End medical school grades [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“There should be no grades in medical school. Forty-something percent of applicants get accepted to one or more medical schools. To even apply to medical school, one needs to have not only graduated or be on track to graduate college, but also needs to have passed the MCAT and have the support of a pre-medical application committee. I am no mathematician, but I do not think that it is a stretch to say that less than 10 percent of those who wanted to go to medical school on their first day of college do, in fact, end up matriculating into medical school.”

Adam Lieber is a medical student.

He shares his story and discusses his KevinMD article, “End medical school grades.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Adam Lieber. He’s a medical student, and he wrote the KevinMD article “End medical school grades.” Adam, welcome to the show.

Adam Lieber: Thank you so much for having me. I’m really excited to be here.

Kevin Pho: So we’re going to get to the article in a little bit, but first off, can you share your story and your journey to where you are today?

Adam Lieber: Yeah, absolutely. I’m originally from New York City. I was born and raised here, went to Stuyvesant High School downtown, and then went to college up at Columbia, where I studied biology and also did a lot of music performance.

My pathway to medical school: Even though I went the traditional route, in terms of going straight through to medical school, it was pretty late in the game that I decided I wanted to go to medical school. I was actually planning on becoming a musician, and I had some different performance venues, a couple of which were in the medical field. I was playing piano at the Ronald McDonald House, which is for children who are suffering from cancer who need a place to stay when they’re getting care, as well as at some assisted living and rehab facilities. I sort of fell in love with interacting with patients in that setting. It was a very low-stress environment to be doing so, and it got me interested in the health care field.

Starting from my sophomore year of college, I went pedal to the metal trying to make up all the pre-med classes that I hadn’t done before and trying to go from there. Before I knew it, I was starting medical school straight out of college at Mount Sinai in New York City. Since I started at Mount Sinai, I’ve been exploring a lot of different specialties and have settled on emergency medicine. That’s what I’ve decided to apply into, and I’m awaiting Match Day in a couple of weeks.

Kevin Pho: There are a lot of physicians who have a background in music. I played violin and piano myself, and I’ve talked to a lot of physicians who have that background in music. Now, what’s something about music that can inform and influence how physicians practice medicine going forward?

Adam Lieber: Yeah, it’s interesting. I think that it depends a lot on what kind of music you play. For me, I’m a jazz musician, and in jazz music there’s a lot of call and response and improvisation. I’ve found that to be helpful in the medical setting, because you’re often thrown into situations that are new to you and different, and having the ability to think on your feet and improvise can be a really good skill to have.

And then I think, just from the standpoint of musical dexterity, I’ve been playing piano since I was five and became good with my hands because of that, and I didn’t really realize it might transfer over to the medical setting until I was learning how to suture. It came more naturally to me than I would have otherwise thought, had I not been doing something with my hands for a long time.

I’ve read Oliver Sacks’s books on music. I know he was a music lover; I recently read “Musicophilia” by him. It seems like music just activates a lot of parts of the brain, and early development and learning, and that could help you down the line and could make you think in creative ways. So I think that music has been a huge benefit to me, and also just a good outlet in medical school, as days get stressful and as you’re studying for exams. It’s nice to be able to have a really healthy outlet. A lot of people go to the gym, for example, a lot of people play sports, and music is another one of those things that could just get your mind off things.

Kevin Pho: Excellent. And speaking of studying for exams, I think that’s a nice transition to your KevinMD article. It’s titled “End medical school grades.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Adam Lieber: Yeah. I mean, it’s a provocative title, and I’ve been reading the comments and seeing the response to the article. It’s been quite interesting.

I would say the context in which I wrote the article was that we had just gone through the first and second wave of COVID. Medical school rotations had been suspended for my school, and I think for a lot of schools around the country, from March of 2020 to really around the summer, June, July, and I guess it was different depending on where the exact location was. It gave medical students really a lot of free time and a lot of time to reflect on the road they’ve taken to get here. In my class, there was a lot of really amazing group work that happened during that period when we weren’t on rotations, with volunteering, going to phone banks, calling patients about COVID results, and helping inpatient teams relay medical information to families who couldn’t visit patients at the bedside. I felt that for the first time there was such a cohesive experience, with all the students working together as a team, and it made me reflect on the way we go through medical training in general and the way that we go from college to med school to residency.

In the article, I talk about how it’s very hard to get into medical school. Really, only about 40 percent of people get in in the first place, and even the people who are applying to med school are a very select bunch who are able to complete all the pre-med requirements, take the MCAT, and so forth. So when you get to medical school, you have a group of students who have very high GPAs. A lot of top medical schools have average GPAs of 3.9 out of 4, which is extremely high, and very high MCAT scores. And you put them in an environment where we’re told that we are supposed to be working on teams and being extremely interactive, but unfortunately, sometimes what happens is that all the tests, all the grades, and all the evaluations, I think, could make us lose sight of the bigger picture, which is to become doctors and become team players. So that was the context in which I wrote the article.

A few thoughts I had about why, specifically, I think third-year clerkship grades can sometimes cause more harm than good are really threefold. I mean, first is that I think that the self-efficacy and self-worth piece of medical students is a concern. A lot of medical schools are realizing this and adding a lot of wellness modules to the curriculum and trying to make the experience more tolerable from that standpoint. I think that one very hard thing is that we are told that we are to work in teams and ingratiate ourselves in the team, but as the medical student, if you’re being graded, it feels like you’re not quite part of the team sometimes. So that’s where I’ll start. If you have any follow-up questions or anything you want to talk about specifically, I’d love to talk about that.

Kevin Pho: So I know that there is a movement toward pass/fail. I know Step 1 is now pass/fail, and I think there are some medical schools where the first couple of years are pass/fail, and one of the reasons they say they do that is to decrease some of that mental stress and burden on medical students. So what is the correlation between grades and stress and potential behavioral health, anxiety, and stress issues with medical students?

Adam Lieber: Yeah, first of all, I think it’s really good that a lot of medical schools have made pre-clinical classes pass/fail. I think that there’s just so much information to learn, and we hear the term “drinking out of that fire hose” and that kind of thing with reference to just the sheer amount of information you have to learn. I think that in a class like anatomy lab, it’s imperative that that’s a pass/fail class, because you are really working as a team with your cadaver, and just thinking about other people in my group getting a different grade than me would feel odd as you’re unpacking the body together and learning about this as a unit.

With Step 1 being pass/fail, I actually feel a little bit mixed about the board exams being pass/fail, from the standpoint that I think the board exams are very objective and do accurately reflect your medical knowledge at a given time.

The way I think third-year grades impact people’s behavioral health and mental health is that I think that there is a lot of subjectivity to the grades. I think that the grades are often highly dependent on who you’re working with and who you’re clicking with. I think that certain students have figured out how to play the game better than others. So that might mean a certain student was told by a fourth-year medical student that it’s really important to bring papers to rounds and present on that without the nudging of the attending.

I think that what happens is that when you are given a grade, if it’s not an honors or even a high pass, sometimes you feel, I think, a lack of self-worth. This is something that I’ve discussed a lot with classmates, and I’ve heard it from students at other medical schools. I think there is a correlation between getting a less favorable grade and feeling depressed or anxious about the next rotation.

And I also think the problem with grades is that it actually makes the resident’s and the attending’s job a little bit more reductive when evaluating a student. What I would propose instead of grades would be just longer narratives about the student’s performance and a detailed feedback session with the student, because I think that ultimately the grades not only hurt, I think, self-esteem, I think they also make it harder to learn. I think knowing that you’re going to be graded and evaluated might make you act differently than if you just knew that this was purely a learning environment. On every rotation you’re put on a new unit, you’re put on new teams, the note styles are different, the presentation styles are different, and the pathology is very different. So I think that that’s a lot to adjust to as a student, and adding the grade component to that could make the student feel like just a cog in the machine.

Kevin Pho: Now, to your knowledge, what proportion of medical schools today have pass/fail clinical grades in third and fourth years?

Adam Lieber: To my knowledge, I mean, I don’t know an exact number, but I think it’s an extremely low number. Anecdotally, I don’t really know of any medical schools that have clinical pass/fail grades. I know a lot of them have pre-clinical pass/fail grades.

I think that one concern that a lot of people were bringing up with the article is how residencies will then evaluate candidates, and I think that that’s a very valid and important question. I think that one of the issues with grades is that it fosters applying to a lot of residency programs. Sometimes way too many people are applying to 50, 60 residency programs because they want to be competitive. But I think that if people applied to fewer residency programs, residency programs would be able to more holistically evaluate the applicant: read their evaluations, read their personal statements, look at their Step scores, and see the student’s activities outside of the classroom. And I think that that would potentially actually give the residency program more information and a better overall picture of someone than just looking at their grades.

Kevin Pho: We’re talking to Adam Lieber. He’s a medical student, and he wrote the KevinMD article “End medical school grades.” Adam, as you approach the end of your fourth year, is there something that you know now that you wish you knew back before you started your clinical years?

Adam Lieber: Yeah, I think that one thing I would advise anybody going into second year or third year of medical school is to try to do a lot of research up front about different specialties. It’s really important as a first- and second-year to start learning about what the hospital is like, what different specialties are like, what the personalities of the specialties are like, and the types of pathology and patients you’ll be interacting with. There are ample opportunities to shadow, and I remember that as a first-year, I was often a little bit scared to just email an attending, “Hey, can I shadow you in your cardiology clinic today?” because I felt like I didn’t know a lot about that subject.

But I think it’s so helpful to go into third year with an idea of what you might want to do, and I think that way, on every rotation you’re on, you could take a piece of information that’s helpful to you for your future career. For me, in emergency medicine, going into third year I had a strong feeling I would want to do emergency medicine, and I was able to learn things from each rotation that I think would be directly applicable to my career. And I think it made me get more out of the rotation than had I not done that thinking previously about my future career.

Kevin Pho: And after writing this article, aside from the comments pushing back on some of those points, what was the general reaction among your colleagues and your peers?

Adam Lieber: I think my colleagues and peers are very supportive. I think that a lot of us who are going through this understand the stress of grades and have all viscerally felt some sort of way when we didn’t get a good grade. I think that one challenging thing about grades is that only 20 to 40 percent of the class is going to get honors, depending on the school, and you’re sometimes told, as advice from upperclassmen, that it’s important to get honors in the rotation you want to go into. But that doesn’t often pan out, because the distribution of grades doesn’t really lend itself to that.

So I think among my classmates there’s been a lot of support, and I think in general, among the younger generation, there’s more of a push for a more collaborative medical school, a school focused a little bit more on narrative evaluations than raw numbers and grades. So I was pleased with the feedback I got from others. And I hope that this, I know that this article may not move the needle a ton right now, but maybe in the future it will. So I was happy with the feedback.

Kevin Pho: So to those residency directors who may be listening to this, what kind of advice can you give them, when you tell them to look more holistically at applicants and look beyond grades? What are some actionable ways they can do that?

Adam Lieber: Yeah, I think that one thing that I would say for residency directors is that there could be a more interactive interview day, actually, that could, I think, evaluate the student more and see if they’re a good fit for your program. A lot of residency interviews are very personality-based, with questions like this, where we’re just talking and getting to know each other, which I think serves a purpose. But I think it would be interesting to introduce a multiple mini interview, an MMI format, for some of the interviews, where you are either tasked with counseling a standardized patient or solving a problem with another applicant. I had a few of those interviews for medical school, but not so much for residency, and I think that those actually are very telling. It tells you whether the student is a team player, whether the student is adaptable, and how they’ll ultimately be as a resident. So I think that the interview days could actually be structured a little bit differently.

And then I would say, don’t overlook a student who may not have gotten honors in the rotation that they’re going into. There might have been multiple reasons for that. Just take a holistic look at everything they’ve done, from research, from volunteering, from their personal statement, and from their letters.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Adam Lieber: Yeah, I think the take-home message is really for fellow medical students. I think that we put ourselves under a lot of stress, and I think grades are part of that, but I think a lot of it is also self-inflicted. I look at data on burnout and substance use and other mental health concerns among residents and physicians, and I see that these problems don’t end at the medical student level, and they really can last throughout an entire career.

So I think that a take-home message would be to give yourself a break sometimes. Realize that what you’re doing is very hard, realize that it’s normal to feel like an imposter sometimes, and ultimately, we all are trying to be in the business of helping people. So what you’re doing is meaningful, and you should feel proud of yourself.

Kevin Pho: Well, Adam, thank you so much for sharing your time and insight, and thanks again for being on the show.

Adam Lieber: Thank you so much.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes