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Medical School Grading: Everyone Gets a Trophy

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Skeptical Scalpel

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 275,000 page views, and he has over 3600 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 275,000 page views, and he has over 3600 followers on Twitter.

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Grading in medical school is an excellent example of what I call the “T-ball culture”: No one keeps score. All games end in a tie. Everyone gets a trophy.

“Variation and Imprecision of Clerkship Grading in US Medical Schools” is the understated title of the paper in the August 2012 issue of the journal Academic Medicine. The authors, from the department of medicine at Brigham and Women’s Hospital, analyzed 2009-2010 third-year clerkship grades from 119 (97%) of the 123 US medical schools. They found many different grading systems ranging from two levels (pass/fail) to 11 levels of grades.

The terminology used by the schools to describe the different grades is positively comical. To borrow an analogy I’ve used in a previous blog about dean’s letters, the citizens of Lake Wobegon would be proud because no student is “average.”

Here are some examples:

High honors, honors, pass, fail (In some schools “honors” is not the highest possible grade).
Honors, satisfactory plus, satisfactory, fail.
Honors, satisfactory, low satisfactory, fail.
Honors, high satisfactory, satisfactory, low satisfactory, unsatisfactory. (Does “unsatisfactory” mean, dare I say it, “fail”?)
Honors, near honors, pass, fail.
Excellent, good, fail.
Honors, advanced, proficient, fail.
Honors, letter of commendation, fail.

The highest grade attainable was awarded to 23% of those students in schools with three-tiered systems (range 5-51%), to 34% (range 2-84%) in four-tiered systems and to 33% (7-93%) in schools with five grade levels.

It gets worse. The authors noted that 97% of all medical students were given one of the top three grades regardless of whether the schools used 4, 5, or 6 levels of grading.

From the paper, “Less than 1% of all US medical students fail required clerkships, regardless of the grading system used.” This raises the question of whether the grade “fail” is even necessary.

Focusing on surgery, an average of about 30% of all students got the highest grade possible in their surgical clerkship, but the percentage of the class receiving the top grade ranged from 7% to 67%. This may account for the paradox found in a paper on surgical resident performance: A significant predictor of the need for remediation was that the resident had received honors in his surgical third-year clerkship. It appears that a grade of honors is virtually meaningless.

This is an excellent example of what I call the “T-ball culture”: No one keeps score. All games end in a tie. Everyone gets a trophy.

The authors of the paper recommended that schools consider creating a more consistent, transparent and reliable system of grading. As a former surgical residency program director who grappled with the difficulty in interpreting the meaning of applicant grades from different schools, this seems remarkably clear to me.

An editorial in the same issue of the journal agreed that grade terminology should be standardized but cautioned that normative grading (establishing a set distribution or “curve” of grades) may not be the answer. The editorialists offered some other possibilities such as criterion-based grading or emphasizing the mastery of a subject as a goal rather than the achieving of a specific grade.

I do not have the background in educational theory to say what is right or wrong. I do know that a grading system with so many variables and such a skewed distribution is of no help whatsoever in evaluating the desirability of an individual applicant to a residency program.

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 275,000 page views, and he has over 3,600 followers on Twitter.

4 Comments

  1. MedStudent, I agree that the clinical grade is very subjective. The inter-rater reliability of such grades is poor. Some clinicians are lousy teachers and graders. You may be correct that this problem may not have a solution.

    Because I liked Thin Lizzy’s “The Boys Are Back in Town” but am not a fan of Foghat, I can only assign you the grade “letter of commendation” for your comment.

    Reply
  2. It’s hard to take criticism of the H/HP/S/F system seriously when the criteria for dishing out those grades is so incredibly subjective, as it is. For example, I know at some schools you can ace the shelf exam, but if you don’t know the names of all the classic rock songs in the OR, you’re doomed to an HP or S. So what’s being rewarded here is a deep knowledge of Foghat and Thin Lizzy, and while this anecdote may draw some chuckles, it illustrates a large part of the problem.

    Or how about the attending at my university who only gives HP or lower as a matter of some odd “principle,” regardless of how much excellence you display in your rotation? In an era of medicine where a mere HP in surgery can be enough to lose you a few coveted residency interviews, you have to wonder why this attending doesn’t take his/her evaluation responsibilities more seriously.

    Unfortunately, I’m not confident there’s a way to fix this problem. It’s a tall order to evaluate students objectively in the chaos of 3rd year, and unless we want to go down the road of putting unduly large emphasis on shelf exams, I think the strangeness you mention in this article is here to stay.

    Reply
  3. Student, thanks for commenting. Your assumption would be correct if grades correlated with performance during residency. A paper in the Sept 2012 issue of Annals of Surgery (http://www.ncbi.nlm.nih.gov/pubmed/22987173) on remediation of surgery residents states that 31% required remediation. A strong predictor of the need for remediation was that the resident had received a grade of “honors” in his third-year clerkship. So tell me what does a grade of honors mean?

    Reply
  4. You’ve made the assumption that not all the students are deserving of the high grades they received. There is absolutely nothing wrong with all students succeeding. If they do then the medical school would have done their job. If older physicians would learn this we’d have many more successful, and well supported physicians trained — a pretty good problem for residency programs to have.

    Reply

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