P/F Clerkship Debate

[lt*@46Xg0YFv1@g^]

Currently at a T20 school where student body is pushing for PF clerkships to a relatively receptive admin. Was wondering what I should advocate for, as the ideal of PF clerkships sounds good but I am concerned about potential residency impacts as I am going into a surgery subspecialty?

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[Anakinmemer]

The true powerhouse schools like Harvard, Stanford, UCSF, Hopkins, Penn, Columbia p/f has no effect as everyone is assumed to be top tier. The lower ranked schools p/f obviously hurts the top performers and benefits the low performers. Anything in between is up to you to decide and it really comes down to whether you actually think you will have first quartile clinical grades. Also consider the immense stress relief of not thinking about every single action you take and how it will affect your grade

 

[Esmolol]

Our school has pre-clinical PF and graded clerkships. Having gone through MS1-MS3 I'd say that I would love if it were the other way. Grades on clerkships, especially if 50% of the grade is based on clinical evaluations, are sometimes very random. For instance, how can you compare students who were on an intense cardiac surgery rotation in their surgery clerkship with students who drew the easy outpatient outside facility same day surgery...

 

[coffegroundemesis]

At a t5 p/f school. Life is good. However, it really depends on where your school is in terms of ranking. T20 is a bit vague. If it’s a bona fide t10, I think it can be great. If it’s more like at the bottom of t20, I am not so sure.

 

[operaman]

As noted above - hurts the top, helps the bottom, and probably neutral for everyone else. It basically makes S2 the only meaningful item in your application in terms of helping PDs determine how strong you really are. That’s an awful lot of pressure for one test and it comes rather late in school too. If your entire transcript says P and you bang out a 240 on S2, then you would be hard pressed to match competitive fields even coming from a top top school unless your home dept loved you and went to bat for you.

I would argue in favor of graded clerkships but perhaps find ways to make the grading a bit more objective and transparent. Some schools have gone to shelf only or shelf plus osce as a way to cut out the frustrating aspect of clinical evals being used for grades. Some schools have tried the milestone based grading but it’s always a colossal flop.

Personally I think shelf plus osce is a nice way to make it purely objective and gives you a chance to be evaluated and stratified fairly. Gives top students a reasonable shot at honoring everything, and also gives your app some additional data points beyond just S2. That way if you have a bad day and score a 240-250, you might have some other numbers to help make up for it.

 

[lt*@46Xg0YFv1@g^]

At a t5 p/f school. Life is good. However, it really depends on where your school is in terms of ranking. T20 is a bit vague. If it’s a bona fide t10, I think it can be great. If it’s more like at the bottom of t20, I am not so sure.

I think the school is a solid t15, probably approaching t10 (definitely in the next couple of years I'd say).

 

[lt*@46Xg0YFv1@g^]

I'm asking because I know there are a wide array of schools with PF clerkships that aren't necessarily T5s (like UCLA) . And also even though the core clerkships would become P/F, the sub-I's and electives would be ranked so you can show excellence in the specific speciality you are interested in (versus having to care about doing well in clerkships you have no intention of going into). But the emphasis on Step 2 seems like a lot - seems like a very complicated issue.

 

[Anakinmemer]

I'm asking because I know there are a wide array of schools with PF clerkships that aren't necessarily T5s (like UCLA) . And also even though the core clerkships would become P/F, the sub-I's and electives would be ranked so you can show excellence in the specific speciality you are interested in (versus having to care about doing well in clerkships you have no intention of going into). But the emphasis on Step 2 seems like a lot - seems like a very complicated issue.

The problem with 4th year grades is that many schools give auto honors unless you are really bad so I don't know if programs weight an honors 4th year that heavily, what's more important is the LOR that can come from it.

 

[Esmolol]

The problem with 4th year grades is that many schools give auto honors unless you are really bad so I don't know if programs weight an honors 4th year that heavily, what's more important is the LOR that can come from it.

Waaaaaiitttt.... 4th year grades matter?!?!?!

 

[Putkernerinthehall]

That way if you have a bad day and score a 240-250, you might have some other numbers to help make up for it.

So now 250 is a "bad day" Step 2 score?

 

[operaman]

So now 250 is a "bad day" Step 2 score?

Well by percentiles it’s roughly on par with a 235-240 S1 which is fairly below average for matched applicants to top fields. Many programs in these fields would even auto screen at this range.

It’s going to take a couple cycles for the S2 numbers to settle out since the old data include a lot of people like me who took S2 with about 8 hours of dedicated prep time because it didn’t matter to us.

 

[Esmolol]

Is this going to be another thread about "Is the 260 the new average?"

 

[operaman]

Is this going to be another thread about "Is the 260 the new average?"

Nah that’s pretty much a given at this point, at least as far as average for competitive fields goes where their S1 avg was 250ish.

Last charting outcomes for my field of ent showed average s1 of 250 and s2 of 257. That’s a for a field where s2 had long been regarded an unnecessary for those with high s1. I’m sure we will see a small bump in those numbers when people start actually studying for s2. Ortho was right up there too.

 

[coffegroundemesis]

I'm asking because I know there are a wide array of schools with PF clerkships that aren't necessarily T5s (like UCLA) . And also even though the core clerkships would become P/F, the sub-I's and electives would be ranked so you can show excellence in the specific speciality you are interested in (versus having to care about doing well in clerkships you have no intention of going into). But the emphasis on Step 2 seems like a lot - seems like a very complicated issue.

For competitive specialties, LOR’s and research and then clear the S2 screener threshold. p/f clerkship is actually not a bad thing, because more likely than not you will miss honors, and if you were to go to a p/f, you have one less bar to clear.

 

[lt*@46Xg0YFv1@g^]

For competitive specialties, LOR’s and research and then clear the S2 screener threshold. p/f clerkship is actually not a bad thing, because more likely than not you will miss honors, and if you were to go to a p/f, you have one less bar to clear.

Never thought about it like this but you're right. Tiered clerkships only really benefit you if you get all honors. One of the main reasons for removing clerkships at our school is that there's an issue with AOA where the top 20% that gets into AOA on average does 1.3 points better on OSCEs than the next 20%, which results in a difference of one more Honors vs one more High Pass. Pretty much everyone gets 3-4 HP and 2-3 Honors in a random order because clerkship grading is super random, so AOA doesn't mean anything more than just being a little more lucky. So it seems that PF clerkships are the way to go, since the massive stress reduction outweighs the tiny chance that you'll be one of the 3-5 people a year who get all honors. And as you said, it's one less thing to keep track of (and arguably the one thing you have the least control over compared to research and Step 2).

 

[ChordaEpiphany]

The true powerhouse schools like Harvard, Stanford, UCSF, Hopkins, Penn, Columbia p/f has no effect as everyone is assumed to be top tier. The lower ranked schools p/f obviously hurts the top performers and benefits the low performers. Anything in between is up to you to decide and it really comes down to whether you actually think you will have first quartile clinical grades. Also consider the immense stress relief of not thinking about every single action you take and how it will affect your grade

Really depends on how grades are structured. A faulty grading system can be far worse than P/F for top performers. My school has P/HP/H, but very few people get H (~15-25%) and very few get P (~5-10%). So to any competitive PD looking at the MSPE, HP doesn't really inspire much confidence since all it says it that you weren't in the bottom 5-10%. Again, this would be fine, but then you look at how H's are distributed. It's 75% subjective evals, 20% shelf, 5% random assignments or SP exams. Sometimes you get stuck with attendings who simply don't believe in giving Honors. Sometimes you get an evaluation back from someone who doesn't understand the grading system and thinks they are giving you a good eval, but are actually skewering you.

People quickly realized that the only way to succeed was to game the system. People who perform best curate a large group of friends who exchange information about which attendings/residents give good evals and which site placements allow for lots of shelf study time. Students are calling out sick when they're on service with a bad attending. They experience "technical difficulties" when sending evaluation forms to attendings they didn't like. They lie about the number of days they worked with people to skew the weighting of their evaluations. It's a mess. You can influence your evaluations with good performance, but it's nowhere near a good enough system to ensure success without being a little shady about it.

IMO P/F clerkships will inevitably result in people slacking on clinical duties and spending most of their effort on step 2 prep, research, etc... But for the students, it's likely to be a huge bonus as it won't hurt most and will allow for you to stand out in other ways given the extra time you won't have to spend on BS (see above).

 

[coffegroundemesis]

People quickly realized that the only way to succeed was to game the system. People who perform best curate a large group of friends who exchange information about which attendings/residents give good evals and which site placements allow for lots of shelf study time. Students are calling out sick when they're on service with a bad attending. They experience "technical difficulties" when sending evaluation forms to attendings they didn't like. They lie about the number of days they worked with people to skew the weighting of their evaluations. It's a mess. You can influence your evaluations with good performance, but it's nowhere near a good enough system to ensure success without being a little shady about it.

This is so screwed up. Yeah PF makes this completely go away. Didn’t care who would evaluate me at all.

 

[deleted1095841]

Clinical grades encourage some amusing behaviors:
1. Students asking questions with a long preface to showcase what they already know.
2. Students showing inexplicable delight in doing non-educational scut work and begging for more.
3. Students fighting over who gets to fetch PPE for the team (when going to see patients with contact precautions/isolation) and who gets to hold beverages and folders/bags for more senior team members.
4. Students bringing treats for the team (e.g. donuts, cookies) on the first day of rotations.

 

[Dr G Oogle]

Grades and test scores are imperfect and a single mark doesn’t reflect the ability of the student, but multiples grades and scores over 2-3 years certainly reflect a pattern of ability. There needs to be some objective way to evaluate students for residency, otherwise it will be next to impossible to measure adequacy for residency preparedness. Step 2 will gain more importance, until someone complains and then it too will be P/F, and research and school rank will then be objective metrics. Students get in to high ranked schools on objective criteria of achievement, but doesn’t mean that that translates into being a competent doctor. And my experience with med student research is basically that they just want their name on a paper and some people are willing to do that. I’ve been asking every med student applying for both obgyn and urology specific questions about research on which they are first author (or any author for that matter) and maybe 1 in 5 can provide any evidence that they actually did and understand the research and of those maybe 10% is actually meaningful research. And research is a poor measure of ability as a physician.

TLDR: p/f for clerkships is a bad idea

 

[Putkernerinthehall]

Never thought about it like this but you're right. Tiered clerkships only really benefit you if you get all honors. One of the main reasons for removing clerkships at our school is that there's an issue with AOA where the top 20% that gets into AOA on average does 1.3 points better on OSCEs than the next 20%, which results in a difference of one more Honors vs one more High Pass. Pretty much everyone gets 3-4 HP and 2-3 Honors in a random order because clerkship grading is super random, so AOA doesn't mean anything more than just being a little more lucky. So it seems that PF clerkships are the way to go, since the massive stress reduction outweighs the tiny chance that you'll be one of the 3-5 people a year who get all honors. And as you said, it's one less thing to keep track of (and arguably the one thing you have the least control over compared to research and Step 2).

Don't pre-clerkship grades also factor into AOA?

 

[MDMechEngr]

Don't pre-clerkship grades also factor into AOA?

It certainly does at many schools.

 

[Kierkegaard's Bud]

It certainly does at many schools.

It does if it’s graded, not the case at many schools.

 

[ChordaEpiphany]

Clinical grades encourage some amusing behaviors:
1. Students asking questions with a long preface to showcase what they already know.
2. Students showing inexplicable delight in doing non-educational scut work and begging for more.
3. Students fighting over who gets to fetch PPE for the team (when going to see patients with contact precautions/isolation) and who gets to hold beverages and folders/bags for more senior team members.
4. Students bringing treats for the team (e.g. donuts, cookies) on the first day of rotations.

Yup. I was certainly guilty of 2 early in my 1st rotation. Quickly put myself in the residents' shoes and realized no one actually wanted that. Just make yourself available and don't complain if scut comes your way. There's a fine line between "I'm available to do a task" vs. "find me a task to do." The latter is more work for no reason for everyone.

Though I'm still guilty of some variation of 1 with attendings, and I think it's at least a little necessary. Certainly strategic questions get better evals in my experience. I don't ask things I don't know unless it leads us down a path where I can contribute to the conversation. If it's day 3 of medicine and I've had 2 COPD patients and read extensively on management vs. 0 diverticulitis patients and I only know a few factoids from step 1, I'm not asking anything about diverticulitis.