Is it just me or is third grading a incredibly flawed system?

[sliceofbread136]

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Biggest thing third year had taught me is how to successfully engage in friendly banter. 99% of attendings have no objective criteria for grading so when they decide they just shrug and either think "who the heck was this person again?", or "this guy was kind of cool, I'll give him honors". It seems like there must be some sort of better way...

Typed on phone excuse errors please

 

[cbrons]

Yep that is pretty much how it is

 

[TBV]

Gotta say the double edged sword of being URM is they'll know exactly who I am, but better not F it up I suppose because they'll know exactly who I am.

 

[PL198]

what is your alternative

 

[PhillyMed777]

what is your alternative

make the majority of the clerkship grade come from shelf.
minority from hospital/clinic stuff, but enough so that you arn't enouraged to slack off.
like 75% shelf, 25% hospital

 

[Moko]

The current system is subjective and frustrating, but this is how evaluations in the real world will be when we are residents, fellows, and eventually attendings. A purely objective grading schema (e.g. one in which clerkship grades are determined solely or even mostly by shelf scores) would not sufficiently take into account people's character, interpersonal skills and critical thinking skills that are equally as (if not more) important in medicine.

Granted, there is a lot of luck involved when it comes to any individual evaluator, e.g whether they know how to provide useful feedback / have clashing personalities / consistently give everyone glowing undeserved praise, etc. But, once all the comments are aggregated, these individual variations average out and it should become clear which students consistently performed well vs. who just skated by.

Getting a mediocre and non-insightful evaluation from one evaluator? That can be from bad luck.

But if someone is consistently getting these average comments from multiple evaluators, then it would be foolish to continue chalking it up to bad luck alone. That should be a wake-up call that there are underlying problems that need to be fixed (whether it be improving one's knowledge base, being a better team player, or learning better interpersonal skills). JMT

 

[PhillyMed777]

A purely objective grading schema (e.g. one in which clerkship grades are determined solely or even mostly by shelf scores) would not sufficiently take into account people's character, interpersonal skills and critical thinking skills that are equally as (if not more) important in medicine.

Some-to-many folks can fake/force character and interpersonal skills. It's the only way some of the people in my class could get into medical school. It's the only way some of those people get good clinical evaluations.
My attendings rarely watch me take a history/pe, when I first meet the patient. They never see what kind of interpersonal skills I have or don't have with patients during this most important interaction.
What if the one rotation you get a bad evaluation from ("out of bad luck") happens to be the field you want to persue? I'll give you a hint. It looks really bad
Medicine is disappointing, in that the level of critical thinking is extremely low. Things are being checklisted and people follow guidelines.

I do agree however, that a pattern of bad or mediocre comments is telling.
At my school it doesn't even matter. The people who did well in the first 2 years, continue to do well in clinical years.

 

[aafisahar]

The current system is subjective and frustrating, but this is how evaluations in the real world will be when we are residents, fellows, and eventually attendings. A purely objective grading schema (e.g. one in which clerkship grades are determined solely or even mostly by shelf scores) would not sufficiently take into account people's character, interpersonal skills and critical thinking skills that are equally as (if not more) important in medicine.

unless you are going for fellowship, i doubt residency evals mean much other than work on improving and don't get fired. if you are done after residency, your "educators" can go pound sand.

 

[psychMDhopefully]

Yep that is pretty much how it is

Well im screwed

 

[cbrons]

Some-to-many folks can fake/force character and interpersonal skills. It's the only way some of the people in my class could get into medical school.

Guess what? Faking empathy, compassion, attentiveness.. that can actually be very important in medicine.

Most normal people dont have sympathy for a slovenly, non-compliant 400 lb 100-pack/year smoker on their 3rd admission with acute decompensated heart failure. But in the age of PressGaney, you damn well better seem like you care.

Similar examples with interactions with admin and nursing staff can also be considered.

Sent from my SM-N910P using SDN mobile

 

[Moko]

Some-to-many folks can fake/force character and interpersonal skills. It's the only way some of the people in my class could get into medical school. It's the only way some of those people get good clinical evaluations.
My attendings rarely watch me take a history/pe, when I first meet the patient. They never see what kind of interpersonal skills I have or don't have with patients during this most important interaction.
What if the one rotation you get a bad evaluation from ("out of bad luck") happens to be the field you want to persue? I'll give you a hint. It looks really bad
Medicine is disappointing, in that the level of critical thinking is extremely low. Things are being checklisted and people follow guidelines.

I do agree however, that a pattern of bad or mediocre comments is telling.
At my school it doesn't even matter. The people who did well in the first 2 years, continue to do well in clinical years.

Agree with your points, but to offer some counterpoints:

- There's a lot of pretending in the real world as well 🙂

- Patients often do mention positive interactions that they had with students/residents to the attending. So if a student is consistently going above and beyond for patients, someone should eventually take notice.

- Someone getting a pass / high pass in their desired field doesn't look great, but most people will also do electives and Sub-I's / Aways prior to applying. So for most people who operate at a Honors level (whatever that means) but were just 'unlucky', they would likely do better on their sub-i/aways/electives and other rotations, which could signal that the lower grade was a fluke. The current system's not perfect, but it's still better than the alternative imo.

 

[lymphocyte]

what is your alternative

One observed clinical encounter with a complicated patient--everything from the initial evaluation, work-up, and then proposed plan of care, with comments reflecting communication, conveyed empathy and professionalism. That's what our school does and it works pretty well. Eats up only about 45 minutes worth of time from the consultants or registrars. Any other comments are gravey.

 

[Southplains]

One observed clinical encounter with a complicated patient--everything from the initial evaluation, work-up, and then proposed plan of care, with comments reflecting communication, conveyed empathy and professionalism. That's what our school does and it works pretty well. Eats up only about 45 minutes worth of time from the consultants or registrars. Any other comments are gravey.

I'm assuming you're in a system outside the US by your use of registrars, but we have that in our 3rd year clinicals as well. Each rotation essentially has three components: subjective evaluations from attendings/residents, objective exam taken at the end of rotation, and a standardized patient experience that is recorded, observed and graded by faculty. How each component is weighted varies from school to school.

 

[lymphocyte]

I'm assuming you're in a system outside the US by your use of registrars, but we have that in our 3rd year clinicals as well. Each rotation essentially has three components: subjective evaluations from attendings/residents, objective exam taken at the end of rotation, and a standardized patient experience that is recorded, observed and graded by faculty. How each component is weighted varies from school to school.

Australian. But I did several Sub-I's in the US at some well known institutions. I was shocked at the range of quality in third years, which went from "Can't do a proper neuro exam" to "I'll put in the next chest tube." Very neat experience.

We rarely have attending evaluations for the reasons mentioned above (unless you were exceptionally good or bad). But we also don't have competitive internship allocation, so evaluations are only for self-improvement. All that matters are objective exams and so-called long cases (observed patient encounters--not standardised but allowances made for complexity).

 

[neusu]

As a third year student, I was incredibly frustrated with the system of grading. You are absolutely correct, it is subjective and mostly based on how well you get along with the group. For those who are not particularly political, it can be difficult. Even so, the grading method is actually rather important. The evaluations you will have throughout the remainder of your career are based on similar criteria. Learning to excel in this environment is important.

What I would propose, is prior to third year, having the administration make it transparent that the grading is subjective. Provide a framework for success for those who feel disingenuous in that environment, and allow for coaching and mentoring with check-ins to ensure students do not fall behind. The phrase "fake it until you make it" applies not only to your clinical skills confidence, but also your interpersonal relations with the team. Pandering to the attending and residents who will be evaluating you may feel fake, but after enough encounters it becomes second nature. The hospital and clinic are professional work environments. Interacting with the others by the standard set of subjective rules is something new to most students, and the third year grading system reflects how well you integrate in to that environment.

 

[TBV]

Guess what? Faking empathy, compassion, attentiveness.. that can actually be very important in medicine.

Most normal people dont have sympathy for a slovenly, non-compliant 400 lb 100-pack/year smoker on their 3rd admission with acute decompensated heart failure. But in the age of PressGaney, you damn well better seem like you care.

Similar examples with interactions with admin and nursing staff can also be considered.

Sent from my SM-N910P using SDN mobile

I am going to have so much trouble with this 🙁

 

[NickNaylor]

But if someone is consistently getting these average comments from multiple evaluators, then it would be foolish to continue chalking it up to bad luck alone. That should be a wake-up call that there are underlying problems that need to be fixed (whether it be improving one's knowledge base, being a better team player, or learning better interpersonal skills). JMT

Exactly. And frankly, once you get into residency the subjective evaluations of you by attendings and your peers will matter that much more. Yes, you will have a "shelf" equivalent which may matter from a lot to very little, but you will also be getting feedback based on attendings' comments of you. Nearly all of the time during my biannual review with my PD was discussion of the comments by people who had supervised me. My scores on the in-service exam were a passing comment.

There is significant variance in one evaluation to another, but they can form an overall picture which can often reveal a trend.

 

[PL198]

from what I hear at most schools, a majority of students honor so sometimes idk what people are complaining about. if 3/4 of your class honors then if anything the grading should be harder, not less subjective, which pretty much implies easier.

 

[mcloaf]

from what I hear at most schools, a majority of students honor so sometimes idk what people are complaining about. if 3/4 of your class honors then if anything the grading should be harder, not less subjective, which pretty much implies easier.

15% of my class is allowed to honor any given rotation, kind of frustrating to think I'll be applying against kids from schools where you basically get an H for showing up on time and not killing anybody. That being said, I think if you're generally a nice person and reasonably competent you'll come out ok overall in spite of the subjectivity of the grading.

Similar examples with interactions with admin and nursing staff can also be considered.

Hmm, are you implying that my profuse thanks to the PA student who told me I could cause foot drop by applying like 0.25lb of weight resting my hand on the patient's leg for a minute in the OR was less than genuine?

 

[alpinism]

Ideally 3rd year would involve more objective clinical criteria rather than just increasing the percentage of the shelf grade.

Ability to come up with differentials, diagnostic tests, treatment plans, etc...

 

[PhillyMed777]

I think its 1 out of 5 Honor at my school.
Basically the approach I've taken is to be a little spineless . Let anyone say anything to you no matter how bad, but never say anything bad myself. The most draining part of 3rd year is pretending to care about things you don't care about. And my smile muscles. Boy are they sore. They need good rest this weekend.

 

[TooMuchResearch]

Back in my day, third grade was hard. Recess. Cursive. Gym class. You young people don't know how easy you have it.

 

[PL198]

I've heard way more scores where > 50 % honor than where 1 in 5 is common. Like mcloaf said a lot of schools give you a HP just for breathing and then honors if you're on time

 

[NickNaylor]

I've heard way more scores where > 50 % honor than where 1 in 5 is common. Like mcloaf said a lot of schools give you a HP just for breathing and then honors if you're on time

At my institution, 40-50% of students honored any one rotation (we saw this data prior to starting the year). The reality was that the shelf for the rotation essentially determined your score as most - though not all - people did very well on their clinical evals.

The gut shot of this is that our dean's letter includes the distribution of grades for each rotation, so programs - assuming they actually look at that data - know what's going in terms of grade inflation.

 

[PL198]

At my institution, 40-50% of students honored any one rotation (we saw this data prior to starting the year). The reality was that the shelf for the rotation essentially determined your score as most - though not all - people did very well on their clinical evals.

The gut shot of this is that our dean's letter includes the distribution of grades for each rotation, so programs - assuming they actually look at that data - know what's going in terms of grade inflation.

just because that information is included doesn't mean people read it. I doubt programs actually take enough time to look at the grade distributions for each candidates school

 

[PL198]

take a step back and think about why grade inflation happens. because it works.

 

[PhillyMed777]

take a step back and think about why grade inflation happens. because it works.

Then the solution to this is for everyone to grade inflate. Done.

 

[tantacles]

I think its 1 out of 5 Honor at my school.
Basically the approach I've taken is to be a little spineless b****. Let anyone say anything to you no matter how bad, but never say anything bad myself. The most draining part of 3rd year is pretending to care about things you don't care about. And my smile muscles. Boy are they sore. They need good rest this weekend.

This is the truth. The best eval you could get, in short form, is "works hard, doesn't complain."


Large dogs

 

[Anicetus]

As a third year student, I was incredibly frustrated with the system of grading. You are absolutely correct, it is subjective and mostly based on how well you get along with the group. For those who are not particularly political, it can be difficult. Even so, the grading method is actually rather important. The evaluations you will have throughout the remainder of your career are based on similar criteria. Learning to excel in this environment is important.

What I would propose, is prior to third year, having the administration make it transparent that the grading is subjective. Provide a framework for success for those who feel disingenuous in that environment, and allow for coaching and mentoring with check-ins to ensure students do not fall behind. The phrase "fake it until you make it" applies not only to your clinical skills confidence, but also your interpersonal relations with the team. Pandering to the attending and residents who will be evaluating you may feel fake, but after enough encounters it becomes second nature. The hospital and clinic are professional work environments. Interacting with the others by the standard set of subjective rules is something new to most students, and the third year grading system reflects how well you integrate in to that environment.

Political? Easy. You're talking to a person making under 150k a year: be a democrat. If you're talking to an attending making over 250k a year? Be a republican.

 

[WilliamofOckham]

I think its 1 out of 5 Honor at my school.
Basically the approach I've taken is to be a little spineless b****. Let anyone say anything to you no matter how bad, but never say anything bad myself. The most draining part of 3rd year is pretending to care about things you don't care about. And my smile muscles. Boy are they sore. They need good rest this weekend.

You've heard of the term "resting b**** face", I presume? Well, I've perfected my resting contemplative face, and that was was definitely helpful in M3.