Should we standardize clerkship grades?

I’ll be honest, when I first matriculated into medical school, I didn’t even know what a USMLE Step exam or clinical clerkship was. In fact, the first time I ever heard of them was from another applicant on the interview trail. I have always been a take-it-one-step-at-a-time type of person, but eventually, I would have to succumb to the pressure and ask upperclassmen about the exam. And what did they tell me? Almost unanimously, it was proclaimed to be the single most important exam of medical school, and that I should, “Do well on Step 1 so I don’t have to worry about third-year clerkship grades or Step 2 CK.” Many of my specialty advisors projected the same theme. But could it be that easy? Just work hard for the first two years of medical school, ace the USMLE Step 1 exam and then coast until graduation? It sounded too good to be true, and guess what, those sort of things always are.

Inevitably, the impact of grade inflation would reach USMLE scores. Mean scores have significantly risen throughout the years, and will likely continue to do so. According to the AAMC results from first-year residents, the average Step 1 score in 2008 was 221, and just this past year in 2016 it was reported to be 231. Medical school curricula are consistently updated, more efficient study resources are produced, and students are getting smarter. As a result, the adage of getting a high score on Step 1 so you can coast through third year clerkships has begun to lose its validity. Why? Because it has become too commonplace to score high on the exam.

Every few years the NRMP surveys residency program directors regarding the importance of various factors in selecting applicants for interview and assigning their rank. In 2008, 71% of directors reported taking clerkship grades into consideration when selecting applicants to interview and assigned it a mean importance rating of 3.8/5 when ranking applicants. In 2016, 79 percent of directors felt clerkship grades were important in selecting applicants to interview with a mean importance rating of 4.1/5 when ranking applicants. As applicants score higher on Step 1 exams each year, programs are beginning to use additional metrics such as clerkship grades in the residency application selection process.

Similar to the Medical College Admission Test (MCAT), USMLE exams are standardized and designed to compare applicants across the nation fairly. This makes sense because USMLE Step 1 and Step 2CK scores have historically been the key determining factors in stratifying applicants in the residency selection process. However, the critical element of grade standardization is often lost in third-year clerkship grading systems. As previously mentioned, more medical schools are moving towards pass/fail pre-clinical grading systems. Consequently, third-year clerkship grades have gained significantly more importance in the residency application process.

In general, clerkship grades represent a combination of each student’s performance on a clerkship “shelf exam,” and clinical performance evaluations completed by physicians and residents. The exam is produced by the National Board of Medical Examiners (NBME) and is standardized for administration across all medical schools. The remainder of the grade is determined by performance evaluations. There are several problems with this system because each medical school goes about it very differently. Firstly, not all medical schools allow the same number of weeks for a clerkship. Students at one institution may have 12 weeks for their internal medicine clerkship, whereas students at another only get six-weeks but still have to take the same shelf exam. Secondly, clerkship directors assign very different shelf examination cut-off scores for achieving honors, high pass, or pass in the clerkship — it may be 70th percentile at one school and 90th percentile at the next. Thirdly, clinical performance evaluations have very different evaluation criteria between institutions (i.e., assigning a number from 1 to 5). This portion of the grade is highly subjective, open to unconscious and conscious biases, and is essentially completely up to the discretion of whoever is filling it out.

In a perfect world this wouldn’t be a problem because evaluations are more than necessary. However, it has become a fiercely debated topic in previous years and presents an academic “make or break” point for students in their applications. In today’s system, residents and physicians are flooded with medical student evaluations that only add to their already long list of evaluations to be filled out for each other. I have personally worked with multiple individuals who have 50+ incomplete evaluations in their inbox, and it is entirely unreasonable to believe that one can adequately and accurately fill out that many evaluations without cutting corners. It’s called evaluation burnout, and it’s a real problem. Evaluations should be filled out within a set amount of time of working with the person in order to ensure accuracy, and if not then it should be automatically deleted. Medical student evaluations are too often completed several weeks later after interacting with them and, therefore, should not serve as a significant contributor to their final grade. Reminder processes have been implemented with hopes of preventing evaluations from piling up, but they typically come in the form of an email which is easily deleted and forgotten.

On the flipside, I would be remiss if I didn’t also note that evaluations are fundamental in the process of learning to become a physician and ensuring quality improvement. Personal evaluations are among the most effective tools in assessing one’s ability to work with others, demonstrate professionalism and clinically apply one’s knowledge to patient care. We absolutely cannot get rid of them, but they also cannot continue to exist as they do. Especially when it comes to the evaluation of third-year medical students, we need to implement a sense of standardization and objectivity to fairly and accurately evaluate medical students. Otherwise, it would be very unreasonable for them to carry any significant degree of weight in deciding clerkship grades or which applicants to interview for residency.

Evaluations are meant to not only highlight they things we do well but bring light to the things we need to work on. No one wants to hear about the things they do poorly, but it’s a very important conversation that needs to happen. To provide the best care for our patients, we must also provide the best tools for bettering ourselves.

The author is an anonymous medical student.

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