Average midterm PGY1 evaluations in residency - should I be worried?

[throwaway118]

I'm currently in the middle of my PGY1 year as a psychiatry resident and have received my evaluations for 3 rotations so far (all psychiatry rotations). I had some difficulty adjusting to residency in the beginning but think I adapted well to the workflow about 2 months into intern year. My evaluations are very average (using the milestones rating scale with 1 being the level expected for an incoming intern and 5 being someone who has been in practice as an attending for several yrs) - in the beginning, I received mostly 1's, some 1.5's and 2's. For my most recent rotation, I am still getting mostly 1.5's and some 2's with a few 1's. I met with my PD who says this is typical - interns will get 1's and 2's, PGY2 will get 2's and 3's and so on.

However, I can't help but feel disheartened. Maybe it's just my ego talking but as someone who was a strong performer throughout undergrad and med school (honored most rotations, high board scores), being told I'm just average or performing as expected feels like a big blow. Should I be worried about these evaluations? Are residency evals just harsher/more honest than med school evals? If it matters, I'm not planning to do fellowship or academia. Any insight is appreciated.

---

Members don't see this ad.

 

[psychattending]

Milestones are program specific as they are a reflection of what each program is teaching in each year.

If your PD is telling you that you are doing fine, then don't worry. If you are unsatisfied with how well you are doing compared to your classmates, then push yourself harder (but stay healthy).

 

[OldPsychDoc]

However, I can't help but feel disheartened. Maybe it's just my ego talking but as someone who was a strong performer throughout undergrad and med school (honored most rotations, high board scores), being told I'm just average or performing as expected feels like a big blow. Should I be worried about these evaluations? Are residency evals just harsher/more honest than med school evals? If it matters, I'm not planning to do fellowship or academia. Any insight is appreciated.

"Average" and "as expected" are good. It's hard to move past the "gunner" mentality that got you into and through medical school--but there are no more grades, no more competitions. You aren't expected at all to be performing at level 3 & 4 milestones as a first semester PGY1.

 

[Ironspy]

The average psychiatry resident is average. Deep breaths

 

[Sushirolls]

If your PD says you are fine, then you are fine. When your PD says you aren't, then you worry.

Now you focus on being in competition with yourself only. Develop the behaviors you will use once you are out of residency. Seek out the challenging patients, cases when you can. Discern from attendings what they expect from you each rotation, and the ones that don't want a quick succinct presentation, take advantage of it. Give a nice long presentation with differential, ultimate diagnosis, and plan. Expand after that by asking them if they care if you verbalize your in depth thought process as to why those Dx/Plans, and if they have a critique.

You'll get more out of attendings by laying it out there what your thoughts/plans are and setting them up to simply say, "nah, look at it from this angle, and offer this treatment, and this is why/how I look at it." You'll learn more that way.

Simply put, aspire to be the doctor you would want to go to or your own family would want to see.

 

[Animal Mother]

I wouldn’t sweat it. All subjective and mostly meaningless. They are like 3rd year clinical rotation evals, only much less important.

 

[nexus73]

This all seems like worry for nothing. What do you think happens to psychiatrists with average residency evaluations?

 

[clausewitz2]

If you are getting 3+s as an intern on your milestone evaluations your evaluators don't really understand the milestone system in all likelihood

 

[Monocles]

If you are getting 3+s as an intern on your milestone evaluations your evaluators don't really understand the milestone system in all likelihood

Agreed! The milestones seem like an arbitrary way to keep track of progress for ABPN/ACGME anyway. I remember evals each year being like "well you're doing great as a pgy-[whatever], but the administration encourages us not to give numbers higher than the corresponding year, so you get a [rating same as pgy year]"

I stopped looking at the numbers on my evals. The written comments are more helpful anyway. Residency is about survival, so if you're "average" then you're doing it right.

 

[deleted957339]

God I hate milestones. Am I the only one? I guess I understand the theory behind them, but the rate at which I seem to be progressing at times seems like it has been decided in advance and only minimally influenced by my actual performance.

 

[Attending1985]

Undergrad and medical school prime you to compete and value performance as compared to others. Now that you’ve started your career that mentality will no longer serve you. It will drain you and make you preoccupied with yourself. A new mindset that values honing your skills and serving others is a more beneficial mindset that will benefit you in residency and beyond. You are no longer a student you are now “practicing medicine” something you’ll be doing for many, many years. I’m glad you have high standard for yourself but good work is much more important than impressing your superiors.

 

[bashir]

God I hate milestones. Am I the only one? I guess I understand the theory behind them, but the rate at which I seem to be progressing at times seems like it has been decided in advance and only minimally influenced by my actual performance.

When you say, "at times," you do mean all of the times, yes? If so, I couldn't agree more. It seems to be the least meaningful feedback system ever devised.

 

[splik]

the ACGME milestones, if used properly, are a much more specific, detailed, targeted, and measurable way of ourlining your competencies developmentally than what we had before. This means it is much easier for you to demonstrate how you meet said milestones. Your evaluations from rotations are heavily relied upon but they should not be the only thing relied up in order to assess your competency on various milestones. people (americans in particular) tend to overestimate their competency in relation to peers. but there is a 50% chance you are below average.

things in addition to your attending evaluations that are/can be taken into account include: evaluations/letters from nursing staff, from patients and family members, involvement in QI projects, publications worked on during residency, presentations at national meetings, involvement with local APA district branch and other advocacy efforts (e.g. NAMI), performance on the PRITE, your own reflective practice, your involvement in curriculum development etc.

Think about how much reading you have been doing. Most residents do not read sufficiently. Pick up K&S, the DSM, Stahl, Maudsley prescribing guidelines, and read through the 100 papers etc. Write good notes and come up with a decent formulation or at least give it a stab. know your patient's charts inside out. keep your signup updated. pre-empt next steps in clinical care. always been preparing for discharge. actively solicit feedback from your attendings. do CSVs to get feedback on your interviewing skills. ask for help when you need it.

If you feel disheartened, use that feeling as motivation to be the best you possibly can. for your patients.

also remember first impressions matter. your performance and attitudes during your first weeks and months of residency will impact how people see you throughout. each time you move onto a new rotation, expect that your new attendings will get the dirt on you. you said you had difficulty adjusting at the beginning so it not should come as a surprise that your evals are very average. your fate has been sealed. free yourself from caring what these people think of you, and instead work to be the best psychiatrist you can be so you earn a good reputation with patients and your colleagues when you start out in practice.

 

[Sushirolls]

I feel sorry for current residents. It sounds like the ACGME has just dumped a significant layer of bureaucracy upon them. Like most bureaucracy, good intentioned, but will only further serve to foster resident burn out as the rippling out of collateral damage ensues. Already it seems like these evaluation metrics are yielding to the pressures of Goodhart's Law.

Sadly, this same level of bureaucracy persists even beyond residency in the form of MOC and CMS induced meaningful use criteria (MUC).

 

[NontradCA]

I feel sorry for current residents. It sounds like the ACGME has just dumped a significant layer of bureaucracy upon them. Like most bureaucracy, good intentioned, but will only further serve to foster resident burn out as the rippling out of collateral damage ensues. Already it seems like these evaluation metrics are yielding to the pressures of Goodhart's Law.

Sadly, this same level of bureaucracy persists even beyond residency in the form of MOC and CMS induced meaningful use criteria (MUC).

At my place, the resident hears about this but it doesn’t add anything to our work or worries. The OP is an exception. These milestones are a burden to the PD and I’d wager that most residents don’t know or care about the details within them.

 

[Attending1985]

I feel sorry for current residents. It sounds like the ACGME has just dumped a significant layer of bureaucracy upon them. Like most bureaucracy, good intentioned, but will only further serve to foster resident burn out as the rippling out of collateral damage ensues. Already it seems like these evaluation metrics are yielding to the pressures of Goodhart's Law.

Sadly, this same level of bureaucracy persists even beyond residency in the form of MOC and CMS induced meaningful use criteria (MUC).

Yes why is it everytime something “innovative” in education comes along it is always bull**** that makes things worse. Milestones were just starting when I graduated. I was so happy to not have to deal with them.

 

[pbdoctor1]

The concern by the OP resident is not unfounded because the new milestones can easily be "weaponized" by a program directors to threaten a "problem resident". Enough of a drop in milestone below passing can lead to non-contract renewal or reason for termination. One tactic is if a PD "encourages" faculty to down grade residents and pretends it is a "normal" part of the new ACGME milestones. The excuse stems from subjectively "mandating" early training years be scored lower to reflect ACGME suggested trends (there is none) to show a "more accurate" timeline of improvement in following years. The reality is that the lower scores can be used as a way to show lack of improvement to meeting milestones in subsequent future evaluations and pose a risk for residents to fail out. It rarely shows a resident score well on milestones early on and suddently fail milestones later on. This is especially concerning regarding the professionalism milestone which can be highly subjective and problematic if an attending or worse a PD dislikes a resident. This is another method of legal protection for residencies to document in case a "problem resident" acts out or burns out.

While most residencies are professional and don't do this, it is a common tactic in some malignant programs. It is more of the same ways to maintain obedience and monitor behavior that is way too easily abused by any residency. Any program director can dictate subjective milestone scores arbitrarily low and use it to threaten a resident to stay in a program (if they need them) or kick them out. Either way it's a way to provide a legally documented paper trail and way too easily abused should it become necessary. It is reasonable for any resident to be worried. Our thoughts and prayers this tactic doesn't become more prevalent in other residencies and lead to more burnout.

 

[hamstergang]

The concern by the OP resident is not unfounded because the new milestones can easily be "weaponized" by a program directors to threaten a "problem resident".

I don't see how this is any different than with normal evals. In general, in fact, I don't see how the milestones affect residents any differently than the prior evals.

 

[hallowmann]

I find the milestones virtually useless. Half of the evaluators don't even know how to use it, and those who do rarely grade outside of your expected "level". Sure it can be weaponized, but so could literally any type of evaluation.