how do you compare the competitiveness of these students??

AJ2000 · Dec 29, 2005

Lets say we have student A and B. A goes to a top 15 med school with no preclinical grades and no class ranking. He/she scores a 250 on boards. Then we have student B, goes to a top 15 school with preclinical grades (lets say Honors/Pass/Fail). Student B does not honor any classes (lets say they get just below honors for each exam), but they score a 250 as well. All other aspects of the application are equal.

Are residency committees going to assume student A would have done well if there were grades and therefore give them the benefit of the doubt?

Just curious, thanks.

cyanocobalamin · Dec 29, 2005

AJ2000 said:
Lets say we have student A and B. A goes to a top 15 med school with no preclinical grades and no class ranking. He/she scores a 250 on boards. Then we have student B, goes to a top 15 school with preclinical grades (lets say Honors/Pass/Fail). Student B does not honor any classes (lets say they get just below honors for each exam), but they score a 250 as well. All other aspects of the application are equal.

Are residency committees going to assume student A would have done well if there were grades and therefore give them the benefit of the doubt?

Just curious, thanks.

All schools have different systems. Some seem to give a lot of honors, others are very stingy. Even schools without grades like mine still have to submit the mspe on our behalf (aka dean's letter) which has narrative evaluations which speak to how one did in their clinical years. Even here there is variation - some put the comments in word-for-word while others are simply excerpts. From what I know some programs look at whatever grading system a school utilises and then arbitrarily assigns an academic competitiveness score maybe on a 1-5 or 1-10 scale. This is of course a holistic, subjective score.

You mention 'preclinical classes.' I believe those are one of the lowest factors on residency director's lists. They care more about clincial performance, generally. Maybe path and rads may care more about preclinical. Clinical honors tends to be a capricious and somewhat arbitrary event IMHO. You click with some attendings and others, well...I think the success to doing well is to anticipate exactly what your attending wants and then do that without being asked.

DOCTORSAIB · Dec 29, 2005

cyanocobalamin said:
I think the success to doing well is to anticipate exactly what your attending wants and then do that without being asked.

This is very true. I've heard this from several of my ophtho resident friends.

Von Hohenheim · Dec 29, 2005

cyanocobalamin said:
I think the success to doing well is to anticipate exactly what your attending wants and then do that without being asked.

Yeah, your attending wants you to kiss butt. A whole lot of butt. :laugh:

cchoukal · Dec 29, 2005

I think people get misguided when schools say they "don't have grading and are only pass/fail." I mean, you still get a certain score on each test, and most schools still rank everyone, or at least put them in quartiles based on your summed exam performance. I suppose if you're at hopkins or harvard, you can just pass everyone and say to the world, "These people are all awesome," but at most schools, they still need a way to differentiate their good graduates from their bad. Believe it or not, this works to your advantage if you work hard and want a competitive specialty.

At my medical school, they advertised being pass/fail, but, again, you knew what your test scores were, and in any given semester you were either pass/fail/honors, so instead of a 5 tiered system (A-F) it was only 3 tiers, but it's still grading, isn't it? And for the Dean's letter, they printed a histogram of the class's performance and our place in it, I think for each course. Each year, they toyed with different ways to do this. I think some years they listed your overall quartile for years 1-2, other years they listed your rank based on total points accumulated. There was even a push for awhile to use a "key word sentence" at the end of the dean;s letter that would say, "So and so has a good/verygood/excellent/outstanding potential to excel in your program." Again, a 4-tiered system that looks an awful lot like A, B, C, or D.

So, I guess in sum, sure, pass/fail sounds good, but ultimately, when it comes time to compete for a residency spot, you'll be competing with your peers and graduates from other schools and your school is keeping track of your performance and is grading you in one way or another. And if you are smart and work hard and want to go into something competitive, you'll actually WANT there to be some form of grade or whatever to distinguish yuo from your peers.

cyanocobalamin · Dec 29, 2005

Some schools are really just pass/fail though. They don't put exam scores on the transcripts or on the mspe. For us they're confidential. It's just narratives. I guess the only thing that 'ranks' people at these schools is the 'rank' word, but that is pseudo-objective/mostly subjective. What I'm driving at is that a lot of 3rd year clerkship evaluation is very capricious and while anal-retentive premed types may think, oh, I can be so the captain of my ship, what it comes down to is simply trying your best - whatever will be will be.

The trend is definitely moving to P/F though or variants of it. Vanderbilt and Virigina are two more places that have recently gone this way.

Here's an article that generally shows no real harm in going to a P/F system. Most of the top schools are already there anyway, even Stanford (though being excellent and having a great matchlist every year was nearly put on probation a few years back, surprisingly, for poor facilities).

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=10353289&dopt=Citation

BKN · Dec 29, 2005

AJ2000 said:
Lets say we have student A and B. A goes to a top 15 med school with no preclinical grades and no class ranking. He/she scores a 250 on boards. Then we have student B, goes to a top 15 school with preclinical grades (lets say Honors/Pass/Fail). Student B does not honor any classes (lets say they get just below honors for each exam), but they score a 250 as well. All other aspects of the application are equal.

Are residency committees going to assume student A would have done well if there were grades and therefore give them the benefit of the doubt?

Just curious, thanks.

This is how I see it. When I get a dean's letter that is uninformative combined with a complete pass/fail grading system (all grades pass), I can't evaluate these pieces of evidence at all. A measure with no variance is not a measure.

I plug them into the formula as bottom 1/3 of their class. Yes, that's unfair to the better students from the school, but I didn't do it to them.

For the same reasons, the dean's letter and grades are actually a much smaller proportion of our formula than MLEs, SLORs and interviews. So it doesn't hurt the p/f students that much.

There is a price for opting out of competition.

cyanocobalamin · Dec 29, 2005

BKN said:
There is a price for opting out of competition.

I would argue more that there's a price for too much competition which really kills the spirit of collaboration and diminishes camaraderie. I think that's why the trend has been inexorably towards P/F. I've seen the atmosphere at P/F schools versus letter graded ones and the P/F students in general are more into learning for the sake of learning and not fretting about ooh, am I going to be in the top quintile for my exam in k-ology? There are many ways to distinguish yourself and to highlight just how unique you are. Most of my residency interviews have been about my unique characteristics and experiences - not about whether I can spout off the TCA cycle. I guess once you get over the first hurdle - the rest is about fit.

On the interview trail I have never been challeneged about my school's P/F status. One PD I interviewed with was less familiar our variant of it and I simply told her that most of our evaluation is narrative and on the dean's letter. It's 7 pages long. What really gets my goat is how many people that have interviewed me haven't bothered to look at any of my application. They are flipping through it as I'm talking to them.

FACS · Dec 29, 2005

cyanocobalamin said:
I would argue more that there's a price for too much competition which really kills the spirit of collaboration and diminishes camaraderie. I think that's why the trend has been inexorably towards P/F.

This is absolutely true. Many of the old gaurd just don't get it. Fortunately they'll soon wither and die.

deleted4401 · Dec 29, 2005

There's two parameters to be truly pass/fail.

1) No AOA
2) No one liner at the end of the MSPE

Not sure how many of the "P/F" schools have both of those in place. If they do, congrats, they've effectively killed any incentive to compete.

That being said, if I took an anatomy test and instead of a 45/50, or an A-, or a "high pass", all I got was a "P" no matter what how I did, I truly wouldn't work as hard. All people are different, and some people are truly just knowledge driven, but for me, if I didn't have some metric to know how I was doing, I wouldn't know whether to work harder or not. It felt good to ace something and it felt crappy to nearly fail.

If I couldn't tell the difference between performances, there's no way I'd now how I was doing. If my med school didn't honor those who just cleaned house (i.e. AOA), in my opinion, they cheapened the efforts of those that truly took it upon themselves to fulfill all the objectives. I didn't make AOA, but I do respect what it took to get there. My school used a modified grading scale (H, HP, P, C, F) - I agree, a thinly veiled A,B,C,D,F system - and it worked. It's not the grading scale ... it's the students in the system and the system itself.

And on a personal note, I took P/F classes in both high school and college. I did "just enough" in those courses. There ought to be a difference between a 70% and a 100% on an exam, and by not valuing that, I believe the bell curve moves to the left.

Finally, to bring it back to 3rd/4th year grading, most schools move from a purely meritocratic system for the basic sciences to one that is 1/3 to 2/3 subjective. And by subjective, I mean the faculty pretend it's objective, give you a rubric to reveal how they grade, and then dismiss it totally when grading students. Then, they throw in a shelf exam that doesn't correspond to what they taught you in lectures.

Someone said it - the best schools Harvard, Hopkins, whatever - can give you a "P" and you'll be fine. The rest of us need some metric to show that there is a difference between the top student and the worst student that nearly failed.

Later,
S

BKN · Dec 30, 2005

FACS said:
This is absolutely true. Many of the old gaurd just don't get it. Fortunately they'll soon wither and die.

The "old gaurd" (sic) = baby boomers, and we invented pass/fail. Now most of us, in Medicine at least, would like to do away with it. We aren't withering away, we just create clones. :laugh:

What you and cyano, as well as many gunners don't seem to get, is that it's not about the grades. That stopped the day you entered med school. It's about your obligation to your patients to be the best doctor that you can.

To be the best Doctor that you can, you need knowledge, the ability to synthesize and professionalism. Grades and tests are essential to evaluate the potential for all of those things. They also help you to avoid the natural laziness that SimulD referred to and all of us feel after a hard day in class or in practice.

Please remember, you are not in competition with others, you are in competition with yourself. And if you're not willing to do your best for your entire career, please do something other than medicine, other will step in and be better Docs.

BKN (once and future antigunner)

BKN · Dec 30, 2005

SimulD said:
There's two parameters to be truly pass/fail.

1) No AOA
2) No one liner at the end of the MSPE

Not sure how many of the "P/F" schools have both of those in place. If they do, congrats, they've effectively killed any incentive to compete.

S

From Dean's letters to my program, I'd estimate about 1/4 are devoid of any useful information. 1/2 of them require very careful reading to get the message, for example often a student has many high passes and honors, but when you look carefully at their grade distributions, it turns out that the majority of students got honors in the same courses.

Poety · Dec 30, 2005

Ha! So they will catch me with my little deviant tricks will they? hehe

I'm so "average" it almost hurts

BKN · Dec 30, 2005

Poety said:
Ha! So they will catch me with my little deviant tricks will they? hehe

I'm so "average" it almost hurts

No P, you're not.

My point is that nobody who makes it into Med school is. The choice to be a doctor is to use all of your gifts for others. I'm suggesting that we should use them to the best of our abilities.

Poety · Dec 30, 2005

Thanks BKN - and I agree, just to get INTO med school you have to be what? Top 15% of U.S.? Something silly like that

cyanocobalamin · Dec 30, 2005

BKN said:
What you and cyano, as well as many gunners don't seem to get, is that it's not about the grades. That stopped the day you entered med school. It's about your obligation to your patients to be the best doctor that you can.

To be the best Doctor that you can, you need knowledge, the ability to synthesize and professionalism. Grades and tests are essential to evaluate the potential for all of those things.

I am just arguing that since we don't have letter grades we are more willing to help each other out in learning things..and it has been a good experience. We work hard - but we as a group in general are a collaborative non-cutthroat bunch.

With grades and ranking one can only do better if they are better than their peers. By working with their peers they jeopardize their own rank. So that's what I mean by a 'poisoned' atmosphere at schools with an over-emphasis on rank and grades. I did an away rotation at an institution with letter grades and saw how there were so many more gunners than back home and how they didn't study together and didn't help each other learn the material. It felt strange to me. Everyone was obsessing over how they could get an 'a' in the rotation. My 2p.

OneStrongBro · Dec 30, 2005

BKN said:
when you look carefully at their grade distributions, it turns out that the majority of students got honors in the same courses.

Dr. BKN, would you elaborate on this comment. Do you mean that the majority of the "honor students" get honors in the 3 signature courses in medical school such as pathology, surgery, and internal medicine?

Since it is rare for one student to honor every class in medical school, you would assume that the there would be more variance for "honor students" in classes such as histology and psychiatry which tend to be hit or miss.

thanks

jennyboo · Dec 30, 2005

OneStrongBro said:
Dr. BKN, would you elaborate on this comment. Do you mean that the majority of the honor students get honors in the 3 signature courses in medical school such as pathology, surgery, and internal medicine?

I think he meant that suppose Joe, a student, got Honors in histology. You could then look at the information provided by the school which tells what percentage of students got honors in histology. If it's 10%, Joe was truly at the top of his class. If, however, Honors was received by 70%, it doesn't really mean Joe was at the top of his class. It was just that Histology at that particular school was graded easy. ;-)

BKN · Dec 30, 2005

OneStrongBro said:
Dr. BKN, would you elaborate on this comment. Do you mean that the majority of the "honor students" get honors in the 3 signature courses in medical school such as pathology, surgery, and internal medicine?

Since it is rare for one student to honor every class in medical school, you would assume that the there would be more variance for "honor students" in classes such as histology and psychiatry which tend to be hit or miss.

thanks

No, what JB said. In some schools with H/P/F or H/HP/P/F the proportion with honors in courses is very small in others, it's >1/2 the class. These are not necessarily the schools with the strongest reps. At least if the grade distribution is given, i can figure it out. Actually, I've gotten letters where the majority of the students grades are H and HP but a word descriptor identifies them in the bottom 1/4! The AAMC suggested format helps a little over 10 years ago, but it's still a struggle.

BKN · Dec 30, 2005

cyanocobalamin said:
I am just arguing that since we don't have letter grades we are more willing to help each other out in learning things..and it has been a good experience. We work hard - but we as a group in general are a collaborative non-cutthroat bunch.

With grades and ranking one can only do better if they are better than their peers. By working with their peers they jeopardize their own rank. So that's what I mean by a 'poisoned' atmosphere at schools with an over-emphasis on rank and grades. I did an away rotation at an institution with letter grades and saw how there were so many more gunners than back home and how they didn't study together and didn't help each other learn the material. It felt strange to me. Everyone was obsessing over how they could get an 'a' in the rotation. My 2p.

I understand your feelings and don't completely disagree. I went to a H/P/F school where the average entering GPA from college was the highest published in the Med School admission guide. Most of our class were gunners (not me, but that's another story). Perhaps we were better off with a three point scale then we would have been with 5.

But I've got to say a completely P/F system:
1. probably takes too much pressure off
2. If you have school with no classification possible even in to 1/3s, the PD must put undue emphasis on the MLEs.
3. I fear that some students, perhaps the majority will learn less than they might have otherwise.

BKN · Dec 30, 2005

Poety said:
Thanks BKN - and I agree, just to get INTO med school you have to be what? Top 15% of U.S.? Something silly like that

Worse than that. Think about it, 1/2 of high school grads go to college, about 1/4 of college freshman say they want to be be docs but only about 5% apply and 1/2? make it. Myy numbers may be a little out of date, I don't do Med school admissions any more. But .5*.05*.5, we're probably looking at the upper 5% of IQ*perserverence.

Poety · Dec 30, 2005

BKN said:
Worse than that. Think about it, 1/2 of high school grads go to college, about 1/4 of college freshman say they want to be be docs but only about 5% apply and 1/2? make it. Myy numbers may be a little out of date, I don't do Med school admissions any more. But .5*.05*.5, we're probably looking at the upper 5% of IQ*perserverence.

And today I was having an "I don't feel so smart day" (babies will do that to ya) THANKS BKN!! :laugh:

And to comment on the thread, I think that we are (luckily) moving toward looking at applicants as a whole - they're EC's, how vested they were in research, teaching, etc. At least for me, I think the other parts of my app stood out way more than my grades or board scores. Just my .02

AngryTesticle · Dec 31, 2005

As BKN alluded, I find many of the MSPE's to be quite generic and uninformative. I do see quite a few applications where the applicant has honored surgery and medicine. But when I see this, my ears perk up. At certain schools, and I won't mention which ones but some of them are your ivy-league caliber schools, it seems that like half of the students get honors in these rotations. I'm sorry but I take these honors grades less seriously in compared to students from schools such as my alma mater where only 10-15% of students get honors in these two major core rotations.

Ultimately, when I score an applicant, most of my score is based on meeting the person. So, to the OP, the interview can serve as a good tiebreaker. Is the person cool? The MSPE, for example, says that he/she is cool and easy to get along with...does my impressions match the profile on paper? Is the person really dedicated to the field (any dingbat can write some BS on a one-page personal statement)? Is this person a good fit for our particular program?

USMLE scores are an equalizer and I do pay quite some attention to them too.

cyanocobalamin · Dec 31, 2005

BKN said:
I understand your feelings and don't completely disagree. I went to a H/P/F school where the average entering GPA from college was the highest published in the Med School admission guide. Most of our class were gunners (not me, but that's another story). Perhaps we were better off with a three point scale then we would have been with 5.

But I've got to say a completely P/F system:
1. probably takes too much pressure off
2. If you have school with no classification possible even in to 1/3s, the PD must put undue emphasis on the MLEs.
3. I fear that some students, perhaps the majority will learn less than they might have otherwise.

I don't understand how this takes the pressure off that much. One still has to pass and to do so has to study an immense amount. But as stated the competition is not against your peers but for yourself and the knowledge that will allow you to become a better clinician (or researcher, educator, or administrator). As stated, in the end it's a all about you and how you can help your patients and I don't think that fundamentally changes P/F versus H/HP/P/MP/F or A/B/C/D/E.

We all still have to take steps and our BS average has been about 1/2 an SD above the national mean which compares favorably to many institutions which have letter grades. For EM which had been popular in the past we've had matches to some solid programs including Harbor/UCLA and Highland/Alameda County which are hard Californian matches coming from a non-Californian school.

BKN · Dec 31, 2005

cyanocobalamin said:
...I think the success to doing well is to anticipate exactly what your attending wants and then do that without being asked.

Cyano, I think we've had about as good a discussion about grading systems as we are going to.

Let me take exception to your success comment as well and see where that gets us.

Here I'm speaking for myself and my colleagues. Honors in our department is based on more than anticipating our wants and doing them without being asked. . .although that may be what it appears to be from the student's viewpoint.

We look for the following things in our EM MS4 rotation:
1. Does the student alert us immediately for an unstable patient, rather than doing a H&P? (Evidence of ability to prioritize and to recognize serious illness)
2a. Can the student generate a sensible provisional diagnosis, differential and diagnostic plan at the end of the H&P?
2b.Does she have an understanding of standard treatment, potential complications and controversies once the diagnosis is made.(Evidence of medical knowledge, synthesis and systems-based practice)
3. Does the student show up on time and work hard? (professionalism)
4. Does the student have good interpersonal and communication skills (maturity, ICS)
5. Does the student take on the right number of patients and regularly check for progress of workup so decisions can be made? (patient care).
6. Score on the posttest (medical knowledge again)
7. A formal case presentation at conference to all of the residents at the end of the month, based on the most interesting case seen. A literature search, powerpoint presentation, images, etc. are expected. (practice-based learning).
For me, the most important thing of all is
8. Is the student's primary concern the patient's well-being rather than that of faculty, consultants, system or themselves?

Yes, that may all boil down to keeping the faculty happy, but I think what keep us happy is evidence that the student is on his way to being a great doctor.

I do agree that there is a great deal of subjective judgement involved. But even though we each supervise students on different days, we usually find ourselves in agreement about a student's grade. That suggests to me that there is something to our system.

cyanocobalamin · Jan 1, 2006

Since I am flying to Chicago tomorrow I will answer this briefly.

During 3rd year orientation I was told that going forward unlike before everything would be subjective and that frequently there would be at least one rotation where we just might not click with the attending du mois. Like most everyone else we too have a framework for evaluation that is specialty specific based on different areas of review (for our own growth). But it's important to remember that students rotate through different sites and have different preceptors with different expectations and why I suppose we in confidence evaluate our preceptors as they evaluate us. Also, sometimes interactions are rather brief and this may be a + or a - depending on whether you impressed or made yourself seem like an imbecile at that particular moment. Medical knowledge for example is frequently assessed by a few pimping questions, like can you tell me about the triangle of Calot, e.g. - you either get 'em right or wrong. Maybe I'm on time every day and the one time I'm late because I'm stuck in traffic is when preceptor Z is actually paying attention and thus gives a poor rating for reliability. Thus, for these metrics it's still very holistic as to whether a student meet or exceeds expectations.

Some preceptors I have known will give everyone regardless of performance average ratings in every category. Others will give everyone superior marks in every category. The system is what it is and there's no reason why it should be any different. I just think it's important to recognize it for what it is though - an oftentimes capricious and imperfect system based on perception (which is one's own reality).

Back to my comment on anticipating attending wants..everyone likes to think they do things in a manner that's satisfactory and pretty good. A student who can anticipate this style of her attending will be golden and shine in her attending's eyes. Monet probably likes impressionistic paintings more than a Picasso. My 2p once again.

sophiejane · Jan 1, 2006

BKN said:
For me, the most important thing of all is
8. Is the student's primary concern the patient's well-being rather than that of faculty, consultants, system or themselves?

This is the only way I have found to always, always do the right thing on rotations. I guess it is possible to get yelled at for being late to noon conference or attending rounds (though I never have been), but if it was because I was taking care of a patient, I will never apologize for that, grade/eval/etc. be damned.

And in taking care of a patient, I include the 45 minutes I spent with a terminally ill 39 year old mother, holding her hand while she cried and told me about her kids. That's practicing good medicine, too.

What I've found is that every single attending I've come across is very much like BKN in his/her thinking and approach to teaching. Maybe I've been lucky (apparently I have been), but I have never felt like I had to feed anyone's ego. (Well, there was the one attending who was a racist jerk who I wanted to slap a few times, but I certainly never fed his ego for the sake of my grade).

In the end, I am getting 88-89 averages in all my 3rd year rotations so far (it's average shelf exam scores--in spite of reading a lot--that bring me down--my clinical grades are usually 90-95)...so, I won't "honor" in any of my rotations (though I apparently come as close as humanly possible without ever actually getting the H!!), and being in the dead center of my class with just above average board scores, I won't be a standout on paper, but I can guarantee I will have earned my stripes on the wards this year, whether it shows on my ERAS application or not.

That will help me sleep at night, if nothing else!

Poety · Jan 1, 2006

well said sophie

and just so you know, your preceptors will recognize this - as this is exactly what came up in my deans letter - "the patient comes first - always" so when they see it in you - you will be commended for it (I had NO idea they even said anything about it!)- and good for you!! I hope others in your class can learn from your devotion

BKN · Jan 1, 2006

sophiejane said:
This is the only way I have found to always, always do the right thing on rotations. I guess it is possible to get yelled at for being late to noon conference or attending rounds (though I never have been), but if it was because I was taking care of a patient, I will never apologize for that, grade/eval/etc. be damned.

And in taking care of a patient, I include the 45 minutes I spent with a terminally ill 39 year old mother, holding her hand while she cried and told me about her kids. That's practicing good medicine, too.

What I've found is that every single attending I've come across is very much like BKN in his/her thinking and approach to teaching. Maybe I've been lucky (apparently I have been), but I have never felt like I had to feed anyone's ego. (Well, there was the one attending who was a racist jerk who I wanted to slap a few times, but I certainly never fed his ego for the sake of my grade).

In the end, I am getting 88-89 averages in all my 3rd year rotations so far (it's average shelf exam scores--in spite of reading a lot--that bring me down--my clinical grades are usually 90-95)...so, I won't "honor" in any of my rotations (though I apparently come as close as humanly possible without ever actually getting the H!!), and being in the dead center of my class with just above average board scores, I won't be a standout on paper, but I can guarantee I will have earned my stripes on the wards this year, whether it shows on my ERAS application or not.

That will help me sleep at night, if nothing else!

Pick attendings that have seen your commitment to write your LORs. Although I may come across as a grades guy, nothing gets my attention more than a extreme patient advocate.

I suspect most PDs are the same.

how do you compare the competitiveness of these students??

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