Should we ditch grades in medical school?

No.

My experience with the new anti-grade “pass-fail” culture. Why grades are important, and getting more important, in medical school.

(Note, these stories are commentaries on my time at University, during which I studied at a number of hospitals. They are not commentaries on the hospitals where I have worked).

I was in the hallway of my hospital when I ran into my Australian Medical Students Association representative who told me that she had just been to Canberra to advocate for hospitals ignoring the university grade of final year medical students who are applying to work as intern doctors.

I.e your marks would not matter and hospitals could not find out how you did in your exams.

Why would you want to do that? I asked, genuinely perplexed.

She politely laughed, and then looked confused, as if I’d just told a joke that had fallen flat.

“Oh...really? Oh… you’re really asking. Sorry I thought you were joking. Well, there’s no evidence that the marks have any bearing on your performance as a doctor. That’s what the evidence shows.”

My bullshit detector exploded. Imagine what it would be like if it were true:

You are told that you have two doctor candidates for one position. The only information you have on them is that one was the top medical student in their cohort, having achieved the highest mark. The other was the bottom ranked, having achieved the lowest mark.

You turn to your hiring manager and tell them “What are you telling me this for. Don’t you know that marks have no bearing on performance as a doctor?”.

You instead flip a coin to decide who to hire.

I tried not to let my frustration show. I asked:

How many of the medical students actually support this?

“Well, all of my friends do. I can’t think of a single person I know who doesn’t want the marks ignored. And they all have high marks, so they aren’t just doing it to get something for themselves”.

Regular medical students below being saved by their guardian angel student unionists.

I felt a mild headache begin, the type that starts when you realise that something has gone wrong, but it’s probably too late. This girl’s friends were all in the student union, and had attended “medical leadership” conferences every year (often on scholarships paid by my fees). If there were no marks to rank students, it was obvious that a generously padded resume of political excursions and committees would put you in first place.

I thought of a few of those I had seen electing each other to this committee and that committee as officer for wellbeing, officer for diversity and inclusion, officer for party planning. Many of them I wouldn’t have trusted to lead me to the milk at the supermarket.

I remembered my time on the publications and promotions committee, which I had been picked for due to my affinity for photoshop and also my ability to actually publish funny material, rather than lie in bed at night sweating about what people are going to say about my jokes.

When I had arrived on that committee the President had announced that “For the past few years, I think the students’ society has been run for the benefit of the committee. But now I think that it should be run for the benefit of everyone”. This was well received. I clapped, but was also a little concerned. I’d been forced to be a member of at least one students’ society for the past four years. Forced, as in forced to hand over more than a hundred dollars a year in order to remain a student. This was the first I had heard someone come out and admit that the society or societies had really just been rackets for the elected few. It was a little bit like when McDonalds started advertising that it’s burgers were “100% real beef” in the 2000s. It made me wonder what I’d been eating in the 90s.

I remembered one third year, a particularly blunt medical student (a surgical hopeful, obviously), had been asked during an information session whether he thought that a younger medical student should involve themselves in a student union committee.

“The committees...yeah...hmmmm. They’re really just a bunch of people having meetings and doing not much, I think”

People burst into nervous laughter. This was a rare event. Normally the students society carefully picks who speaks to the juniors. Usually someone with a track record of faithful service. This one had obviously slipped through the cracks.

Stop that man! He’s leading the children and nobody voted for him!

I also recalled a few years ago running into a friend from yoga who was campaigning for me to elect her to some position or another at University of Melbourne Students Society. She put a flyer in my hand and asked me to vote for her. I asked why. She told me about all the great diplomatic missions that her team were planning, sending people to this city, sending people to that city. I had no idea I had so many representatives travelling around the country on my behalf. She was also telling me how corrupt the current union was. I had kind of drifted off with boredom, and when it was my turn to speak I had looked into the distance and said:

Yeah… my suspicion with the student union is that it’s just a way to funnel money to people on the committee to send themselves to conferences in Sydney to boost their resumes.

I looked back at her with a smile, thinking that she would agree at my appraisal of the corrupt student union as it currently was (I really was inclined to put her on the committee to clean things up). Instead, she went bright red, tears sprang into her eyes, and she recoiled slightly. I saw her mouth trying to form words, but nothing was coming out.

Oh bugger. I thought. She thinks I’m talking about her. In retrospect, I probably was, although I didn’t know it. 

I decided to change the topic:

So, you’re doing a masters in mathematics. That’s great, I study a fair bit of maths myself. What are you interested in pursuing?

She looked relieved to discuss something else.

“Oh, I’m mainly interested in representation.”

Oh that’s interesting! Representation of data, or something in geometry…?

“More representation of women in maths”.

I sighed. It’s impossible to talk to these people.

After all…

In my final year of medical school I was sitting in a tutorial with a few other highly political medical students and did two very unpopular things.

First, I had asked the tutor to take us to interesting patients, and then test us on our history and examination skills. As if this were not bad enough, I had asked him to test us in a looping order, so that once every two weeks each student was called upon to talk to the patient and try to figure out what was wrong with them. This meant that If you failed to reach a diagnosis, or stuffed up the physical exam, you would be doing so in front of your own medical student colleagues.

This didn’t bother me at all. It bothered some of the others very much. When I read the anonymous feedback given to the medical school, I was exasperated by how often the students were complaining about ‘being called upon’. I.e the lecturer or teacher directly asks a student a question, instead of offering it up to anyone in the audience. 

The resilience of the average medical student seemed to be dropping rapidly. And anyone who put them, even indirectly, in situations where this was made apparent was hated.

Me answering the senior doctor’s questions in front of my peers (centre) and the earnest student unionist protecting me from scrutiny (right).

Back to the idea that marks have no bearing on performance. Let’s be realistic, please.

First of all, hospitals tend to have stratification of graduates according to marks. So all of the doctors who got H1s  (As) end up in the city, H2s (Bs) end up in the country, and those who passed end up in New South Wales. So within one hospital, you have a very narrow spread of marks, and yet a very large spread of performance scores. So your ability to prove a correlation is already diminished, since you really only have doctors who received very similar marks in one hospitals. 

If you combine two different institutions, you find that they all normalize their own doctors performance scores around ‘average’, which means that taking data from multiple institutions will only make a correlation harder to prove. You’ll find that the average doctor at every hospital is scoring...approximately 3/5.

Whoops, there goes your correlation.

Finally, if you dilute and opacify the performance scores as much as possible, so it no longer measures performance on the tasks involved with the job, but actually measures ‘how much the assessor likes you’ (which is exactly what the scores are according to one head of department in my hospital), then it becomes impossible to prove anything.

Yes, you cured the patient. But sometimes I think that you can be a little bit disrespectful in the way that you don’t agree with everything I say, think, and feel.
You don’t think so? See.
This is what I’m talking about.

I actually met the highest ranked medical student of my cohort. He was lovely. I remember his freakish ability to never backslide on knowledge. He just seemed to build and build. Additionally, he seemed to love being in hospital, and got a massive amount of hands-on time with the patients. In the final weeks of medical school he correctly diagnosed a patient with endocarditis, a bacterial infection within the chamber of the heart. It can cause a lot of pathognomonic signs (pathognomonic: specifically characteristic or indicative of a particular disease or condition), which make detecting it easy in some cases. But it does not produce them reliably, so in other cases it can be a very subtle disease.

Sometimes it presents with fevers, bounding pulse, and a new murmuring sound in the heartbeat.

That’s how this medical student picked it up. There’s a certain amount of kudos that goes to anyone who can make a diagnosis based off of sound. A visual sign, you can take a picture of, share it around, get your ruler out, do colour tests etc. A sound is fleeting, and pretty much non-recordable without a very expensive stethoscope. Yet despite how fleeting a sound is, once you ‘get your ear in’, you can really zero in when something sounds wrong.

Despite having what I considered fairly ‘crap’ ears, I took the time to do stethoscope maintenance over the years and reordered earbuds and diaphragms to keep my stethoscope in good condition. The benefit to that is that, unlike many other doctors, my equipment was not getting worse as my skills increased. Now that I think back, I also recall that many of the medical students didn’t carry their stethoscopes around with them. They would keep them in their lockers or at home. I think part of this was a performative humility, since wearing a steth would have you mistaken for a doctor all the time. Yet whenever they needed one, they would ask me. 

One time my tutorial buddy pulled my stethoscope out of his ears and handed it back to me with a big clump of earwax the size of a smartie on the earbud. 

Are you serious?  I asked, as he tried to hand it back to me.

“Oh… well… I can clean it if you like”.

I think I’ll clean it myself, thanks…

I also did some time in Royal Darwin Hospital Intensive Care Unit, where the ICU Consultant would have me do a full physical on all 32 extremely sick and dying patients daily and ask me to record changes in physical signs. This was going well for 2 weeks until I caught something from one of the patients, spiked a high fever myself, developed rhabdomyolysis when I competed in a local chin-up competition whilst sick. I ended up in the emergency department myself on Boxing Day with jaundice, and learned a valuable lesson about viral infections and muscle catabolism. 

When I returned to Melbourne, I had ‘got my ear in’ and could pick up a lot more through the stethoscope.

One night a doctor colleague came onto the ward, with a medical student trailing him. The medical student was explaining the benefits of disregarding the marks to the doctor he was shadowing. I knew that the doctor himself had topped our hospital in marks as a medical student. 

The doctor said “Well, without marks, what incentive is there to study harder?”

The student replied “Well, I studied hard this year, and they aren’t doing marks due to Covid-19”.

It was all getting very subjective. The doctor handballed it over to me. 

“Hey Woody,” he said, “What do you think? Should they ditch marks and grades?”

No, I responded, and I looked the medical student up and down. 

Keep it... (I made a fist and clenched it)... competitive. 

The medical student guffawed and looked at me in surprise and laughter. He couldn’t tell if I was being serious. I may as well have just said For the glory of the Australian Nation. 

It seems fairly obvious from my experience that the medical students who advocated for removing the marks were also the one advocating for the full set of collectivist policies in medicine.

Their dislike for marks and grades wasn’t based on an objective perspective of correlations between grades and performance. It was based on an intrinsic dislike of being judged, and being ranked against their colleagues. They didn’t like being graded for the same reason that they didn’t like having to perform a physical exam on a patient in front of their peers. It gives other people the opportunity to see how good they really are.

In fact, the second argument for why we should abolish grades and marks is usually that exams are not good for the mental health of the students. This is a particularly egregious use of mental health safetyism since it actually exacerbates the problem, by reinforcing that the best strategy to deal with anxiety is avoidance. By the end of seven years at University, one would hope that students can sit a test without having a breakdown, if only due to desensitisation. It will come as no surprise to the reader that of the people I have recalled who advocated for disregarding grades, many of them did, in fact, have anxiety disorders. Pursuing a strategy of controlling and eliminating external sources of anxiety is a losing play, but one that can unfortunately be sustained for a long, long time by people who know exactly how to simper to each other.

My old classmates when I would absolutely nail my point

We do exams and tests so that we can become comfortable with being judged by someone else. Which is something that tends to happen a lot during practice as a doctor. Moreover, since the questions on exams and tests in medical school are virtually identical to the questions that I have to answer on the wards to keep patients safe, I think it’s good that the hospital knows who can and cannot answer them.

If we don’t have grades and marks, then it’s obvious who wins:

Student Unionists with glowing references from their equally political ‘mentors’, who have sat on a dozen committees and can proudly say that due to their weekly committee meetings, the medical students society has made a formal statement against the playing of Blurred Lines by Robin Thicke at the hospital ball. 

Historically, medical students have been told that if they want to self-elect themselves as the professionals in charge of high stakes life or death decisions, that they also need to prove in some objective way that they are competent enough for those roles. The preservation of objective measures of doctors’ competence is integral to the science of medicine, and the functioning of the work environment as a whole. More importantly, it creates an objective benchmark by which people can assess themselves. With politics invading the workplace at an alarming pace, we should be doing everything we can to conserve the metrics with which we make assessments of people’s works.

And if we’re not conserving them, we should at least be improving them.

The actual reality of getting the best measurements is a little bit more complicated. After all, we’re talking about a lot of data and a lot of required domain knowledge. Not to mention that most of that data will be sitting in a dataframe in a computer somewhere. If only a team had all the necessary skills to put it together…

Sorry got lost in thought there for a second.