, I had the opposite experience. If you said you wanted to go into surgery..on your peds/family rotations....forget about honors. For my surgery rotation you had 3 not 2 criteria for honors with applied percentages....1)evals, 2)shelf, 3) an oral exam (60%). Other rotations were some sort of back door popularity contest..with no numbers applied, tho you still took a shelf...just the weight was variable. So yes I agree, much of the process is subjective, welcome to life. I would also say by the style and tone of your writing you must have done well on your surgery clerkship.

I can promise you it doesnt get better when you are a intern/resident. No better as a Fellow. No better as someone in practice. My advice for a student trying to do well on a clerkship.

1) Be Prompt, (showing up, pages, etc) sometimes just being there is 1/2 the battle
2) Dont lie, if you dont know the answer say so...or respond that you will find out
3) Dont attempt to put others down for your own gain..this is usually plain to see..and you wont do well, I did well on a rotation by bringing my
co-student lunch when they couldnt get it..this was noted to my surprise..."works well with others"
4) "A closed mouth gathers no foot" this was always helpful, works in life too!
5) Dont worry about taking care of the residents..take care of the patients...when a patient remarks to a resident/attending how much they
like you..that carries weight
6) You still need to read/study on your rotations..no matter how much you hate the subject..OB/PEDS/Surgery, acting like you are better than
whatever they chose as a career wont get you far....
7) Learn routines....this is hard to teach..but if something is needed...a dressing..etc every day...and you say..have it ready, pocket..in the room etc
that shows planning
8) a lot of it is personality, there are some people you can "mess with" others you cant, some act like buddies...others keep your distance...it is hard to figure out, but best to start off conservative
9) as i alluded to above, and this gets harder as 3rd year progresses..but i entered every rotation, never mentioning my future goals, but acting like the current rotation was the field i was considering. Not lying, ...it was more of an internal thing, i attempted to perform at the level required for someone trying to get into that field. a lot of it is attitude, and often how you feel on the inside will be reflected on the outside..so i tried to make use of this for the good. i can honestly say..this made the rotations much more fun.


there are probably more..just cant think of them right now........

[DOCTORSAIB]

Seems like Dr. Desai has stirred up some controversy with his article on the SDN homepage!

[ChildNeuro]

Originally Posted by plastikosmd

posted by Child...

Funny, I had the opposite experience. If you said you wanted to go into surgery..on your peds/family rotations....forget about honors. For my surgery rotation you had 3 not 2 criteria for honors with applied percentages....1)evals, 2)shelf, 3) an oral exam (60%). Other rotations were some sort of back door popularity contest..with no numbers applied, tho you still took a shelf...just the weight was variable. So yes I agree, much of the process is subjective, welcome to life. I would also say by the style and tone of your writing you must have done well on your surgery clerkship.

I can promise you it doesnt get better when you are a intern/resident. No better as a Fellow. No better as someone in practice. My advice for a student trying to do well on a clerkship.

4) "A closed mouth gathers no foot" this was always helpful, works in life too!

6) You still need to read/study on your rotations..no matter how much you hate the subject..OB/PEDS/Surgery, acting like you are better than
whatever they chose as a career wont get you far....

9) as i alluded to above, and this gets harder as 3rd year progresses..but i entered every rotation, never mentioning my future goals, but acting like the current rotation was the field i was considering. Not lying, ...it was more of an internal thing, i attempted to perform at the level required for someone trying to get into that field. a lot of it is attitude, and often how you feel on the inside will be reflected on the outside..so i tried to make use of this for the good. i can honestly say..this made the rotations much more fun.


there are probably more..just cant think of them right now........

Your method may work, but personally I am jealous of students who knew to say that they didn't know what the wanted to do, I really wanted to do peds, and told this to my peds attending and they on the spot accussed me of saying that to get a good grade! I guess I don't like students who don't want to do pediatrics who said they wanted it and made my life difficult as I had did not enjoy this rotation. I wouldn't trust your comments that residency is the same (no I don't trust you, there are alot of happy residents), as generalizations usually hide some falsehoods or real differences.

With regards to number 4 on your list, I find that my best evaluations come with I am not afraid to speak up and offer answers. What I recommend against is blabbing about your social life, keep the conversation to clinical stuff. I think it is disrespectful to be blabbing with the resident or worse other students about going to see the latest movie when your attending is working hard reviewing the chart.

And I actually did extremely well on my surgery rotation.

You have to take really good care of residents and attendings on rotations. My rotations where I really tried to be the good doctor to my inpatients were rewarded with less than stellar comments from residents who wanted me to run around and get them food or do scut work on patients I wouldn't recognize on the elevator. The solution? You MUST be a personal concierge for your residents and attendings, their well-being is top priority, above exhausting yourself on reading, above being the most empathetic student with your patients, I have talked to patients who were really scared about being hospitalized only to be yelled at by attendings who wanted to round earlier than we thought or something. I try to be nice to patients, but curt and more clinical with them, this is what being professional means today, cutting off conversations and although you could explain hemodialysis or something else to them tell them to talk to their nephrologist because my a****** attending is going to skin my alive in 10 minutes and I need vitals on 15 patients . . . It takes alot time to be empathetic, something I hope to do later when I am a resident or attending and I don't have someone whipping me like an alaskan snow dog. I took *very* good care of my outpatients in internal med clinic, and the nasty IM doctor (who was probably jealous that I'm not burnt out) only sneared and told me I should work faster. You ARE A FOOL if you don't cater to your residents and attendings whims, please don't cater to your patients as this is the right thing to do for them and in the end the moral thing to do, with modest benefit to the patient, but will get you creamed in clinicals. Attendings and residents are like auto-mechanics, they want to know how the pump is working i.e. lab results, ECG, etc . . . and spending time talking to patients is like polishing the fender, it is rewarding for you and the patient but attendings don't like it, they want you to work for them, I mean like slave work, they treat almost everyone remotely involved in healthcare better than us, i.e. be a clerk do FAXs, run around with paperwork, mass produce worthless progress notes for litigation prophylaxis or payment, being a third year medical student is more about being a clerk than a doctor in training. I weep for the future. I am not surprised that treatment of alcoholism or drug addiction has worsened in the past deacade in US healthcare, patients are more of a problem and a clinical puzzle to be analyzed with lab values rather than to use time honored traditions of actually talking to patients and encouraging lifestyle changes. Of course this is wrong, but also, you must adapt to this corporate model of medicine if you want to honor third year. I did.

[plastikosmd]

sorry you had such bad experiences. while i agree the process was subjective and long work hours with many trying to trip you up along the way, it was still fun and a learned a great deal. (both about medicine and working with people)

regarding catering..and being a fool and all, i guess i didnt see it the way you do.... I also never ran into attendings who were spiteful if you were working with the patients.

If i was doing something that needed to be done, preround, vitals, paperwork etc.. and since it needed to be done...heck i wasnt a doc..but i sure as hell could fax something...i did it..so yes i did all the crappy tasks..with a smile. and i, as you got honors (well 8 out of 9 and have a funny story for that one). as far as i was concerned.. it was work that needed to be done. now going to get their laundry..or some other personal thing..that is over the line...and abuse. never had that happen.

as far as point 4, nobody said you cant talk, i have just seen too many people get judged (proper and improper) for comments they have made without thinking them through.

It took me a while also to figure out what i wanted to do..that is why i attacked every rotation like it was gonna be the "one."

the "surgery" comment was my attempt to poke fun at you for your broad sweeping generalizations about surgery based on some experience that you had. we are just as human and bitter as you are.

o before i forget..the 1 rotation i didnt honor? family med. 99% on the shelf exam...and..get this..my preceptor was pregn. and at the end of the rotation i delivered her child..yep..i caught. got a pass!..grin....she wanted honors for me..but the fam. med committee stated that honors would be given to those going into family med! o well 8/9 aint bad.

[ChildNeuro]

Originally Posted by plastikosmd

sorry you had such bad experiences. while i agree the process was subjective and long work hours with many trying to trip you up along the way, it was still fun and a learned a great deal. (both about medicine and working with people)

regarding catering..and being a fool and all, i guess i didnt see it the way you do.... I also never ran into attendings who were spiteful if you were working with the patients.

If i was doing something that needed to be done, preround, vitals, paperwork etc.. and since it needed to be done...heck i wasnt a doc..but i sure as hell could fax something...i did it..so yes i did all the crappy tasks..with a smile. and i, as you got honors (well 8 out of 9 and have a funny story for that one). as far as i was concerned.. it was work that needed to be done. now going to get their laundry..or some other personal thing..that is over the line...and abuse. never had that happen.

as far as point 4, nobody said you cant talk, i have just seen too many people get judged (proper and improper) for comments they have made without thinking them through.

It took me a while also to figure out what i wanted to do..that is why i attacked every rotation like it was gonna be the "one."

the "surgery" comment was my attempt to poke fun at you for your broad sweeping generalizations about surgery based on some experience that you had. we are just as human and bitter as you are.

o before i forget..the 1 rotation i didnt honor? family med. 99% on the shelf exam...and..get this..my preceptor was pregn. and at the end of the rotation i delivered her child..yep..i caught. got a pass!..grin....she wanted honors for me..but the fam. med committee stated that honors would be given to those going into family med! o well 8/9 aint bad.

Wow. I think it is wrong that the "Family Medicine Committee" didn't give you an honors as it seems you deserved it. If you are thinking about going into a given field sometimes they make it very easy or very hard for you if they think you won't be their type of fill-in-the-blank. That is really cool that you got to deliver your preceptor's baby, IMHO that would be almost worth it as a good story to tell even if you only got a pass! At least the Family Med Committee admited to their "adjusted" grading system, . . . other places don't and it is a mystery unless you know faculty on the inside. I do paperwork and basically anything with alot of energy, but you may not have worked on a busy service where you have to get 25 sets of vitals, write notes on 5-6 patients, and be ready to round at 7 am after you worked on the all important "list." It gets bad when you have to choose between spending an extra 15-minutes with a patient versus eating lunch, versus "volunteering" to help schedule a certain procedure and get the patient to drink barium or whatever. . .

[watermen]

After finishing my 3rd year rotations. I realized that 3rd year grades are just very subjective. It clearly indicates only one thing without much dispute...the person who can get all honors most likely know how to get along with everybody. However, it definitely don't indicate knowledge, enthusiasm, ability to perform well, and most importantly the potential to become a great doctor.

If I were to become a program director one day...3rd year grade certainly won't be high on my list, it is just too subjective. I prefer to personally evaluate that person and also evaluation from people that I know well.

[ChildNeuro]

Originally Posted by watermen

After finishing my 3rd year rotations. I realized that 3rd year grades are just very subjective. It clearly indicates only one thing without much dispute...the person who can get all honors most likely know how to get along with everybody. However, it definitely don't indicate knowledge, enthusiasm, ability to perform well, and most importantly the potential to become a great doctor.

If I were to become a program director one day...3rd year grade certainly won't be high on my list, it is just too subjective. I prefer to personally evaluate that person and also evaluation from people that I know well.

Another piece of credence to this observation is that the same student who somehow is very disliked at one hospital center, goes to another hospital center for a different clerkship and then is really liked by all and gets a great evaluation. I totally agree that often the most successful student may not be very enthuasiastic, but maybe has the same hobby as the attending. Some schools grade students fairly, others could care less if you don't pass the popularity contest. It must make some students who have never honored a clerkship to feel somewhat depressed or discouraged, . . . what many students don't realize is that a large number of attendings use evaluations and grades as a form of punishment rather than objective evaluation, the lesson is to worry most about keeping the attending happy, they don't seem to be required to give a coherent/understandable reason for a poor evaluation.

[novado]

I agree with the above. I do feel that matching into a competitive specialty does come down to more than just your boards scores. Unfortunately, many schools do not realize how subjective that can be. I chose to go to one of the toughest core rotation sites (out of 5 options) at our school. These are each in often completely different locations in our state and sometimes out of state. Many of my preceptors never give PH to anyone, no matter what. They told me that no student is ever worthy of that. Our grade is purely based on passing a silly book of questions (which you can memorize in a few hours) and the preceptor's evaluation. But, I learned a ton and did extremely well on Step 2. I did get questions on the interview trail about why I did not get PH in all my rotations though. I don't regret going to such a tough place. My third year IM rotation was like a Sub-I. We were writing orders and almost completely in charge of our patients. It has made me on top of my game during internship year. I wish that more PD's realized that third year rotations are completely subjective. I know that other students in my school bribed preceptors with gift cards, engraved tie clips, engraved money clips, as they casually dropped their evaluations into their preceptors hands. Others would bring in food everyday. At least I still have my dignity, and I know I earned my PH.

[ChildNeuro]

That is really amazing that some students would bribe attendings and residents for good grades. I have seen students who are *very* strategic about becoming the star on a rotation, which may include shoving other students out of the way. I have been on rotations where I may not know where the lab is or something else, ask a student who knows the hospital and they won't help me, not because they don't know, but because they are super competitive.

The most important things for getting a good to excellent grade in a third year clerkship is location, location, and location. Some sites are pro-student and somes aren't, I find that I function best at the pro-student sites, and the ones where they really try to beat you down or ignore you just grind on my nerves. Again, who you rotate with is a big deal, and you may be with an attending who makes bizarre demands of students and gives out grades, poor and good, as personal favors or rewards for those he or she personally likes or dislikes on a rotation. . . or someone above you just plain make up their own grading scale, IMHO the rotations were you work like a dog, like prison hard rotations, are the ones that can be very fickle and in cases give you a bad grade or eval. Morale of the story is to know the rumors and behind the scenes info about which attendings are malignant at your institution, something you WON'T get out of any nationwide produced book at Barnes and Noble. Third year is very political, and all politics are local.

[heliotrope]

Some schools use a standard grading system (mine, for instance). How does an A in clinical rotations rate compared to Honors? Are honors more difficult to get, or are they equivalent? Just wondering, not obsessing over it.

[domer621]

Originally Posted by heliotrope

Some schools use a standard grading system (mine, for instance). How does an A in clinical rotations rate compared to Honors? Are honors more difficult to get, or are they equivalent? Just wondering, not obsessing over it.

My school uses an A/B/C system and Honors = "A+", so it's higher than an "A".

[AmoryBlaine]

Originally Posted by novado

I agree with the above. I do feel that matching into a competitive specialty does come down to more than just your boards scores. Unfortunately, many schools do not realize how subjective that can be. I chose to go to one of the toughest core rotation sites (out of 5 options) at our school. These are each in often completely different locations in our state and sometimes out of state. Many of my preceptors never give PH to anyone, no matter what. They told me that no student is ever worthy of that. Our grade is purely based on passing a silly book of questions (which you can memorize in a few hours) and the preceptor's evaluation. But, I learned a ton and did extremely well on Step 2. I did get questions on the interview trail about why I did not get PH in all my rotations though. I don't regret going to such a tough place. My third year IM rotation was like a Sub-I. We were writing orders and almost completely in charge of our patients. It has made me on top of my game during internship year. I wish that more PD's realized that third year rotations are completely subjective. I know that other students in my school bribed preceptors with gift cards, engraved tie clips, engraved money clips, as they casually dropped their evaluations into their preceptors hands. Others would bring in food everyday. At least I still have my dignity, and I know I earned my PH.

Gosh, I sure hope that when I'm an attending I don't feel comfortable taking gifts from medical students whose educational debt equals my annual salary...

On one of my medicine months, a visiting student got totally screwed by the chieft. Chief was a total jerk and just hated the student for no apparent reason. He made his life miserable and did everything in his power to belittle the student on rounds in front of us M3s. Then at the end of the month when grades and stuff were already done we all went out for a meal (attending's tradition). The student very publicly thanked all the residents and presented them with fairly large gifts ($50-75 apiece in value). If you knew Student, you would know that he did this a) b/c he was loaded and could easily afford it and b) b/c he was a classy guy and genuinely appreciated the other residents. It was so much fun to what Chief Asshat squirm as he ashamedly accepted the gift.

[t33sg1rl]

If grades are so important, then I think I need some help:

I'm doing a four week family practice rotation at a site that has not had a med student in months and isn't going to get another for several more months. The place is 2 hours away from my school and students are only rarely sent (it's pretty much only open to students who can arrange their own housing in the area-I just happened to have some relatives).

Anyway, my day consists of seeing patients before the doctor, doing CC/HPI and a very focused physical, orally reporting to the doc, lather, rinse, repeat, repeat. This doc doesn't ever pimp so I can't really impress him with my vast fund of knowledge, not that I have one anyway. He does a little teaching here and there, but not too much. I write short notes (HPI only) but I'm not really sure what he thinks of them. I show up early, I smile, I try to be as thorough as I can be without wasting everyone's time, but in a setting like this, what I can do to boost my grade? At my school, the bottom 75% of my class gets Pass. How can I pull the wool over the doctor's eyes-er, show him that I deserve to be in the top 25% when I'm the only student he might see all year? Preferably without looking like I'm kissing *****...

p.s. Is it appropriate to bring cookies or something on my last day? I like to bake and all the receptionists/MA's have been very friendly and accommodating.

[lord_jeebus]

Originally Posted by t33sg1rl

I write short notes (HPI only) but I'm not really sure what he thinks of them. I show up early, I smile, I try to be as thorough as I can be without wasting everyone's time, but in a setting like this, what I can do to boost my grade?

Try coming up with assessment and plan for every patient, even if you're completely wrong. You're not expected to be right on this, and every opportunity to show your thinking process helps.

If you see something interesting in clinic, go home and read about it so you can ask some intelligent questions the next day.

[heliotrope]

Originally Posted by domer621

My school uses an A/B/C system and Honors = "A+", so it's higher than an "A".

Mine has the highest grade as A.