This question has been circulating in the academic medical world for years. As an intern and resident, I would hear complaints about how “unready” they seemed. The grievances often include adjectives like ill-prepared, lazy, or uninterested. The complaints have burgeoned over time, and the examples are numerous in my institution: Students show up late to rounds with coffee in their hands; one med student had the gall to go directly to the attending and request early dismissal because he “had nothing to do.” The problem seems to permeate all schools. Beyond the effects of this behavior on student culture, it results in underprepared interns and residents.
As a chief resident, I have set aside weekly teaching conferences with the students, and I think I have begun to better understand the issues. Just 5 to 10 years ago, medical school expectations were high. You were expected to show up early to rounds, leave late, be at the beck and call of your resident, and have absolute respect for an attending physician. Respect for the process of education was standard. You dressed appropriately. You studied to impress, and you came to rounds prepared to try your best. So why have these standards changed recently? Because none of these qualities are rewarded appropriately in a student’s medical school “report card.”
Medical student grades, and, therefore, class ranks, theoretically are based upon two major components: clinical evaluations and test scores (i.e., shelf exams). But the truth is, in medical education today, evaluations completed by residents and attendings of students on their medical teams are essentially useless. Most evaluations result in clinical grades that are essentially the same, no matter how hard-working or lazy a student was on the floors. Many reasons are put forward to explain why this occurs, but I think the most important is evaluation burnout.
Academic medicine is riddled with so many unneeded and redundant evaluations that most physicians do not put the time or mindshare into making them useful. This results in clinical scores that do not help discern who put forth the work to excel and who just showed up because they needed proof of attendance. It is for this reason that the test scores are weighted so much more heavily than clinical evaluations in the eyes of the average medical student.
“Why get to work early and learn about my patient when my test score and a review of ‘high yield’ facts from a review book will further my career more effectively than learning how to do a good physical exam?” “What is the point of having a well-prepared presentation for rounds when I will get the same score as my colleague who spent the morning going through review questions?” “What is the point of impressing my attendings when all that really matters is my grade and class rank?”
These questions guide the behavior of students, and I cannot blame them. Medical school is competitive. Long-term career plans depend on more than whether a resident team thinks a student is not putting quality time in on the wards. The finger must be pointed at our medical education system, which values test taking over clinical knowledge and skill. How can we expect to produce a generation of quality practitioners without ensuring that we instill the value of actually practicing that theoretical medicine they learn in textbooks and are quizzed on in exams? We somehow have to shift the tide of education toward, or perhaps back toward, an environment in which becoming a physician means more than a number or letter grade or a class rank.
Do you agree that students are ill-prepared? Do you see a solution to the problem of students being less interested in the work on the wards?
Ahmad Yousaf is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.
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