We all know clerkship grading is highly variable, but I hadn't seen it quantified before:

[NickNaylor]

---

Members don't see this ad.

As a now-faculty that evaluates students, we are given clear, narrative descriptions of what each grade "means." As long as you've had enough contact with a student, this makes grading pretty easy and, theoretically, consistent. One thing I've found, however, is that on psychiatry grade inflation is rampant. I grade pretty true to the descriptions provided to us and eventually discovered that I was giving grades much lower than what other faculty give. I was told by one of my faculty colleagues that the general expectation seems to be to give the next grade up from whatever you think the student actually earned. Lol, no thanks.

 

[efle]

As a now-faculty that evaluates students, we are given clear, narrative descriptions of what each grade "means." As long as you've had enough contact with a student, this makes grading pretty easy and, theoretically, consistent. One thing I've found, however, is that on psychiatry grade inflation is rampant. I grade pretty true to the descriptions provided to us and eventually discovered that I was giving grades much lower than what other faculty give. I was told by one of my faculty colleagues that the general expectation seems to be to give the next grade up from whatever you think the student actually earned. Lol, no thanks.

Wow only a couple years into attending and you've already forgotten how it would feel to be a med student on your service

 

[NickNaylor]

Wow only a couple years into attending and you've already forgotten how it would feel to be a med student on your service

Please elaborate - I don't see how not participating in grade inflation is being unaware of the difficulties of being a medical student. The standards at my institution for my clerkship are such that most students will receive the equivalent of high pass. I would argue that that in and of itself is already some degree of grade inflation (the average grade is above average), but those are the standards given to me by the institution, so that's what I go by.

 

[efle]

Please elaborate - I don't see how not participating in grade inflation is being unaware of the difficulties of being a medical student. The standards at my institution for my clerkship are such that most students will receive the equivalent of high pass. I would argue that that in and of itself is already some degree of grade inflation (the average grade is above average), but those are the standards given to me by the institution, so that's what I go by.

A student who comes on your service and performs at the level of Honors, relative to his peers, will likely instead get a High Pass because he had the random back luck of getting assigned to you. You can't tell me that as a med student you'd be fine with that.

It's great that you want to oppose inflation, but the way to do that is as a group, setting some kind of limit for the clerkship overall so that all students are affected equally. Taking your harsher stance on your students, while your colleagues give a letter grade higher to their equivalent peers, just punishes a random handful with bad luck.

 

[Chibucks15]

A student who comes on your service and performs at the level of Honors, relative to his peers, will likely instead get a High Pass because he had the random back luck of getting assigned to you. You can't tell me that as a med student you'd be fine with that.

It's great that you want to oppose inflation, but the way to do that is as a group, setting some kind of limit for the clerkship overall so that all students are affected equally. Taking your harsher stance on your students, while your colleagues give a letter grade higher to their equivalent peers, just punishes a random handful with bad luck.

yes and no. We have entire hospitals that are notorious for being the 'impossible' graders. In turn it just makes everyone at that site look like a worse student than others, regardless of the truth of it. The problem is with the system as a whole not one particular grader

 

[NickNaylor]

A student who comes on your service and performs at the level of Honors, relative to his peers, will likely instead get a High Pass because he had the random back luck of getting assigned to you. You can't tell me that as a med student you'd be fine with that.

It's great that you want to oppose inflation, but the way to do that is as a group, setting some kind of limit for the clerkship overall so that all students are affected equally. Taking your harsher stance on your students, while your colleagues give a letter grade higher to their equivalent peers, just punishes a random handful with bad luck.

But they don't perform at the level of honors... otherwise I would give them honors, lol. The criteria I'm provided have nothing at all to do with how a student performs relative to his/her peers. Every student could get honors if they meet the criteria described. Here's one example that's included in our medical student evaluation form:

6. Able to apply knowledge to individual patients in regards to diagnosis and management (clinical judgement)*

(100) Consistently evaluates data critically and applies all findings to formulate a plan. Can handle even complex patients. Understands events at a conceptual level.​

(90) Evaluates data and applies to most patients to make a plan that is logical. Can handle most patients and determine their level of complexity.​

(80) Evaluates data and applies to simple patients but sometimes has trouble with more complicated patients​

(70) Evaluates data and applies to patients but has gaps in formulating plan in even simple cases​

(60) Unable to evaluate data and apply to patient care with significant gaps in plan in even simple cases. Unable to establish a patient's level of complexity.​

Most students do not perform at a "100" on this criterion or others. That the criteria set out high goals and are difficult to reach is something I agree with, but that doesn't mean, in my opinion, that I am responsible for applying them inappropriately. I stand by my evaluations because they are easily defensible exactly because I don't engage in a bunch of BS related to fudging grades. If students are dissatisfied with their evaluation, they can always request a regrade or appeal their grade - and many avail themselves of this opportunity.

 

[Matthew9Thirtyfive]

Please elaborate - I don't see how not participating in grade inflation is being unaware of the difficulties of being a medical student. The standards at my institution for my clerkship are such that most students will receive the equivalent of high pass. I would argue that that in and of itself is already some degree of grade inflation (the average grade is above average), but those are the standards given to me by the institution, so that's what I go by.

You don’t see how being the only attending who gives lower grades would be frustrating for the student who happens to have you as the attending grading them?

 

[efle]

yes and no. We have entire hospitals that are notorious for being the 'impossible' graders. In turn it just makes everyone at that site look like a worse student than others, regardless of the truth of it. The problem is with the system as a whole not one particular grader

This is again something that should be standardized/corrected for by the clerkship directors. The idea that one site consistently awards Honors and another never does should be a huge red flag to whoever runs that clerkship that they need to adjust for who the evaluators are.

But they don't perform at the level of honors... otherwise I would give them honors, lol. The criteria I'm provided have nothing at all to do with how a student performs relative to his/her peers. Every student could get honors if they meet the criteria described. Here's one example that's included in our medical student evaluation form:

6. Able to apply knowledge to individual patients in regards to diagnosis and management (clinical judgement)*

(100) Consistently evaluates data critically and applies all findings to formulate a plan. Can handle even complex patients. Understands events at a conceptual level.​

(90) Evaluates data and applies to most patients to make a plan that is logical. Can handle most patients and determine their level of complexity.​

(80) Evaluates data and applies to simple patients but sometimes has trouble with more complicated patients​

(70) Evaluates data and applies to patients but has gaps in formulating plan in even simple cases​

(60) Unable to evaluate data and apply to patient care with significant gaps in plan in even simple cases. Unable to establish a patient's level of complexity.​

Most students do not perform at a "100" on this criterion or others. That the criteria set out high goals and are difficult to reach is something I agree with, but that doesn't mean, in my opinion, that I am responsible for applying them inappropriately. I stand by my evaluations because they are easily defensible exactly because I don't engage in a bunch of BS related to fudging grades. If students are dissatisfied with their evaluation, they can always request a regrade or appeal their grade - and many avail themselves of this opportunity.

You're operating under the premise that when a transcript is read, the PD is mentally comparing to the rubric. We all know that's bunk. They're comparing to the bar chart of peer performance and the pile of other applicant transcripts.

And even if we did accept that premise, it's still disproportionately punishing the people who get randomly assigned to you. You can tell yourself "I'm right and all the other inflating graders are wrong" and be correct, and yet also be completely unfair to the students assigned to you. If they alone are being held to a stricter rubric, then they are being unfairly disadvantaged because of luck. The fair way to deal with inflation is at the level of the entire clerkship, not by 1 or 2 preceptors knowingly keeping their average an entire letter grade lower.

Edit: It is extremely telling that many students appeal your grades.

 

[Matthew9Thirtyfive]

This is again something that should be standardized/corrected for by the clerkship directors. The idea that one site consistently awards Honors and another never does should be a huge red flag to whoever runs that clerkship that they need to adjust for who the evaluators are.


You're operating under the premise that when a transcript is read, the PD is mentally comparing to the rubric. We all know that's bunk. They're comparing to the bar chart of peer performance and the pile of other applicant transcripts.

And even if we did accept that premise, it's still disproportionately punishing the people who get randomly assigned to you. You can tell yourself "I'm right and all the other inflating graders are wrong" and be correct, and yet also be completely unfair to the students assigned to you. If they alone are being held to a stricter rubric, then they are being unfairly disadvantaged because of luck. The fair way to deal with inflation is at the level of the entire clerkship, not by 1 or 2 preceptors knowingly keeping their average an entire letter grade lower.

Edit: It is extremely telling that many students appeal your grades.

Agreed. The way to fix that is not to punish random students who get assigned to you. It’s to change the way grades are calculated. It is extremely possible to have, at the clerkship level, grades normalized based on who grades how. I know because they do it at my school. So if you think your colleagues are inflating grades, work with the clerkship folks to implement controls, not punish students.

 

[NickNaylor]

You don’t see how being the only attending who gives lower grades would be frustrating for the student who happens to have you as the attending grading them?

It certainly would be frustrating, but the response to a perceived wrong (believing that I am being overly harsh in my evaluation) is not, in my opinion, another wrong (dishonestly evaluating the student). I agree with @efle's point that this is a larger system-wide program that needs to be addressed in a system-wide way. That said, I feel absolutely zero obligation to do something that I do not think is right nor appropriate (intentionally give someone a grade higher than what I think is earned) just because that's what everyone else is doing.

 

[Matthew9Thirtyfive]

It certainly would be frustrating, but the response to a perceived wrong (believing that I am being overly harsh in my evaluation) is not, in my opinion, another wrong (dishonestly evaluating the student). I agree with @efle's point that this is a larger system-wide program that needs to be addressed in a system-wide way. That said, I feel absolutely zero obligation to do something that I do not think is right nor appropriate (intentionally give someone a grade higher than what I think is earned) just because that's what everyone else is doing.

Read my above post. You’re faculty now. If you see a wrong you should be trying to do something about it.

 

[efle]

It certainly would be frustrating, but the response to a perceived wrong (believing that I am being overly harsh in my evaluation) is not, in my opinion, another wrong (dishonestly evaluating the student). I agree with @efle's point that this is a larger system-wide program that needs to be addressed in a system-wide way. That said, I feel absolutely zero obligation to do something that I do not think is right nor appropriate (intentionally give someone a grade higher than what I think is earned) just because that's what everyone else is doing.

Then you should refuse to participate in student evals or discuss the rubric misuse with the leadership, rather than knowingly dropping your students a grade. Then you can keep your sense of honesty/integrity intact, without your students needing to file appeals or be marked less competitively than their peers.

 

[efle]

Agreed. The way to fix that is not to punish random students who get assigned to you. It’s to change the way grades are calculated. It is extremely possible to have, at the clerkship level, grades normalized based on who grades how. I know because they do it at my school. So if you think your colleagues are inflating grades, work with the clerkship folks to implement controls, not punish students.

I could make a Grade Adjuster 2000 in excel in about ten minutes. There's no excuse not to do this. Glad to hear it's common practice at your school.

 

[NickNaylor]

Read my above post. You’re faculty now. If you see a wrong you should be trying to do something about it.

Sure, but the wheels of bureaucracy move slowly, and quite frankly there are many things professionally that demand my attention and time that I would rather focus my efforts on. I assure you that if I were, for example, a clerkship director, these would be things that I would look into and focus on. But I'm not, and so I can't.

Then you should refuse to participate in student evals or discuss the rubric misuse with the leadership, rather than knowingly dropping your students a grade. Then you can keep your sense of honesty/integrity intact, without your students needing to file appeals or be marked less competitively than their peers.

At my institution, my own annual faculty evaluation includes things like filling out medical student evaluations on time, so not filling out evaluations is not an option, and part of my job is agreeing to participate in the teaching of students - a job that I very much enjoy and am happy to do.


I appreciate both of your frustration with the system and I understand where you're both coming from, and I'm sorry that you seem to be dissatisfied with my responses.

 

[efle]

Sure, but the wheels of bureaucracy move slowly, and quite frankly there are many things professionally that demand my attention and time that I would rather focus my efforts on. I assure you that if I were, for example, a clerkship director, these would be things that I would look into and focus on. But I'm not, and so I can't.



At my institution, my own annual faculty evaluation includes things like filling out medical student evaluations on time, so not filling out evaluations is not an option, and part of my job is agreeing to participate in the teaching of students - a job that I very much enjoy and am happy to do.


I appreciate both of your frustration with the system and I understand where you're both coming from, and I'm sorry that you seem to be dissatisfied with my responses.

Apologize for being so combative. It's bad enough getting eval-bombed by someone out of ignorance, because they don't know how inflated grading is. To hear from a young attending they know about the inflation and still choose to drop their students a grade out of principle is spiking my cortisol.

 

[Chibucks15]

Apologize for being so combative. It's bad enough getting eval-bombed by someone out of ignorance, because they don't know how inflated grading is. To hear from a young attending they know about the inflation and still choose to drop their students a grade out of principle is spiking my cortisol.

We have a surgery attending who trained at a top institution which is awesome, except she explicitly told us that "have the residents fill out your eval because they rate you higher. We (attendings) usually just drop whatever they put for you by 1 number point across the board". It makes zero sense haha

 

[NickNaylor]

Apologize for being so combative. It's bad enough getting eval-bombed by someone out of ignorance, because they don't know how inflated grading is. To hear from a young attending they know about the inflation and still choose to drop their students a grade out of principle is spiking my cortisol.

Where we disagree is that you seem to think that the correct response on my part is that I go along with the pack and inflate grades because of a sense of unfairness on the part of the student. I do not see that as the correct response - that can be distilled down to "everyone is doing this thing that we agree is not right and you are 'harming' the student by not doing this thing that is not right, therefore you need to do it too." I am not "dropping" a student's grade - I am giving them the grade that they earned from my perspective. By definition, students did not earn grades that were inflated in the first place - otherwise they wouldn't be inflated.

I don't engage in grade deflation, where I determine what grade I believe they earned and intentionally reduce it. I see that as equally wrong and unfair as grade inflation.

 

[efle]

Where we disagree is that you seem to think that the correct response on my part is that I go along with the pack and inflate grades because of a sense of unfairness on the part of the student. I do not see that as the correct response - that can be distilled down to "everyone is doing this thing that we agree is not right and you are 'harming' the student by not doing this thing that isn't right, therefore you need to do it too." I am not "dropping" a student's grade - I am giving them the grade that they earned from my perspective. By definition, students did not earn grades that were inflated in the first place - otherwise they wouldn't be inflated.

Right, I agree with you in principle. I'd just never feel comfortable fighting the system in a way that I knew was harmful to only my students compared to their peers. Clerkship grade inflation is a widespread problem in modern medical education, but in my view, giving my students a letter grade lower than all my colleagues would have is not an appropriate way to address it.

 

[NickNaylor]

Right, I agree with you in principle. I'd just never feel comfortable fighting the system in a way that I knew was harmful to only my students compared to their peers. Clerkship grade inflation is a widespread problem in modern medical education, but in my view, giving my students a letter grade lower than all my colleagues would have is not an appropriate way to address it.

I don’t see myself as “fighting the system.” I see myself as a single educator evaluating a single student as objectively as I can based on the criteria given to me by institution and the time that I’ve spent with them. That the integrity of medical education evaluations as completely eroded such that grading has little relation to performance does not factor in there.

The good news for you is that if you find yourself in my position evaluating students and feel comfortable giving students grades that are effectively false and not reflective of their performance due to a sense of unfairness, you will be free to do so.

 

[efle]

I don’t see myself as “fighting the system.” I see myself as a single educator evaluating a single student as objectively as I can based on the criteria given to me by institution and the time that I’ve spent with them. That the integrity of medical education evaluations as completely eroded such that grading has little relation to performance does not factor in there.

The good news for you is that if you find yourself in my position evaluating students and feel comfortable giving students grades that are effectively false and not reflective of their performance due to a sense of unfairness, you will be free to do so.

True, and also good news that many of your students are able to appeal your grading. That's not really a thing here. If we had someone like you on the wards, we'd just have to rely on good old word of mouth to avoid your site/service if we intend to pursue your field.

 

[Matthew9Thirtyfive]

I don’t see myself as “fighting the system.” I see myself as a single educator evaluating a single student as objectively as I can based on the criteria given to me by institution and the time that I’ve spent with them. That the integrity of medical education evaluations as completely eroded such that grading has little relation to performance does not factor in there.

The good news for you is that if you find yourself in my position evaluating students and feel comfortable giving students grades that are effectively false and not reflective of their performance due to a sense of unfairness, you will be free to do so.

You can rationalize it however you want, but you’re still putting your students at a disadvantage compared to their peers.

 

[NickNaylor]

You can rationalize it however you want, but you’re still putting your students at a disadvantage compared to their peers.

That's not my problem, unfortunately. Part of my job does not include "making sure that students feel good about their grades, whether they earned it or not." What is part of my job is teaching students and doing what I can to make them competent physicians in the future and providing them an evaluation of their performance while on my service based on the criteria given to me.

Again, there is nothing in the grading of students that has anything to do with how they perform compared to their peers (at least at my institution). I am also not asked to interpret their grade based on how others grade them. I have not received feedback from the clerkship directors about my grading practices or the fact that I am a particularly "harsh" grader (for the record, I have given every single student that has rotated with me a high pass or honors).

I am sorry that you seem to be upset that I'm not sympathetic to furthering the trend of providing students grades that are inaccurate and do not reflect their clinical performance because you feel that it is "unfair" and that students should benefit from a systematic lack of integrity in how students are assessed. Unfortunately, that has absolutely nothing to do with actually evaluating a student or providing an assessment of their performance during their time with me.

 

[bobjonesbob]

But they don't perform at the level of honors... otherwise I would give them honors, lol. The criteria I'm provided have nothing at all to do with how a student performs relative to his/her peers. Every student could get honors if they meet the criteria described. Here's one example that's included in our medical student evaluation form:

6. Able to apply knowledge to individual patients in regards to diagnosis and management (clinical judgement)*

(100) Consistently evaluates data critically and applies all findings to formulate a plan. Can handle even complex patients. Understands events at a conceptual level.​

(90) Evaluates data and applies to most patients to make a plan that is logical. Can handle most patients and determine their level of complexity.​

(80) Evaluates data and applies to simple patients but sometimes has trouble with more complicated patients​

(70) Evaluates data and applies to patients but has gaps in formulating plan in even simple cases​

(60) Unable to evaluate data and apply to patient care with significant gaps in plan in even simple cases. Unable to establish a patient's level of complexity.​

Most students do not perform at a "100" on this criterion or others. That the criteria set out high goals and are difficult to reach is something I agree with, but that doesn't mean, in my opinion, that I am responsible for applying them inappropriately. I stand by my evaluations because they are easily defensible exactly because I don't engage in a bunch of BS related to fudging grades. If students are dissatisfied with their evaluation, they can always request a regrade or appeal their grade - and many avail themselves of this opportunity.

Where is the honors threshold on this scale?

 

[NickNaylor]

Where is the honors threshold on this scale?

Honors is an average grade of 90+. I forget what the actual terms are, but very roughly 90-100 is honors, 80-90 is high pass, 70-80 is pass, 60-70 is some other title, and 60 or below is fail.

 

[fldoctorgirl]

So in this scenario, would grading that's based entirely on the shelf score be considered preferable to you all? My school does things that way, in a H/P/F setting. From what I understand there is a score set to honor and then to pass (I don't think they adjust it based on the % of students that honor or pass or whatever). I haven't started M3 yet but have gone back and forth about how I feel about this system...on the one hand, it makes grading more objective and I don't have to worry about who I get as an evaluator tanking my grade outside of having their comments show up on my MSPE. On the other hand, it seems weird to totally dismiss actual performance on the wards. Thoughts for seasoned M3s?

 

[NickNaylor]

So in this scenario, would grading that's based entirely on the shelf score be considered preferable to you all? My school does things that way, in a H/P/F setting. From what I understand there is a score set to honor and then to pass (I don't think they adjust it based on the % of students that honor or pass or whatever). I haven't started M3 yet but have gone back and forth about how I feel about this system...on the one hand, it makes grading more objective and I don't have to worry about who I get as an evaluator tanking my grade outside of having their comments show up on my MSPE. On the other hand, it seems weird to totally dismiss actual performance on the wards. Thoughts for seasoned M3s?

As someone who has been involved in the residency selection process, I am not a fan of this type of scheme. Performance on a standardized exam has very little to do with your skills as an actual physician. There are plenty of students who do very well on standardized tests but are horrible with patients and actually doing the work of being a physician (or, in this case, a medical student). When it comes to selecting residents, the latter is far, far more important than the former. At least at our program, the comments included in the MSPE are extremely valuable when it comes to assessing an applicant. Shelf exams scores are effectively useless beyond demonstrating that a student studied and was able to recite what they learned on a multiple choice exam.

 

[bobjonesbob]

Honors is an average grade of 90+. I forget what the actual terms are, but very roughly 90-100 is honors, 80-90 is high pass, 70-80 is pass, 60-70 is some other title, and 60 or below is fail.

I think the scale is out of whack then. You're using this for your 3rd year clerkship students? A 100 sounds like a 2nd-3rd year psych resident and a 90 a good intern / sub-i. 70s to 80s is where you'd expect 3rd year students to be.

 

[efle]

Nick don't you worry about damaging someone's application into your field at all? Maybe psych is insulated from this more than, say, Surgery. But here, I've had friends interested in competitive surgical fields (e.g. Neurosurg) that had their Honors dropped to High Pass by catching a low outlier evaluator, and they seem to think it is going to cost them some of their desired interviews.

 

[Chibucks15]

Nick don't you worry about damaging someone's application into your field at all? Maybe psych is insulated from this more than, say, Surgery. But here, I've had friends interested in competitive surgical fields (e.g. Neurosurg) that had their Honors dropped to High Pass by catching a low outlier evaluator, and they seem to think it is going to cost them some of their desired interviews.

Idk I'm in this boat too as a third year but why is it the attendings problem? Aren't they supposed to actually grade you so you can see where you're at as a physician in training? Like why do people think they deserve honors automatically? Its a problem with the system. My school has the upper levels read "performing at the level of a resident." If any of us were performing at the level of a resident as a third year why even have the education?

Grade inflation is more of a problem than attending actually following the rubric sent out to them and actively grading. It isn't the attendings problem that the student is going for something competitive and it will look 'worse'. As Nick and a few attendings I have talked to about similar things have said, if you actually earn honors according to the rubric sent out by your school then you will get honors. It isn't like people are actively out there sabotaging students for the fun of it cmon now this screams of the classic stereotypes of the generation

 

[NickNaylor]

I think the scale is out of whack then. You're using this for your 3rd year clerkship students? A 100 sounds like a 2nd-3rd year psych resident and a 90 a good intern / sub-i. 70s to 80s is where you'd expect 3rd year students to be.

Bingo! Someone who gets it! I completely agree with you, and the fact that you're surprised by this is exactly the problem. I interpret an "average" grade - in this case, a pass - as essentially performing as I would expect a medical student to perform. That is what "average" means. Grades higher than that require performance beyond what I would expect of an average medical student. Fortunately for students, I assume that they have essentially zero knowledge of psychiatry because they receive so little training in it in the pre-clinical curriculum, and psychiatry has a system of diagnosis and more ambiguous data about treatment than most other fields of medicine, which can make the work more challenging than something more concrete as, say, internal medicine. Thus, in my mind, the bar for "how I would expect a medical student to perform" is actually quite low.

But you're right, and I completely agree with you. As I read the criteria, an "honors" requires a medical student to essentially perform at the level of a strong intern. Believe it or not, there are, infrequently, students that do actually perform this well. I have had students that do better as a student than some of the residents that I have supervised. In my opinion, they rightfully deserve an exceptional grade because they performed exceptionally.

One thing we might debate is whether or not those kind of criteria are appropriate. That's a topic that we can actually debate and discuss, and something that probably should be debated and discussed. My position is that an exceptional grade requires that someone be exceptional. Simply showing up to the unit, not being completely intolerable, and coming up with diagnoses and management that are at least somewhat based in reality does not, in my opinion, qualify as "exceptional." But simply being "average" - even among a peer group that is already, by way of simply getting into medical school to begin with, exceptional - is intolerable to most students. That has led to the systematic issues that @efle and @Matthew9Thirtyfive seem to be using as a basis to completely ignore the whole purpose of an evaluation scheme.

Nick don't you worry about damaging someone's application into your field at all? Maybe psych is insulated from this more than, say, Surgery. But here, I've had friends interested in competitive surgical fields (e.g. Neurosurg) that had their Honors dropped to High Pass by catching a low outlier evaluator, and they seem to think it is going to cost them some of their desired interviews.

No, I don't worry about that. First, as I've said, thus far all of my students have received high pass or honors, even without any intentional grade inflation on my part. A student may be disappointed that they don't get an honors, but that does not mean that they are screwed when it comes to applying for residency, especially in psychiatry. Even though I may be grading lower on average, I am still, on average, giving an above average grade. And if I really am off base, students will have plenty of other opportunities to perform well enough to get an honors. The lowest overall grade I have given is a high pass. That isn't going to be sufficient to prevent a student from getting honors via shelf performance, performance on their other psychiatry services, performance in the clerkship didactics, etc. Even though the student spends half of the clerkship with me, my grade contributes much less than half to their overall clerkship grade.

Additionally, I specifically avoid including negative comments in the part of the evaluation that is included in the student's MSPE. I am very well aware of the potential harms those kinds of comments can do, and the worst a student will ever get from me - barring some kind of extraordinarily bad behavior that is grossly inappropriate or dangerous - are lukewarm comments.

 

[efle]

Idk I'm in this boat too as a third year but why is it the attendings problem? Aren't they supposed to actually grade you so you can see where you're at as a physician in training? Like why do people think they deserve honors automatically? Its a problem with the system. My school has the upper levels read "performing at the level of a resident." If any of us were performing at the level of a resident as a third year why even have the education?

Grade inflation is more of a problem than attending actually following the rubric sent out to them and actively grading. It isn't the attendings problem that the student is going for something competitive and it will look 'worse'. As Nick and a few attendings I have talked to about similar things have said, if you actually earn honors according to the rubric sent out by your school then you will get honors. It isn't like people are actively out there sabotaging students for the fun of it cmon now this screams of the classic stereotypes of the generation

I'm talking about cases where the other evaluators gave him a 95 an lengthy glowing comments, and then one person he was forced to spend a short time with who is new to grading gave a 60 with a short generic comment. Mind you, that 60 (a 3/5) says Performing Appropriate to Level, but goes into the grade as a Fail.

He is absolutely right to view this is an unfair bull**** situation that will probably cost him interviews anywhere that screens for Honors, despite being an exemplary student.

Now in this case I give the evaluator benefit of the doubt - they were an overworked fellow that was new to grading here. But if you told me that evaluator was aware? Then yeah, he did something wrong by going off the rubric.

 

[efle]

Bingo! Someone who gets it! I completely agree with you, and the fact that you're surprised by this is exactly the problem. I interpret an "average" grade - in this case, a pass - as essentially performing as I would expect a medical student to perform. That is what "average" means. Grades higher than that require performance beyond what I would expect of an average medical student. Fortunately for students, I assume that they have essentially zero knowledge of psychiatry because they receive so little training in it in the pre-clinical curriculum, and psychiatry has a system of diagnosis and more ambiguous data about treatment than most other fields of medicine, which can make the work more challenging than something more concrete as, say, internal medicine. Thus, in my mind, the bar for "how I would expect a medical student to perform" is actually quite low.

But you're right, and I completely agree with you. As I read the criteria, an "honors" requires a medical student to essentially perform at the level of a strong intern. Believe it or not, there are, infrequently, students that do actually perform this well. I have had students that do better as a student than some of the residents that I have supervised. In my opinion, they rightfully deserve an exceptional grade because they performed exceptionally.

One thing we might debate is whether or not those kind of criteria are appropriate. That's a topic that we can actually debate and discuss, and something that probably should be debated and discussed. My position is that an exceptional grade requires that someone be exceptional. Simply showing up to the unit, not being completely intolerable, and coming up with diagnoses and management that are at least somewhat based in reality does not, in my opinion, qualify as "exceptional." But simply being "average" - even among a peer group that is already, by way of simply getting into medical school to begin with, exceptional - is intolerable to most students. That has led to the systematic issues that @efle and @Matthew9Thirtyfive seem to be using as a basis to completely ignore the whole purpose of an evaluation scheme.



No, I don't worry about that. First, as I've said, thus far all of my students have received high pass or honors, even without any intentional grade inflation on my part. A student may be disappointed that they don't get an honors, but that does not mean that they are screwed when it comes to applying for residency, especially in psychiatry. Even though I may be grading lower on average, I am still, on average, giving an above average grade. And if I really am off base, students will have plenty of other opportunities to perform well enough to get an honors. The lowest overall grade I have given is a high pass. That isn't going to be sufficient to prevent a student from getting honors via shelf performance, performance on their other psychiatry services, performance in the clerkship didactics, etc. Even though the student spends half of the clerkship with me, my grade contributes much less than half to their overall clerkship grade.

Additionally, I specifically avoid including negative comments in the part of the evaluation that is included in the student's MSPE. I am very well aware of the potential harms those kinds of comments can do, and the worst a student will ever get from me - barring some kind of extraordinarily bad behavior that is grossly inappropriate or dangerous - are lukewarm comments.

I fully support you bringing up the validity of the rubric criteria with your clerkship leadership. That's an entirely separate route than knowingly giving High Pass to students you know all your colleagues would have Honored. It's the route I support for people in your position.

 

[Chibucks15]

I'm talking about cases where the other evaluators gave him a 95 an lengthy glowing comments, and then one person he was forced to spend a short time with who is new to grading gave a 60 with a short generic comment. Mind you, that 60 (a 3/5) says Performing Appropriate to Level, but goes into the grade as a Fail.

He is absolutely right to view this is an unfair bull**** situation that will probably cost him interviews anywhere that screens for Honors, despite being an exemplary student.

Now in this case I give the evaluator benefit of the doubt - they were an overworked fellow that was new to grading here. But if you told me that evaluator was aware? Then yeah, he did something wrong by going off the rubric.

Again thats a system problem. Why does the 95 and glowing eval not make up for the 3/5? Nobody shold just get honors because that;s what the other attendings are doing. The system sucks and we all deal with it. There really aren't solutions unless you standardize it somehow which is damn hard. I don't see it as malicious as you seem to

 

[efle]

Again thats a system problem. Why does the 95 and glowing eval not make up for the 3/5? Nobody shold just get honors because that;s what the other attendings are doing. The system sucks and we all deal with it. There really aren't solutions unless you standardize it somehow which is damn hard. I don't see it as malicious as you seem to

Because the class average is a 90. Welcome to inflated grading where, unfortunately, holdouts like Nick are a landmine to be dodged. I am 100% with him in principle, but if he was a Surgery attending and I wanted to match Barrow I would do everything in my power to avoid his mentorship. Sad reality, I guess.

 

[Matthew9Thirtyfive]

That has led to the systematic issues that @efle and @Matthew9Thirtyfive seem to be using as a basis to completely ignore the whole purpose of an evaluation scheme.

You can put words in my mouth if you want, but I asked you if you are doing anything to change it and you said no. So you’re not doing anything to change the system you know is flawed while continuing to knowingly grade more harshly than the other attendings. I agree with you in principle, but if you’re not willing to try to change the grading system, then you’re just okay hurting your students based on principle.

 

[NickNaylor]

I fully support you bringing up the validity of the rubric criteria with your clerkship leadership. That's an entirely separate route than knowingly giving High Pass to students you know all your colleagues would have Honored. It's the route I support for people in your position.

So it seems like we agree on the basic facts:

1) There are clearly defined criteria - at least in my case - that I am supposed to use to evaluate students. We may agree or disagree as to the validity of those criteria, but those criteria exist.

2) Some attendings disregard these criteria and give students grades higher than what they would earn if the criteria were strictly followed. We call this grade inflation.

3) I do not do #2. The result is that my grades may, on average, be lower than other attendings. You worry that this will harm students when it comes to applying to residency. Maybe it will, maybe it won't. I would argue that it doesn't, but either way I see that as irrelevant as what may or may not happen in the future does not affect how a student performed on their clerkship now and how I evaluate them now.

The problem is in the response. You and @Matthew9Thirtyfive seem to think that the problem is that I do not do #2 and that, because students are "harmed," I need to disregard my own integrity and inflate grades to solve the "problem." I do not see that as the solution. You seem to be implying that students are entitled to a grade from me simply because my peers disregard the criteria that we are all supposed to use to grade students; consequently, because other people do the wrong thing, students are entitled to, and should expect that I provide, a higher grade than what their performance dictates as defined by the criteria we are all given. I don't see that as right morally, academically, or professionally. And even if I were to go on a crusade to correct this problem and make it priority #1 for my academic work, you and @Matthew9Thirtyfive seem to imply that, until the problem is corrected, I should be academically dishonest when it comes to evaluating students until all of our faculty agree to stick to the criteria provided.

Even if you disagree with my position, are you able to see how this issue is, at a minimum, not as clearly black and white as you seem to present it?

 

[NickNaylor]

You can put words in my mouth if you want, but I asked you if you are doing anything to change it and you said no. So you’re not doing anything to change the system you know is flawed while continuing to knowingly grade more harshly than the other attendings. I agree with you in principle, but if you’re not willing to try to change the grading system, then you’re just okay hurting your students based on principle.

Your view is exceedingly naive in thinking that I, a single person in a very large department that has absolutely zero responsibility or authority when it comes to our clerkship, can make any meaningful change. And even if I were to do that, would would you suggest I do in the interim? Let's assume that I am able to magically make all of our teaching faculty approach evaluations the same way that I do. I doubt that would happen overnight. What would you have me do until this rampant grade inflation problem is solved?

 

[Matthew9Thirtyfive]

Your view is exceedingly naive in thinking that I, a single person in a very large department that has absolutely zero responsibility or authority when it comes to our clerkship, can make any meaningful change. And even if I were to do that, would would you suggest I do in the interim? Let's assume that I am able to magically make all of our teaching faculty approach evaluations the same way that I do. I doubt that would happen overnight. What would you have me do until this rampant grade inflation problem is solved?

I mean maybe your department just sucks, but I’ve seen multiple people be able to make actual change in departments in virtually every career I’ve had, including the military which is saying something.

You should keep grading how you’re grading. You’re doing it right. I’m just saying if you’re going to grade properly and knowingly give students significantly lower grades that way, at least try to fix the problem.

 

[NickNaylor]

I mean maybe your department just sucks, but I’ve seen multiple people be able to make actual change in departments in virtually every career I’ve had, including the military which is saying something.

You should keep grading how you’re grading. You’re doing it right. I’m just saying if you’re going to grade properly and knowingly give students significantly lower grades that way, at least try to fix the problem.

So you don't actually disagree with how I evaluate students but, instead, my passivity when it comes to fixing the system?

 

[efle]

So it seems like we agree on the basic facts:

1) There are clearly defined criteria - at least in my case - that I am supposed to use to evaluate students. We may agree or disagree as to the validity of those criteria, but those criteria exist.

2) Some attendings disregard these criteria and give students grades higher than what they would earn if the criteria were strictly followed. We call this grade inflation.

3) I do not do #2. The result is that my grades may, on average, be lower than other attendings. You worry that this will harm students when it comes to applying to residency. Maybe it will, maybe it won't. I would argue that it doesn't, but either way I see that as irrelevant as what may or may not happen in the future does not affect how a student performed on their clerkship now and how I evaluate them now.

The problem is in the response. You and @Matthew9Thirtyfive seem to think that the problem is that I do not do #2 and that, because students are "harmed," I need to disregard my own integrity and inflate grades to solve the "problem." I do not see that as the solution. You seem to be implying that students are entitled to a grade from me simply because my peers disregard the criteria that we are all supposed to use to grade students; consequently, because other people do the wrong thing, students are entitled to, and should expect that I provide, a higher grade than what their performance dictates as defined by the criteria we are all given. I don't see that as right morally, academically, or professionally. And even if I were to go on a crusade to correct this problem and make it priority #1 for my academic work, you and @Matthew9Thirtyfive seem to imply that, until the problem is corrected, I should be academically dishonest when it comes to evaluating students until all of our faculty agree to stick to the criteria provided.

Even if you disagree with my position, are you able to see how this issue is, at a minimum, not as clearly black and white as you seem to present it?

Yes, we both fully understand the situation. I would be willing to try and make a change via leadership, and would not be willing to give my students a letter grade lower than peers if they perform the same as their peers. But that's because I care about practical consequences, like my buddy who has a High Pass in his field of interest because he was assigned to a low outlier. Maybe when I'm an attending I'll also forget about that kind of thing and care only what the rubric says, instead of what the effects are of being the only one to adhere to it.

 

[throwaway1000000]

This thread basically shows that numerical grades for clinical evaluations should be removed or be adjusted compared to the grader's average.
Shelf exams + comments = your grade. I would even take out this "honors" "near honors" etc.
Put the person's shelf exam score and their comments on their evaluation. PDs can interpret it how it best fits their program

 

[Avada Cadaver]

I just want to add another variable that goes into the bias of clerkship grading. Clerkship order. Idk how things are at your program, but at mine the cutoffs for honors/high/pass are predetermined and constant for the year. So a student who starts with medicine and a student who ends their clerkship year with medicine are held to the same standard.

For example two categories that make up part of our total MSPE

Fund of knowledge:

N/A	1/4	2/4	3/4	4/4
Not observed	Demonstrates deficits	Demonstrates knowledge of core areas with gaps	Demonstrates knowledge of core areas: no significant gaps	Demonstrates extensive knowledge: explains pathophysiology and rational for diagnosis and therapy

Clinical skills

N/A	1/4	2/4	3/4	4/4
Not observed	Does not correctly interpret data or develop basic DDX and management plan	Generates basic DDx and management plan but with limitations	Correctly interprets most clinical data; generates appropriate DDx and management plan	Correctly synthesizes clinical data; generates prioritized DDx: able to explain management plan

Keep in mind if you got a 3/4 in every category you’d end up with a pass (pass 2, high pass 3.2, honors 3.5). Half the time the attendings/resident’s don’t even know when we start clerkship and even if they did, there will be a couple 7th year md/phD students or 3rd year’s (we start clerkship 2nd year) on their last rotation on the same team with a 2nd year who just started. I feel like I don’t need to explain how this makes an already subjective system even more subjective.

Maybe things are different at your institutions but my question to those who are all gung-go on grading by the book, how do you reconcile this? I mean if you were true to your word would there just be 0 students getting honors on their first block?

 

[efle]

adjusted compared to the grader's average.

Interested to hear @NickNaylor thoughts on this actually - would you be ok with grading per the rubric but then having the clerkship director adjust so you're even with the other evaluators?

Is having your 3 entered as a 4 by them instead of you more acceptable?

 

[Neopolymath]

Interested to hear @NickNaylor thoughts on this actually - would you be ok with grading per the rubric but then having the clerkship director adjust so you're even with the other evaluators?

Is having your 3 entered as a 4 by them instead of you more acceptable?

At one rotation this is how it was done for me. The PD (or whoever is in charge at your program) knows that X resident gives awful grades to everyone and Y resident gives great grades to bad students so all of it is taken into account by looking at all evaluations for the rotation + the PD's impression from end of rotation presentations or whatever other interaction. That's how we did it in business before med school and I always wondered why medicine tries to reinvent the wheel over and over after HBS figured out the best way to do a fair evaluation in an organization 30 years ago...

 

[Matthew9Thirtyfive]

So you don't actually disagree with how I evaluate students but, instead, my passivity when it comes to fixing the system?

Correct. I just think if you are aware something should be changed, you should at least make an effort to fix it. It’s not fair that some students are given better grades because they got lucky in who their preceptors are, but like you said, the solution isn’t to just give everyone honors.

 

[Matthew9Thirtyfive]

Interested to hear @NickNaylor thoughts on this actually - would you be ok with grading per the rubric but then having the clerkship director adjust so you're even with the other evaluators?

Is having your 3 entered as a 4 by them instead of you more acceptable?

That’s essentially how it’s done here at least one some clerkships. Seems to be viewed as fair afaik.

 

[Ho0v-man]

I think the scale is out of whack then. You're using this for your 3rd year clerkship students? A 100 sounds like a 2nd-3rd year psych resident and a 90 a good intern / sub-i. 70s to 80s is where you'd expect 3rd year students to be.

This is exactly the problem. The system with these eval sheets is basically “Be as good as a PGY-2. You have one month.” and it’s garbage. Of course there’s going to be inflation. If there wasn’t, >50% of the class wouldn’t pass most rotations. I don’t blame attendings for giving scores that are accurate like NickNaylor does. I blame our institutions who for some reason think this is where the bar should be.

Seriously, how am I supposed to realistically get that high score in surgery according to those guidelines? Should I do a Whipple unsupervised? How does a medical student “handle complex patients” when even interns are largely shielded from them/heavily supervised during their care? I’m lucky to get computer access FFS! I swear these things were written by people who never went to medical school.

/rant

 

[throwaway1000000]

Also these conversations are supposed to be had by clerkship directors and deans of clinical year.
I would strongly doubt if half the clerkship directors went through this level of detailed discourse about grading as was done in this thread.

 

[deleted947265]

So you've discovered that grading is arbitrary? Yes. This is also true in kindergarten. The problem isn't that grades are arbitrary. It's that grades are arbitrary and always will be but med school admissions committees, program directors, HR departments, and college admissions committees all care about them for some reason. The idea that grades should be on a bell curve is really dumb and I have no idea where this idea comes from. Grades are always going to be left skewed after a while unless the person assigning the grades is a griefer.

Academia isn't a winner take all competition so you can't have grading system that limits the highest grades to highest X% of the class. You can have a system where grades are a representation of meeting a certain standard, or a system that guarantees people with a certain grade are better by some arbitrary metric than students with lower grades; you can't have both. That's why I don't take them seriously. Some people do grades right, some people want to turn academia into winner-take-all slugfest. I leave my cutthroat competitiveness on the Counter Strike servers where it belongs.

 

[efle]

So you've discovered that grading is arbitrary? Yes. This is also true in kindergarten. The problem isn't that grades are arbitrary. It's that grades are arbitrary and always will be but med school admissions committees, program directors, HR departments, and college admissions committees all care about them for some reason. The idea that grades should be on a bell curve is really dumb and I have no idea where this idea comes from. Grades are always going to be left skewed after a while unless the person assigning the grades is a griefer.

Academia isn't a winner take all competition so you can't have grading system that limits the highest grades to highest X% of the class. You can have a system where grades are a representation of meeting a certain standard, or a system that guarantees people with a certain grade are better by some arbitrary metric than students with lower grades; you can't have both. That's why I don't take them seriously. Some people do grades right, some people want to turn academia into winner-take-all slugfest. I leave my cutthroat competitiveness on the Counter Strike servers where it belongs.

Just because you don't have normalized/z-score based clerkships at your school doesn't mean nobody else does either