Evaluating others

I pretty much give 4s and 5s/5, but I think the "A for effort" thing is stupid, some people do better than others and their evals should reflect that. Otherwise it's kind of worthless to evaluate.



unless it's one of those grade your fellow student things; then I give everyone the highest marks, with the expectation of reciprocation.

I tend to give everyone 5/5 unless they're horrific, and even then, I tend not to write comments unless they're positive. It's a lil bit self preservation and a lil bit schadenfreude at the next people to get f-Ed over by a bad attending/resident.

I evaluate honestly. If someone sucks at teaching or is awful to work for, I'm not going to pretend like he isn't. That's doing a disservice to everyone else coming after you. I don't expect anything to change because of my comments, but at least I try.

Funnily enough, I got a 3/5 in some category on one of my evals. I know exactly who gave it to me since we get to see those evals. I have to work with that resident again. Mad awkward.

unsung said:

Do you tend to give ppl the "benefit of the doubt" & give highest ratings as long as you can tell they're trying their best to teach, mean well, etc.?

OR

Do you tend to be brutally honest?

In the past, I've always leaned toward the former, 'cuz I know how obnoxious it is to receive 3 out of 5 on evals for no good reason. Also, considering how important (yet totally subjective) evals can be, I try not to make ppl's lives more difficult than necessary.

Basically, I think it's wrong for a person who is really making an effort to be helpful to get a lower rating than a person who might be technically better at explaining things but is a total douche.

Your thoughts?

Click to expand...

So... personally, grades are stupid. I actually believe in the principle of the Results Only Work Environment (ROWE) or in the principles discussed in Dan Pink's "Drive." And before I say what I do, I am going to preface it with literally EVERYONE will disagree with me because its awkward, odd, and moves against everything in medical education have come to believe. But I think we have sabotaged ourselves. We reward the wrong behavior with the wrong incentives for the wrong reason. The product is Gunners, competition, and hateful anonymity on the internet accusing one another of cheating.

That being said, here is what I do with my medical students and the rationale.


The thing that motivates medical students far too often is the grade. They perseverate on beating their classmates. They have to be in the top 25% of their class, they have to get AOA, they have to get the residency of their dreams in Urology / Derm / Anesthesia / Optho. They search every day for a way to impress their residents or worse, destroy their colleagues, believing that if their competitors look bad, they look better in comparison.


Since I believe the thing that drives a medical student should be the quest for improvement, helping the team, participating in patient care, and heaven forbid, actually learning a little medicine, and NOT the grade, I take that off the table. "Drive" talks about paying people honestly and fairly. Remove the extrinsic motivator from the equation. The idea is "you are having your survival needs satisfied, now go do good work." Versus the traditional model "if you do good work, I will satisfy your survival needs." So I pay them fairly. I just get that extrinsic motivator off the table altogether. Your grade is fixed. And its awesome. Move on.


What's interesting, and what many people refuse to believe because it IS cutting edge, it IS different, is that people do BETTER WORK when they are freed from the survival drive. When we attend to their internal motivators, that is, autonomy, mastery, and purpose (-Dan Pink) people who do right brain, abstract work (like "taking care of patients" and "developing a differential diagnosis), expand their creativity, they come up with complex solutions, they do better work. Additionally, their desire to work becomes exponentially increased. People WANT to be given the authority to practice on their own, to try, to fail (with a safety net), and belong to a higher purpose.

The problem is that we have been, as a society, socialized into the "grades grades grades" mentality. And initially, people recoil at this new "autonomy and mastery" idea. The reply goes something like this: You mean to say, that I WANT TO FAIL at this lumbar puncture? Like IN FRONT OF OTHER PEOPLE?... I have this inner desire to look like an idiot? I mean, really? You actually believe that?

Yes. The reason why people don't like to fail in front of others is because they think (consciously or unconsciously) it will hurt their grade. If approached instead with the perspective "you don't know how to do this. you will. go learn. Ill be here to watch. try. here's how. now you" instead of the "SUCCEED OR FAILZ!?" perspective, students interest increases, their involvement increases, the bus-throwing decreases, the lying decreases, and the nonsense that plagues medical education on the wards similarly falls.

There is more to this than can be written in a single internet thread. I, as I often do, have rambled longer than most people care to read. But realize that when given operational parameters, the expectation of routine evaluations (self and by superiors) for improvement (not a grade), and a clearly defined goal, students' performance improves.

It takes a major paradigm shift to move from what we all encountered as medical students (and even some of us in residency) to a ROWE. But I promise you, the results are astounding. No, i don't have data, just anecdotes, but so far, the results have been brilliant. Never have I once had to go back on my word. Never have I felt abused, cheated, or that a student was using my "generosity" against me.

ROWE > Our current system.

OveractiveBrain said:

So... personally, grades are stupid. I actually believe in the principle of the Results Only Work Environment (ROWE) or in the principles discussed in Dan Pink's "Drive." And before I say what I do, I am going to preface it with literally EVERYONE will disagree with me because its awkward, odd, and moves against everything in medical education have come to believe. But I think we have sabotaged ourselves. We reward the wrong behavior with the wrong incentives for the wrong reason. The product is Gunners, competition, and hateful anonymity on the internet accusing one another of cheating.

That being said, here is what I do with my medical students and the rationale.

I give everyone honors. And I tell them, on day 1.​

The thing that motivates medical students far too often is the grade. They perseverate on beating their classmates. They have to be in the top 25% of their class, they have to get AOA, they have to get the residency of their dreams in Urology / Derm / Anesthesia / Optho. They search every day for a way to impress their residents or worse, destroy their colleagues, believing that if their competitors look bad, they look better in comparison.

Only unsatisfied needs motivate.​

Since I believe the thing that drives a medical student should be the quest for improvement, helping the team, participating in patient care, and heaven forbid, actually learning a little medicine, and NOT the grade, I take that off the table. "Drive" talks about paying people honestly and fairly. Remove the extrinsic motivator from the equation. The idea is "you are having your survival needs satisfied, now go do good work." Versus the traditional model "if you do good work, I will satisfy your survival needs." So I pay them fairly. I just get that extrinsic motivator off the table altogether. Your grade is fixed. And its awesome. Move on.

Intrinsic Motivators provide creativity and growth ​

What's interesting, and what many people refuse to believe because it IS cutting edge, it IS different, is that people do BETTER WORK when they are freed from the survival drive. When we attend to their internal motivators, that is, autonomy, mastery, and purpose (-Dan Pink) people who do right brain, abstract work (like "taking care of patients" and "developing a differential diagnosis), expand their creativity, they come up with complex solutions, they do better work. Additionally, their desire to work becomes exponentially increased. People WANT to be given the authority to practice on their own, to try, to fail (with a safety net), and belong to a higher purpose.

The problem is that we have been, as a society, socialized into the "grades grades grades" mentality. And initially, people recoil at this new "autonomy and mastery" idea. The reply goes something like this: You mean to say, that I WANT TO FAIL at this lumbar puncture? Like IN FRONT OF OTHER PEOPLE?... I have this inner desire to look like an idiot? I mean, really? You actually believe that?

Yes. The reason why people don't like to fail in front of others is because they think (consciously or unconsciously) it will hurt their grade. If approached instead with the perspective "you don't know how to do this. you will. go learn. Ill be here to watch. try. here's how. now you" instead of the "SUCCEED OR FAILZ!?" perspective, students interest increases, their involvement increases, the bus-throwing decreases, the lying decreases, and the nonsense that plagues medical education on the wards similarly falls.

There is more to this than can be written in a single internet thread. I, as I often do, have rambled longer than most people care to read. But realize that when given operational parameters, the expectation of routine evaluations (self and by superiors) for improvement (not a grade), and a clearly defined goal, students' performance improves.

It takes a major paradigm shift to move from what we all encountered as medical students (and even some of us in residency) to a ROWE. But I promise you, the results are astounding. No, i don't have data, just anecdotes, but so far, the results have been brilliant. Never have I once had to go back on my word. Never have I felt abused, cheated, or that a student was using my "generosity" against me.

ROWE > Our current system.

Click to expand...

Subjective evaluations are just that. I feel they are worthless, yet because they are subjective many medical students believe they have to partake in non-medical ass-kissing and embarrassing brown-nosing to suck-seed..ahem...I mean succeed. Unfortunately, many times they're right. I've had attendings who awarded higher grades to the more chipper, buttkissy types, and I've had times when I was buttkissy and chipper and got higher grades as a result. Not to mention competence tends to be something we judge within the first few seconds of seeing someone, as shown in studies where barely-functioning toddlers pick which presidential candidate would be the best sea-captain (they almost always pick the winner), rather than a quality we observe over time.

I also give all of my students honors from the beginning, and they all perform very well afterwards not having the burden of stupid subjective bull**** holding them back. Who am I to screw them over? What do I know? They might hate what I do and not want to be here, and that's fair. I'm not going to penalize them for disliking my work. Nor am I going to be dismissive of them not knowing the correct answer to the pimp question du-jour. If they don't know the answers, that's more of a reflection of their pre-clinical medical education than of their knowledge.


Grading should be used solely for objective testing. USMLE, etc. Rotational objectives should be to "be a good doctor". Not " to get an honors so I can match to plastics"

I would never start with giving "honors" to everyone. I heard the rationale, I just find it garbage. Almost every single student I deal with is completely appropriate for level of training. Rare are the honors students, and rarer yet are the students so bad they require a bad evaluation. Giving everyone high marks is stupid and demeans the value.

jdh71 said:

I would never start with giving "honors" to everyone. I heard the rationale, I just find it garbage. Almost every single student I deal with is completely appropriate for level of training. Rare are the honors students, and rarer yet are the students so bad they require a bad evaluation. Giving everyone high marks is stupid and demeans the value.

Click to expand...

I think that to judge someone as being worthy of honors without any objective standard is so fraught with bias and poor interrater reliability that it is as much garbage as giving everyone honors.

Substance said:

I think that to judge someone as being worthy of honors without any objective standard is so fraught with bias and poor interrater reliability that it is as much garbage as giving everyone honors.

Click to expand...

A fair criticism.

Though, I refuse to give anyone "honors" who I don't think is "honors" by whatever subjective criteria I espouse. To do otherwise is intellectually dishonest.

It's like pizza. Most is alright. Occasionally very, very good. Every once in awhile someone screws up dough, sauce, cheese, and delicious toppings.

MilkmanAl said:

I evaluate honestly. If someone sucks at teaching or is awful to work for, I'm not going to pretend like he isn't. That's doing a disservice to everyone else coming after you. I don't expect anything to change because of my comments, but at least I try.

Click to expand...

same here, I am brutally honest. No 5/5 for any reason other than deserving it. I know I never got 5/5 for nothing....plus giving everybody good evals makes it not worth for the people who actually do put in the effort.

smq123 said:

I think giving everyone Honors, off the bat, is a little disingenuous. It ignores the few students that, arguably, should NOT be doctors. And before you say anything, trust me, they exist.

It's not hard to get honors from me. Really, it isn't. Just don't be a d-bag, don't be disrespectful to me (or the patients or the office staff), and don't embarrass the residency program. We've, unfortunately, had students who HAVE violated these not-very-onerous rules.

- We were consulting an attending cardiologist over the phone. The med student told the cardiologist over the phone, "I'm sorry, but you're wrong." Ummm....he's the head of cardiology at our hospital. And he was NOT wrong, by the way. The assistant PD, who was sitting in another corner of the room, actually facepalmed so hard it made a loud smacking noise.

- If you're going to have the audacity to tell me that you think that my specialty is so easy that you don't need to go to med school to do it, you have to back it up by being a stellar clinical student. And not, for instance, telling a 70 year old guy who had new onset DOE that, "Oh, you're just deconditioned! Go to the gym more often; you'll be fine." He seriously would have ended up killing half the patients that I let him see if allowed to manage them on her own.

- I understand that it's football season, and your team is in the playoffs, but checking your Blackberry for scores WHILE ACTUALLY SEEING A PATIENT is just idiotic.

If I automatically gave everyone honors....I would have thrown up in my mouth a little when it came to these three. I guess that's harsh, but they were seriously awful.

Click to expand...

I know what you're saying, and I knew ahead of time people wouldn't like what I say. There are, of course, certain minimum required expectations I lay down (honesty, integrity, team effort, patient care) but the removal of if-then rewards (extrinsic motivators) gets the students motivated and participating in the RIGHT part of their education. I say "you get honors." then i say "here are the rules." I haven't had to deal with someone who has violated the rules.


I know these were just examples, but let me give you my perspective on what you've posted.

Cardiology. So the med student told a cardiologist he was wrong. He made an error. An error that should be addressed and corrected. Giving a lower grade for it only teaches the students "don't fight for your opinion, it will get you penalized." Albeit, he needs some correction on social interactions (one of the major core competencies for physicians) but having said that you now get to work on THAT. And instead of doign whatever you say to appease you (to get the grade), the emphasis can be on doing what's right (for the sake of being a better person).

Football. People checking their smart phones is a product of a lack of motivation. And here's the weird thing. We think that by giving people bad grades retroactively, while not addressing the inciting event while its going on, will some how demonstrate to the student how he was wrong, and how he can improve. Evaluations that come days to weeks after a rotation are like traffic cam tickets: a penalty we have to pay, but without changing behavior or making the road safer. They just make the driver (and, in this case, the student) angry. After he did it, you could go up to him and be "dude, not cool. show some respect for the patient, for the attending, for me." And again, instead of doign whatever you say to appease you (to get the grade), the emphasis can be on doing what's right (for the sake of being a better person).

plauto said:

same here, I am brutally honest. No 5/5 for any reason other than deserving it. I know I never got 5/5 for nothing....plus giving everybody good evals makes it not worth for the people who actually do put in the effort.

Click to expand...

So... I think it is far better if we use the "here is your honors, up front. Now, be a good person. Let's meet periodically and talk about how you're doing, here are the criteria I'd like you to judge yourself on." Intrinsic motivation. Self-assessment. Real-time feedback. This makes poor students good ones, and good students stellar ones. The stellar ones are already stellar, and are going to do well on the objective stuff (shelf, orals, step) anyway, and there will be their reward. The whole point is that EVERYONE puts in more effort!

And you SHOULD be brutally honest. Just not on an evaluation that comes 14 days after the infraction. Be honest with them now. Make it NOT about the grade, but behavior, attitude. Make it personal. Grading at the end is easy. You never see them again, its basically anonymous, and there is no repercussion for you. Evaluating face to face is hard. Its uncomfortable. But it is MORE MEANINGFUL.

jdh71 said:

Though, I refuse to give anyone "honors" who I don't think is "honors" by whatever subjective criteria I espouse. To do otherwise is intellectually dishonest.

Click to expand...

Though, JDH, if you tell your students what your expectations are up front, and they know what and how they are being evaluated, then that's up to your discretion. To arbitrarily evaluate students on an arbitrary checklist they can't see or have never seen/heard before isn't fair. That's what drives students to ass-kissing and bus-throwing. Mostly because your arbitrary list isn't the same as the peds resident's list which isn't the same as the vascular attending's arbitrary list. The confusion leads the student to do whatever has worked before, rather than doing the medicine.

jdh71 said:

I would never start with giving "honors" to everyone. I heard the rationale, I just find it garbage. Almost every single student I deal with is completely appropriate for level of training. Rare are the honors students, and rarer yet are the students so bad they require a bad evaluation. Giving everyone high marks is stupid and demeans the value.

Click to expand...

Ok, most people aren't going to do what I suggest. That's fine. I don't expect anyone to change what they're doing. JDH has the confidence and experience to be vocal, though I know there are other people reading my post and are thinking the exact same thing. They might even be a little offended. This is difficult for most of the world to accept. It is going to be even harder for people ingrained in our current system. Worse, there is only a hand-full of good evidence for this working, and it isn't in medical school. Its brand new, and I do not forsee it catching on any time soon. Hell, I don't even know if it will work! But it has so far.


I've taken what psychology and business know and have applied it to medical education. I just see a problem, a problem of medical students who do the wrong things for the wrong reasons, residents who are angry about it, and yet everyone keeps doing what we've always done, assuming the players are broken, not the system.


The current mindset is "only those people who shine in a bad system are great people, and deserve honors." I like to think that everyone who has made it to their 3rd year of medical school (privileged or entitled as they may be) has the capacity to do great work. Its easy to get great people to do great work. Its hard to get middle-of-the-road people to do great work. I just believe its possible.

I guess what is comes down to is that I see my responsibility not as determine where this person is in their training now, but rather as it is my responsibility to motivate and improve them from wherever they are.

I've used this quote before:

I give all top grades for my residents unless they are totally awful (like 1-2 residents ever). I've never been in their position to deal with the work load so I think its unfair for us students to have an expectation for how much teaching, their clinical knowledge etc. I'll leave their evaluations for their superiors who have been where they are to really differentiate their performance.
We nominate best residents in each department so they do get their praise in other ways.

OveractiveBrain said:

Though, JDH, if you tell your students what your expectations are up front, and they know what and how they are being evaluated, then that's up to your discretion. To arbitrarily evaluate students on an arbitrary checklist they can't see or have never seen/heard before isn't fair. That's what drives students to ass-kissing and bus-throwing. Mostly because your arbitrary list isn't the same as the peds resident's list which isn't the same as the vascular attending's arbitrary list. The confusion leads the student to do whatever has worked before, rather than doing the medicine.

Click to expand...

I don't think my list is that much different than anyone else. Staff and myself all seem to recognize the same exceptional students. And it has nothing to do with "kissing" ass

Ok, most people aren't going to do what I suggest. That's fine. I don't expect anyone to change what they're doing. JDH has the confidence and experience to be vocal, though I know there are other people reading my post and are thinking the exact same thing. They might even be a little offended. This is difficult for most of the world to accept. It is going to be even harder for people ingrained in our current system. Worse, there is only a hand-full of good evidence for this working, and it isn't in medical school. Its brand new, and I do not forsee it catching on any time soon. Hell, I don't even know if it will work! But it has so far.

the minds who created the problem cannot be the ones to fix it, for they see only their error and not the solution​

I've taken what psychology and business know and have applied it to medical education. I just see a problem, a problem of medical students who do the wrong things for the wrong reasons, residents who are angry about it, and yet everyone keeps doing what we've always done, assuming the players are broken, not the system.

Putting good people into bad systems makes bad results. ​

The current mindset is "only those people who shine in a bad system are great people, and deserve honors." I like to think that everyone who has made it to their 3rd year of medical school (privileged or entitled as they may be) has the capacity to do great work. Its easy to get great people to do great work. Its hard to get middle-of-the-road people to do great work. I just believe its possible.

I guess what is comes down to is that I see my responsibility not as determine where this person is in their training now, but rather as it is my responsibility to motivate and improve them from wherever they are.

I've used this quote before:

Treat a man as he is, make him worse.
Treat him as what he could be, make him what he should be​

Click to expand...

Part of my disconnect here is that I wasn't then, nor am I to this day, motivated by getting the best grade, doing "better" than my classmates, or making other people like me. I think that is co-dependent nonsense. And I think telling everyone they are a unique and pretty flower is feeding into the bull**** entitlement attitude of so many medical students. Most students are simply average. And when they get that through their heads they'll stop trying so hard in ineffectual ways.

jdh71 said:

I don't think my list is that much different than anyone else. Staff and myself all seem to recognize the same exceptional students. And it has nothing to do with "kissing" ass



Part of my disconnect here is that I wasn't then, nor am I to this day, motivated by getting the best grade, doing "better" than my classmates, or making other people like me. I think that is co-dependent nonsense. And I think telling everyone they are a unique and pretty flower is feeding into the bull**** entitlement attitude of so many medical students. Most students are simply average. And when they get that through their heads they'll stop trying so hard in ineffectual ways.

Click to expand...

(And i mean this in a good way), You were a special flower. There are too few of you, and too many of them. Im trying to find a way to bring the curve a little more towards the top end...

Though I do feel you on the potential side effect in bold. As hard as I try to be objective and teach the students to be better, the entitlement thing really nags on me. Maybe its just observer bias, but I feel less awful with my med students, running it under the new method. Then again, maybe I just got lucky so far...

smq123 said:

I think giving everyone Honors, off the bat, is a little disingenuous. It ignores the few students that, arguably, should NOT be doctors. And before you say anything, trust me, they exist.

Click to expand...

unless you fail them they will still be doctors even if they dont get honors