For the record, the pediatric ward lacked a salon

The professor never knew what hit him.

It was midway through my medical school career, and I was taking a course in plant physiology.  Now, since plants and humans have markedly different physiologies, such that your average layperson can usually tell them apart with ease, it may seem confusing to you that I would be taking a course in the former.  It was certainly confusing to the professor teaching the course.  But because of quirks particular to my medical school, certain academic requirements and the vagaries of scheduling that semester, I was joined by a surprisingly large number of fellow medical students.

As he surveyed the roster on the first day of class, the professor was clearly struck by our presence.  “How many of you are medical students?” he asked.  At least a third of the students raised their hands.  “Why are you here?” was his obvious follow-up question, to which he got a chorus of answers along the lines of the last sentence of the above paragraph.  Nobody thought it made any sense, but there we all were.

He never knew what hit him.

I will never forget the look on his face, somehow both panicked and weary, as he was mobbed at his desk after some test or another.  My friends, there is nobody like a medical student to argue over every last measly point on an exam.  Barnacles let go faster.  And he was beset by some of our school’s more tenacious souls after he had the temerity to give them scores they didn’t feel were sufficiently high.  I pitied him (all the more in retrospect when I recall how nice and helpful he was after my incident with the gun).

I had my own slightly less harrowing experience of this phenomenon from the other side of the student/teacher relationship.  During my fellowship I was asked if I’d like to serve as preceptor for a small group of medical students on their pediatrics clerkship.  As it was relatively unusual for fellows to be asked and I took it as rather a compliment, I readily agreed.  On balance, it was well worth my time.

But…

Medical school rotations are usually graded on a “pass/fail” basis, with “honors” available for truly exceptional students.  And there was one student whose work was clearly competent and satisfactory, but not stellar enough to really warrant honors in my opinion.  I don’t recall exactly how the topic was broached, but at some point during the rotation I communicated to her that I didn’t think her work at that point was honors-worthy.  However, I advised her that if she did an additional patient write-up that was especially good I might be able to reconsider.

Whoops.

She turned in a perfectly decent additional write-up that did nothing to change my opinion that she had done good but not superlative work.  And I gave her a passing grade.  Unfortunately, in our communications with each other the subtle difference between “I would consider” and “I will definitely give you” was lost.  She was not pleased.  If memory serves, she ended up griping to the administrator in charge of the rotation, and in the end may have even gotten my evaluation overridden.

All of this is a length preamble to me thoughts about this article in the New York Times about the difficulty delivering a failing grade to medical students:

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

[snip]

But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course.

[snip

About a quarter of the course directors surveyed believed that grade inflation occurred because senior doctors were loath to deal with students who could become angry, upset or even turn litigious over grades. Some confessed to feeling pressure to help students get into more selective internships and training programs.

All of this brings to mind yet another anecdote from my days in training, this time in residency.  (I appreciate the indulgence of those of you who are bearing with these little reminiscences of mine.)  Like my fellowship (though at a different institution), I did my residency at a Major Metropolitan Hospital with a Well-Regarded Medical School.  And many of the students at WRMS had no compunction whatsoever about communicating their lack of interest in pediatrics as they did their rotation.  My favorite example of this will always be the young lady who disappeared for an entire afternoon, only to reemerge for sign-out rounds having plainly spent the time getting her hair cut and colored.

I don’t know if I would have been failed outright for skipping out on a core rotation to head off to the salon, but it would certainly have led to a pretty severe dressing down.  (My medical school had plenty of shortcomings [believe me], but it was very demanding of its students when it came to performance on clinical rotations.)  But when I made note of her absence and subsequent change in appearance, I was later told by one of the attending physicians that she had complained that I wasn’t being nice to her.

Frankly, I can’t even imagine trying to tell a competitive, ambitious and academically talented student that his patient care skills were too poor to pass him.  I really can’t.  Considering how apeshit I’ve seen students go over not getting as high a passing score as they’d like, the idea of telling someone they’d failed because of something as arguably subjective as bedside manner or diagnostic acumen… that student would have to be a total train wreck to get failed.

This is not to say that such failures wouldn’t be warranted.  Rest assured, I have zero doubt such failures should happen, and far more often than they do.  But when the failure isn’t something quantifiable like an insufficient number of correct answers on an examination and requires something of a judgment call on the part of the evaluator, I can see it being a gigantic headache that medical schools are all too willing to avoid.