This response is intended to expand upon the Letter to the Editor by Bohler[1] regarding the grading of physicians during the training and posttraining portions of their careers. Grading people and processes is commonplace in medicine. Most medical students receive considerable exposure to grades during their premedical school years. Some experience suggests grades are subjective or unreliable reflections of the pre hoc grading criteria and goals. Grades may lead to hypercompetitiveness, anxiety, stress, and other characteristics related to the potential for nonsuperlative grades to negatively affect one's likelihood of being admitted to medical school.
Once someone is admitted to medical school, the same issues may continue to be experienced. In some cases, the stress of grades during medical school may shift to concerns regarding one's likelihood of being accepted into a highly competitive residency program. Competition with other students may become more intense because medical school classmates are much more highly selected than are high school or college classmates for their ability to overachieve with respect to grades.
Medical school is an excellent time to increasingly focus on learning how to analyze and react to grades. This is important because issues associated with grades will persevere after medical school during residency/fellowship training and throughout one's career as an attending physician. Colleagues, patients, caregivers, government and private insurers, other healthcare workers, family and friends, and other stakeholders will grade you implicitly and/or explicitly. Some of these grades will be assigned without any obvious or identifiable objective grading criteria. Lifelong learning and development of skills to process grades will be needed and valuable.
As physicians progress through their careers, they likely will be required to grade other healthcare personnel (eg, supervisory physician reports); other physicians (eg, letters of recommendation, evaluations for hospital privileges, expert testimony or reviews); patients/caregivers (eg, bedside manner, disability or insurance reports); and perhaps most important of all, themselves (eg, self-improvement, responses to complaints, self-assessment of clinical performance, relationships, personal health status, teaching effectiveness, communications).
When analyzing a process such as grading during medical school, the place to begin is to select a frame of reference for the analysis. Grading in medical school is driven to aid multiple different stakeholders who are interested in specific information outputs. For example, residency programs are interested in identifying which graduates will be outstanding, satisfactory, or unsatisfactory residents; medical schools are interested in becoming prestigious and attracting capital such as donations and grants; students are interested in a system that prepares them to pass their licensing and specialty boards readily; medical school faculty are interested in showing that their teaching efforts produce positive learning outcomes; and so on. The Accreditation Council for Graduate Medical Education and other entities that analyze and/or regulate medical education have noted some issues during the last several years associated with grades. In particular, concerns about the impact of high stress levels over long intervals during medical school and residency have driven recent efforts by these entities to change grading systems. These concerns have led to recommendations to adopt Pass/Fail grading systems during medical school and for US Medical Licensing Examination Step 1 examinations and specialty board certification examinations. Some evidence suggests that the adoption of these recommendations lessens the intensity of the stress of physician trainees.[2] Reductions in suicide rates involving physician trainees also may be occurring as a result.
Physicians will be assigned poor grades at times during their career. It is important to pause and reflect on the circumstances and factors that contributed to each poor grade. Sometimes the grade is a result of a grader (ie, patient or caregiver) assigning a grade that is unwarranted. For example, frustrations with other staff and/or processes involved in delivering clinical care by a physician may be transferred onto the physician, even though the physician had no direct or significant role in the event that caused the poor grade. Patients, caregivers, and other individuals may assign poor grades to physicians because they interpret the physician's demeanor or bedside manner to be tired, distracted, frustrated, inconvenienced, or some other negative perception registered by the individual observing them. It is important to remember that physicians are always observable by other people most of the time when they are working. Physicians should learn how to avoid the negative perceptions of other people regarding the body language and/or demeanor of physicians. For example, sitting down when talking to a patient or family members/caregivers often will lead to a perception that the physician spent more time and was more empathetic toward the patient/caregivers.
When a physician receives a poor grade inappropriately, the physician should learn how to flush the poor grade and not perseverate about it. (Passing information about the poor grade on to other individuals or to responsible supervisors who can work on removing the triggering issue is a process improvement opportunity that may reduce the risk of further occurrence.) When physicians merit an excellent grade, they should privately celebrate the event. Making a difficult or esoteric diagnosis or saving someone's life are examples that will occur from time to time during a physician's career.
Grading of physicians may involve biases or subjective judgments. A mentor can help a physician with self-assessment and self-management strategies that can be applied to better understand and resolve the basis when an unexpectedly low grade is received. Mentors also can help physicians analyze and manage previously unfamiliar grades (eg, malpractice complaints).
Much literature exists regarding the grading of physicians during training and while in practice.[3–5] Searching for medical school or physician grading information on the Internet will produce a plethora of articles and policy recommendations.
Readers and other individuals with an interest in or experience related to the grading of physicians are welcome and encouraged to contribute to further discussion of this topic.
South Med J. 2023;116(8):699-700. © 2023 Lippincott Williams & Wilkins
