VIEWPOINT * POINT DE VUE
Is the "avera e" ined'ical student becoming extinct?
Eric Letovsky, MD, FRCPC I recently had to review more than 400 applications for my hospital's 20 rotating internship positions and the 1200-plus letters of recommendation that accompanied them. I've been doing this job for several years now and although it is often a tedious experience, it does provide some revelations. This past year, for instance, I discovered that the "average" medical student has become an endangered species. When I was in medical school, I felt most of the students in my class were more or less of the same calibre. There were a couple of kids who were clearly outstanding - we all knew who they were and that they would eventually end up at the Massachusetts General doing residencies in pathology or nephrology. Similarly, there were a few classmates at the other end of the spectrum and we all knew who they were, too. They kept failing exams, and when you were paired with them as clerks on a ward they left you with a raft of unfinished business when you were on call. However, Eric Letovsky is assistant director in the Division of Emergency Medicine, Mount Sinai Hospital, and assistant professor in
the Department ofFamily and Community Medicine, University of Toronto.
most students were somewhere in between - hard working, conscientious, reliable and all destined to become good, competent interns.
Most medical school graduates continue to be "average" but anyone who reads their letters of reference will have trouble believing this.
I considered myself and the rest of this middle group as equals; from a clinical perspective, we were interchangeable. We were "average," a term my Webster's Third New International Dictionary defines as "something felt as representing an arithmetic average and hence typical of a group, class or series." I now have worked in a teaching hospital for 10 years and have been exposed to hundreds of medical students and interns. Not
much has changed. The spectrum of quality found among today's medical school graduates is still broad, but most of them continue to hover somewhere in the middle and continue to be "average." However, anyone who reads the letters of reference provided to support the applications for internship received at my hospital would have trouble believing this. Of the 1200 letters received last year, only a handful described the subject of the letter as average. The rest of the referees considered the applicants they were supporting "above average" or even better. What is going on here? I'm not naive. I do not think that we get this flood of glowing letters because only the top students in every medical school class apply to complete their internship at Mount Sinai. And I do know that students shopping around for letters of recommendation will gravitate to those clinicians or basic scientists whom they think they impressed. Indeed, many will gravitate to where their clinical interests lie - it is not uncommon to see a single student with reference letters from three plastic surgeons! Although the perspective of these clinicians is useful, the value of their letters is limited because they are invariCAN MED ASSOC J 1991; 144 (6)
753
ROYAL COLLEGE OF
PHYSICIANS AND SURGEONS OF CANADA Examinations in Medical
Genetics The first examinations leading to certification in Medical Genetics will be held in May or June, 1992. Every candidate for admission to the examinations must submit an application for assessment of training. Candidates who wish to take the examinations in 1992 should apply for a preliminary assessment of training as soon as possible, and in any event, not later than 30 April 1991. Only applicants whose assessment of credentials and training is complete can be considered for the examinations. Information and application forms may be obtained from: Office of Training and Evaluation The Royal College of Physicians and Surgeons of Canada 74 Stanley OTTAWA, Canada KIM 1P4
COLLtGE ROYAL DES MEDECINS ET CHIRURGIENS DU CANADA Examens de g6n6tique m6dicale Les premiers examens en vue du certificat en genetique medicale auront lieu en mai ou juin 1992. Tous les candidats ou candidates qui sont interesses ou int6ress6es A se presenter a cet examen devront soumettre une demande d'evaluation. Ceux et celles qui veulent se presenter aux examens de 1992 doivent soumettre une demande aussit6t que possible, et au plus tard le 30 avril 1991. Les candidats ou candidates ne peuvent etre admis ou admises a l'examen avant que l'appr6ciation de la formation ne soit termin6e. On peut obtenir de plus amples renseignements A I'adresse suivante:
Bureau de la formation et de
1'1valuatlon
Le Collge royal des m6decins et chirurgiens du Canada 74 Stonley
OTTAWA, Canada KIM 1P4
754
CAN MED ASSOC J 1991; 144 (6)
ably laudatory and simply reflect a narrow focus of interest for which the student has shown some enthusiasm and inclination. There is, however, a more insidious aspect to this problem - the role of deans' offices in fostering and abetting this entire sham. Two years ago a fourth-year student from another university completed an elective with me. He was incapable of taking a reliable history, his physical exams were invariably incomplete, he was totally unable to present his findings in any organized fashion, and his diagnoses were uniformly wrong. In my evaluation letter to the student's dean's office I recorded my impressions and included a strong letter advising the office that the student was in urgent need of close supervision and was clearly not passable. Three months later I read this same young man's internship application and not a single word of my evaluation was included in the dean's letter that accompanied it. In fact, the entire tone of the letter was fairly neutral and contained no negative comments. He was "pleasant, respectful, hard working, and on time." He was also totally incompetent, but the fact was ignored. Why the distortion? A while ago I wrote to the associate dean of student affairs at one of the medical schools, commenting on the distribution of marks for the various clerkship rotations; the marks accompany the dean's letters. I noted that in most of the disciplines the majority of students were either "above average" or "outstanding"; few if any students were below average or unsatisfactory. I suggested that the school's evaluation system was obviously skewed, since "above average" was now the class norm. The dean, who acknowledged that the school's clinical-evaluation system was somewhat soft, was forthcoming with her explanation. "With ever decreasing numbers of specialty positions,
competition for these positions has become fierce and the process is stressful and demoralizing." She added that "many program directors do not want an 'average' student." So that's it. Have our medical schools become so ego fragile and competitive that they are willing to distort or misrepresent a student's true profile to ensure his or her acceptance into a top program? I wonder what Sir William Osler would think. There are alternatives to the present system. One would be to establish "student assessors" clinicians with the responsibility for accumulating an honest and thorough profile of a student through their own observations and by interviewing the various rotation supervisors. These assessors would remain anonymous to the student and their summary assessments would act as letters of reference - students would no longer be able to choose their own referees. Orientation workshops could be held to inform clinicians what was expected of them and to standardize their assessments. There are other possibilities because there is much room for innovation. What is needed now, however, is a willingness in the medical schools to admit that there is a problem and a promise to address it at the institutional and national levels. I suggest that the medical school deans convene a national task force to look at the issue. It should have a mandate to develop a more accurate, fair and honest evaluation system. To do less would be to abrogate our moral responsibility to students and faculty. Meanwhile, a plea to those of you who write letters of reference and to deans' offices across the country. Please revive the "average" medical student before the species becomes extinct. Greenpeace already has enough on its
plate..
Is the "avera e" ined'ical student becoming extinct?
Eric Letovsky, MD, FRCPC I recently had to review more than 400 applications for my hospital's 20 rotating internship positions and the 1200-plus letters of recommendation that accompanied them. I've been doing this job for several years now and although it is often a tedious experience, it does provide some revelations. This past year, for instance, I discovered that the "average" medical student has become an endangered species. When I was in medical school, I felt most of the students in my class were more or less of the same calibre. There were a couple of kids who were clearly outstanding - we all knew who they were and that they would eventually end up at the Massachusetts General doing residencies in pathology or nephrology. Similarly, there were a few classmates at the other end of the spectrum and we all knew who they were, too. They kept failing exams, and when you were paired with them as clerks on a ward they left you with a raft of unfinished business when you were on call. However, Eric Letovsky is assistant director in the Division of Emergency Medicine, Mount Sinai Hospital, and assistant professor in
the Department ofFamily and Community Medicine, University of Toronto.
most students were somewhere in between - hard working, conscientious, reliable and all destined to become good, competent interns.
Most medical school graduates continue to be "average" but anyone who reads their letters of reference will have trouble believing this.
I considered myself and the rest of this middle group as equals; from a clinical perspective, we were interchangeable. We were "average," a term my Webster's Third New International Dictionary defines as "something felt as representing an arithmetic average and hence typical of a group, class or series." I now have worked in a teaching hospital for 10 years and have been exposed to hundreds of medical students and interns. Not
much has changed. The spectrum of quality found among today's medical school graduates is still broad, but most of them continue to hover somewhere in the middle and continue to be "average." However, anyone who reads the letters of reference provided to support the applications for internship received at my hospital would have trouble believing this. Of the 1200 letters received last year, only a handful described the subject of the letter as average. The rest of the referees considered the applicants they were supporting "above average" or even better. What is going on here? I'm not naive. I do not think that we get this flood of glowing letters because only the top students in every medical school class apply to complete their internship at Mount Sinai. And I do know that students shopping around for letters of recommendation will gravitate to those clinicians or basic scientists whom they think they impressed. Indeed, many will gravitate to where their clinical interests lie - it is not uncommon to see a single student with reference letters from three plastic surgeons! Although the perspective of these clinicians is useful, the value of their letters is limited because they are invariCAN MED ASSOC J 1991; 144 (6)
753
ROYAL COLLEGE OF
PHYSICIANS AND SURGEONS OF CANADA Examinations in Medical
Genetics The first examinations leading to certification in Medical Genetics will be held in May or June, 1992. Every candidate for admission to the examinations must submit an application for assessment of training. Candidates who wish to take the examinations in 1992 should apply for a preliminary assessment of training as soon as possible, and in any event, not later than 30 April 1991. Only applicants whose assessment of credentials and training is complete can be considered for the examinations. Information and application forms may be obtained from: Office of Training and Evaluation The Royal College of Physicians and Surgeons of Canada 74 Stanley OTTAWA, Canada KIM 1P4
COLLtGE ROYAL DES MEDECINS ET CHIRURGIENS DU CANADA Examens de g6n6tique m6dicale Les premiers examens en vue du certificat en genetique medicale auront lieu en mai ou juin 1992. Tous les candidats ou candidates qui sont interesses ou int6ress6es A se presenter a cet examen devront soumettre une demande d'evaluation. Ceux et celles qui veulent se presenter aux examens de 1992 doivent soumettre une demande aussit6t que possible, et au plus tard le 30 avril 1991. Les candidats ou candidates ne peuvent etre admis ou admises a l'examen avant que l'appr6ciation de la formation ne soit termin6e. On peut obtenir de plus amples renseignements A I'adresse suivante:
Bureau de la formation et de
1'1valuatlon
Le Collge royal des m6decins et chirurgiens du Canada 74 Stonley
OTTAWA, Canada KIM 1P4
754
CAN MED ASSOC J 1991; 144 (6)
ably laudatory and simply reflect a narrow focus of interest for which the student has shown some enthusiasm and inclination. There is, however, a more insidious aspect to this problem - the role of deans' offices in fostering and abetting this entire sham. Two years ago a fourth-year student from another university completed an elective with me. He was incapable of taking a reliable history, his physical exams were invariably incomplete, he was totally unable to present his findings in any organized fashion, and his diagnoses were uniformly wrong. In my evaluation letter to the student's dean's office I recorded my impressions and included a strong letter advising the office that the student was in urgent need of close supervision and was clearly not passable. Three months later I read this same young man's internship application and not a single word of my evaluation was included in the dean's letter that accompanied it. In fact, the entire tone of the letter was fairly neutral and contained no negative comments. He was "pleasant, respectful, hard working, and on time." He was also totally incompetent, but the fact was ignored. Why the distortion? A while ago I wrote to the associate dean of student affairs at one of the medical schools, commenting on the distribution of marks for the various clerkship rotations; the marks accompany the dean's letters. I noted that in most of the disciplines the majority of students were either "above average" or "outstanding"; few if any students were below average or unsatisfactory. I suggested that the school's evaluation system was obviously skewed, since "above average" was now the class norm. The dean, who acknowledged that the school's clinical-evaluation system was somewhat soft, was forthcoming with her explanation. "With ever decreasing numbers of specialty positions,
competition for these positions has become fierce and the process is stressful and demoralizing." She added that "many program directors do not want an 'average' student." So that's it. Have our medical schools become so ego fragile and competitive that they are willing to distort or misrepresent a student's true profile to ensure his or her acceptance into a top program? I wonder what Sir William Osler would think. There are alternatives to the present system. One would be to establish "student assessors" clinicians with the responsibility for accumulating an honest and thorough profile of a student through their own observations and by interviewing the various rotation supervisors. These assessors would remain anonymous to the student and their summary assessments would act as letters of reference - students would no longer be able to choose their own referees. Orientation workshops could be held to inform clinicians what was expected of them and to standardize their assessments. There are other possibilities because there is much room for innovation. What is needed now, however, is a willingness in the medical schools to admit that there is a problem and a promise to address it at the institutional and national levels. I suggest that the medical school deans convene a national task force to look at the issue. It should have a mandate to develop a more accurate, fair and honest evaluation system. To do less would be to abrogate our moral responsibility to students and faculty. Meanwhile, a plea to those of you who write letters of reference and to deans' offices across the country. Please revive the "average" medical student before the species becomes extinct. Greenpeace already has enough on its
plate..
