Eric Grosch, Letter to Dr. Morgenstern on LOR - Semmelweis ...

DR. ERIC N GROSCH - A new approach <strong>to</strong> LOR
Dear <strong>Dr</strong>. <strong>Morgenstern</strong>:
I read your article[1] with interest. You wrote:
In considering a new approach <strong>to</strong> the pediatric LOR, COMSEP and the APPD welcome the input
of the broader pediatric community.
Thanks for expressing an interest in receiving my comments, since I'm an internist, not a
pediatrician. I'm pleased <strong>to</strong> contribute <strong>to</strong> the dialogue, which I think is important. I apologize, in
advance for the length of my text but I think the <strong>to</strong>pic warrants it. Quoted text is indented and my
own unindented.
The LOR and its close relative, the performance-appraisal, are sacred cows in medical education,
training and job-placement. They purport <strong>to</strong> provide means of communicating a candidate's traits
among men<strong>to</strong>rs -- the performance-appraisal among men<strong>to</strong>rs within an institution; the LOR from
men<strong>to</strong>rs in one institution <strong>to</strong> those in another. The approach for each is much the same.
That purpose seems analogous <strong>to</strong> the medical record in patient-care, which provides a means of
communicating a patient's disease-traits among the patient's physicians. The analogy is false for
reasons I cite, in the chart, below:
Clinical chart LOR/performance-appraisal
appraisal and appropriate appraisal summative, end of rotation presented usually action at least
daily after the fact, <strong>to</strong>o late for improvement
goal is improvement of the patient goal varies between promotion of the candidate <strong>to</strong> his
elimination from consideration
Relies on objective evidence for Often relies on rumor, innuendo, scuttlebutt for decision-making
decision-making
Documentation is as long as is Documentation is as brief as possible <strong>to</strong> save
necessary reading time
Documentation is in terms of specific Documentation is in terms of unsubstantiated
clinical events opinions, couched in generalities, of men<strong>to</strong>rs, peers, etc.
On the evidence that I've examined, I believe that there are better ways than the LOR and the
performance-appraisal <strong>to</strong> accomplish the mission. I don't consider that a flippant belief. I've
arrived at my opposition <strong>to</strong> the LOR/performance-appraisal through considerable thought, reading

and anecdotal experience, both as an author and subject of LORs. Most of what I say here is in
the public domain and obvious. I get the impression that nobody ever puts it <strong>to</strong>gether, so I've
done that, though, perhaps incompletely. If you have any objections <strong>to</strong> what I've said here, please
let me know them.
I divide my reasons in<strong>to</strong> generic sections:
1. Golden Rule: Do un<strong>to</strong> others as you would have others do un<strong>to</strong> you. The Golden Rule[2],
alone, should persuade anyone with any insight in<strong>to</strong> the treatment that he would ideally prefer for
himself, that the performance-appraisal/LOR can never work.
2. Comparisons are always odious.
3. Deleterious effect: The idea of performance-appraisal is fundamentally flawed, even
dysfunctional, because of the often deleterious effect it has on those trainees that appraisers rate
as less than the very best, even though quality of performance is a lottery, governed in large part
by random chance. Accordingly, rating people who are of the system makes no sense.
4. Improper substitute for “where do I stand”: LORs and performance-appraisals serve the
organization or institution, not the individual appraised.
5. Inaccuracy:
a. misapplication of the Likert-scale principle
b. inevitability of rating-inflation
c. popularity-contest
d. mismeasure of “excellence”
e. men<strong>to</strong>r-inattention: Men<strong>to</strong>rs, who are supposed <strong>to</strong> do the evaluations and LORs, don't pay
enough attention <strong>to</strong> their trainees' performance <strong>to</strong> fulfill that function adequately because their
contact with trainees is minimal and sporadic, so their appraisal of the performance of their
trainees is most often inaccurate and may even reverse the reality on the ground.
f. self-fulfilling prophecy
g. absence of evidence-basis
h. glittering generalities: Even if men<strong>to</strong>rs paid attention <strong>to</strong> trainees' performance, the rating
systems that they use address only glittering generalities, such as “general medical knowledge,”
require presentation of no supporting evidence and rarely <strong>to</strong> never address the only index of
work-performance in medicine, namely, clinical outcomes of patients under the trainees' care.

i. dis<strong>to</strong>rtion from “confidentiality,” under perpetual tension
6. The ultimate goal: communion of “<strong>to</strong>p” talent in “<strong>to</strong>p” institutions
7. Illustrative anecdote which is more typical than it should be
1. Golden Rule[2]
The performance-appraisal and the LOR are exercises in disregarding the needs of others and in
attributing <strong>to</strong> others the character and nature of objects. The psychic mechanisms that prompt
those in authority <strong>to</strong> impose performance-appraisal/LOR on others -- what they would not want
for themselves -- are obscure but the most likely reason seems <strong>to</strong> be that the very act of
imposition may, in and of itself, provide a pleasurable and ego-boosting exercise of arbitrary
authority.
Whatever the psychic mechanisms, the proof of the observation appears in the contrast between
the AMA's consistent endorsement of peer-review for physicians they presume, generically, <strong>to</strong> be
“bad doc<strong>to</strong>rs and its disparagment of Professional Standards Review Organizations (PSROs).
For example, it is a matter of record that the AMA was a strong supporter of enactment of the
Health Care Quality Improvement Act of 1986 (HCQIA), which codified peer-review provisions
from hospital bylaws in<strong>to</strong> federal law. The AMA initially supported the HCQIA because it
supports peer-review of “bad doc<strong>to</strong>rs” but opposed one feature of that act, the National
Practitioners Data Bank (NPDB), and withdrew its support al<strong>to</strong>gether from the HCQIA over that
issue, but it eventually obtained a quid pro quo: NPDB as well as absolute immunity from liability
for hospital-level peer-reviewers, a provision that has led <strong>to</strong> the proliferation of bad-fath
peer-review.[3]
At the same time, JAMA and other journals have published articles that have impugned the
accuracy of the findings of PSROs, the agents of which may conduct peer-review on any
practicing physician, including one whom the AMA would presume <strong>to</strong> be a “good doc<strong>to</strong>r.”
Neither JAMA nor any other medical journal has published even one article that has examined the
accuracy or validity of hospital-based peer-review, which the AMA enthusiastically approves
because statutes render such peer-review privileged/confidential.
2. Comparisons are always odious
Farrell[4] noted the emotional effect of sex-reversed beauty-contests among men. The winner
was, of course, ecstatic, enthusiastic and high in self-esteem but the runner-ups felt devastated at
the relative rejection and they experienced an epiphany: why women (at least those of runner-up
grade [or less] physical appearance) dislike cus<strong>to</strong>mary beauty-contests. Comparisons are always
odious because the comparison-game is a zero-sum proposition. Performance-appraisal is an
appraisal of something that the evaluee can control <strong>to</strong> some extent by his conscious will, as
opposed <strong>to</strong> appearance, which he can't, so it's marginally less pernicious than a beauty-contest but
not much. The fact remains that the better one individual rates, the worse others do. It's

inescapable.
The performance-appraisal/LOR in most fields, including medical education, always hinges on
comparing one trainee, by various criteria, with others. The comparison may appear as a
class-rank or as a comparison of the subject's rating with an ideal rating, e.g., 6 of a possible 10
points, 4 of a possible 5 points, etc. The message is always: “You don't measure up.”
That message is especially demoralizing <strong>to</strong> the usual medical trainee, since the very fact that he's
survived <strong>to</strong> the stage of medical training means that he has already survived very stringent
selection/exclusion filters and thus become accus<strong>to</strong>med <strong>to</strong> superlative accolades in his early
education, through schooling and his undergraduate years. Thrown in the midst of similar
high-achievers, the normative performance is likely <strong>to</strong> be uniformly high and he may rate merely
“average.”
3. Deleterious effect:
Deming lists the performance-appraisal (and, by implication, also the cus<strong>to</strong>mary LOR) among the
deadly diseases of business-organizations. The same ideas apply, in spades <strong>to</strong> medical
organizations and <strong>to</strong> LORs, which are retrospective, summative performance-appraisals, frozen
and immutable, in perpetuity:
...the deadly diseases...
3. Evaluation of performance, merit rating...Many companies in America have systems by which
everyone...receives from his superior...a rating...(101) Management by objective leads <strong>to</strong> the same
evil...Management by fear would be a better name...(Deming 1986 107)
Fair rating is impossible. A common fallacy is the supposition that it is possible <strong>to</strong> rate people; <strong>to</strong>
put them in rank order of performance for next year, based on performance last year.
The performance of anybody is the result of a combination of many forces -- the person himself,
the people that he works with, the job, the material that he works on, his equipment, his cus<strong>to</strong>mer,
his management, his supervision, environmental conditions (noise, confusion, poor food in the
company's cafeteria). (109) These forces...[which]...arise almost entirely from action of the
system...will produce...large differences between people....A man not promoted is unable <strong>to</strong>
understand why his performance is lower than someone else's. No wonder; his rating was the
result of a lottery. Unfortunately, he takes his rating seriously...(Deming 1986, 110)
The effect is devastating:
It nourishes short-term performance, annihilates long-term planning, builds fear, demolishes
teamwork, nourishes rivalry and politics.
It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior,
some even depressed, unfit for work for weeks after receipt of rating unable <strong>to</strong> comprehend why

they were inferior. It is unfair, as it ascribes <strong>to</strong> the people in a group differences that may be
caused <strong>to</strong>tally by the system that they work in.
...what is wrong is that the performance appraisal or merit rating focuses on the end product, at
the end of the stream, not on leadership <strong>to</strong> help people. This is a way <strong>to</strong> avoid the problems of
people. A manager becomes, in effect, manager of defects.
The idea of merit rating is alluring. The sound of the words captivates the imagination: pay for
what you get; get what you pay for; motivate people <strong>to</strong> do their best, for their own good.
The effect is exactly the opposite of what the words promise. Everyone propels himself forward,
or tries <strong>to</strong>, for his own good, on his own life preserver. The organization is the loser.
Merit rating rewards people that do well in the system. It does not reward attempts <strong>to</strong> improve
the system. Don't rock the boat.
...a merit rating is meaningless as a predic<strong>to</strong>r of performance, except for someone that falls
outside the limits of dif- (102) ferences attributable <strong>to</strong> the system that the people work in...
Traditional appraisal systems increase the variability of performance of people. The trouble lies in
the implied preciseness of rating schemes...Somebody is rated below average, takes a look at
people that are rated above average; naturally wonders why the difference exists. He tries <strong>to</strong>
emulate people above average. The result is impairment of performance. (103)
...The problem lies in the difficulty <strong>to</strong> define a meaningful measure of performance. The only
verifiable measure is a short-term count of some kind...(Deming 1986, 103)
Degeneration <strong>to</strong> counting. One of the main effects of evaluation of performance is nourishment of
short-term thinking and short-time performance...(103) A man must have something <strong>to</strong> show. His
superior is forced in<strong>to</strong> numerics. It is easy <strong>to</strong> count. Counts relieve management of the necessity
<strong>to</strong> contrive a measure with meaning.
...people that are measured by counting are deprived of pride of workmanship. Number of designs
that an engineer turns out in a period of time would be an example of an index that provides no
chance for pride of workmanship. He dare not take time <strong>to</strong> study and amend the design just
completed. To do so would decrease his output. (105)
A good rating for work on new product and new service that may generate new business five or
eight years hence, and provide better material living, requires enlightened management. He that
engages in such work would study changes in education, changes in style of living, migration in
and out of urban areas. He would attend meetings of the American Sociological society, the
Business Section of the American Statistical Association, the American Marketing Association.
He would write professional papers <strong>to</strong> deliver at such meetings, all of which are necessary for the
planning of product and service of the future. He would not for years have anything <strong>to</strong> show for
his labors. Meanwhile, in the absence of enlightened management, other people getting good

atings on short-run projects would leave him behind. (Deming 1986, 106)
Stifling teamwork. Evaluation of performance explains...why it is difficult for staff areas <strong>to</strong> work
<strong>to</strong>gether for the good of the company. They work instead as prima donnas, <strong>to</strong> the defeat of the
company. Good performance on a team helps the company but leads <strong>to</strong> less tangible results <strong>to</strong>
count for the individual. The problem on a team is: who did what?
How could the people in the purchasing department, under the present system of evaluation, take
an interest in improvement of quality of materials for production, service, <strong>to</strong>ols, and other
materials for nonproductive purposes? This would require cooperation with manufacturing. It
would impede productivity in the purchasing department, which is often measured by the number
of contracts negotiated per man-year, without regard <strong>to</strong> performance of materials or services
purchased. If there be an accomplishment <strong>to</strong> boast about the people in manufacturing might get
the credit, not the people in purchasing. Or, it could be the other way around. Thus...teamwork so
highly desirable, can not thrive under the annual rating. Fear grips everyone. Be careful; don't take
a risk; go along.
Heard in a seminar. One gets a good rating for fighting a fire. The result is visible: can be
quantified. If you do it right the first time, you are invisible. You satisfied the requirements. That
is your job. Mess it up, and correct it later, you become a hero.
Two chemists work <strong>to</strong>gether on a project, and write up their work as a scientific paper. The paper
is accepted for a meeting in Hamburg...only one of the pair may go <strong>to</strong> Hamburg <strong>to</strong> deliver the
paper -- viz., the one with the higher rating. The one with the lower rating vows never again <strong>to</strong>
work close with anyone else.
Result: every man for himself.
Evaluation of performance nourishes fear. People are afraid <strong>to</strong> ask questions that might indicate
any possible doubt about the boss's ideas and decisions, or about his logic. The game becomes
one of politics. Keep on the good side of the boss. Anyone that presents another point of view or
asks questions runs the risk of being called disloyal, not a team player, trying <strong>to</strong> push himself
ahead. Be a yes man.
Top levels of salaries and bonuses are in many American companies sky-high. It is human nature
for a young man <strong>to</strong> aspire...<strong>to</strong>...one of these positions. The only chance <strong>to</strong> reach a high level is by
consistent, unfailing promotion, year after year. The aspiring man's quest is not how <strong>to</strong> serve the
company with whatever knowledge he has, but how <strong>to</strong> get a good rating. Miss one raise, you
won't make it: Someone else will. (108)
A man dare not take a risk. Don't change a procedure. Change might not work well. What would
happen <strong>to</strong> him that changed it? He must guard his own security. It is safer <strong>to</strong> stay in line.
The manager, under the review system, like the people that he manages, works as an individual
for his own advancement, not for the company. He must make a good showing for himself.

Another Irving Langmuir? Can American his<strong>to</strong>ry, under handicap of the annual rating, produce
another Irving Langmuir, a Nobel Prize winner, or another W. D. Coolidge? Both these men were
with the General Electric Company. Could the Siemens company produce another Ernst Werner
von Siemens?
...It is worthy of note that the 80 American Nobel prize winners all had tenure, security. They
were answerable only <strong>to</strong> themselves. (Deming 1986, 109)
“It can't be all bad.”...<strong>to</strong>p management delay[s abolition]...of the annual rating of performance...by
refuge in the...corollary that “It can't be all bad. It put me in<strong>to</strong> this position.”...He reached this
position by coming out on <strong>to</strong>p in every annual rating, at the ruination of the lives of a score of
other men. There is a better way.
Modern Principles of Leadership...will replace the annual performance review. The first step...will
be <strong>to</strong> provide education in leadership. The annual perfor- (116) mance review may then be
abolished. Leadership will take its place...
The annual performance review sneaked in and became popular because it does not require
anyone <strong>to</strong> face the problems of people. It is easier <strong>to</strong> rate them; focus on the outcome...Western
industry needs...methods that will improve the outcome. Suggestions follow.
1. Institute education in leadership; obligations, principles, and methods.
2. More careful selection of the people in the first place.[5]
It seems difficult <strong>to</strong> imagine selecting medical trainees by methods any more careful than current
ones.
3. Better training and education after selection.
4. A leader, instead of being a judge, will be a colleague, counseling and leading his people on a
day-<strong>to</strong>-day basis, learning from them and with them. Everybody must be on a team <strong>to</strong> work for
improvement of quality in the four steps of the Shewhart cycle:...
In the absence of numerical data, a leader must make subjective judgment. A leader will spend
hours with every one of his people.. They will know what kind of help they need. There will
sometimes be incontrovertible evidence of excellent performance, such as patients, publication of
papers, invitations <strong>to</strong> give lectures.
People that are on the poor side of the sytem will require individual help...(Deming 1986, 117)
a. What could be the most important accomplishments of this team? What changes might be
desirable? What data are available? Are new observations needed? If yes, plan a change or test.
Decide how <strong>to</strong> use the observations.

. Carry out the change or test decided upon, preferably on a small scale.
c. Observe the effects of the change or test.
d. Study the results. What did we learn? What can we predict?...(Deming 1986, 88)
5. A leader will discover who if any of his people is (a) outside the system on the good side, (b)
outside on the poor side, (c) belonging <strong>to</strong> the system. The calculations required...are...simple if
numbers are used for measures of performance. Ranking of people...that belong <strong>to</strong> the system
violates scientific logic and is ruinous as a policy,...
In the absence of numerical data, a leader must make subjective judgment. A leader will spend
hours with every one of his people. They will know what kind of help they need...
People...on the poor side of the system will require individual help....(Deming 1986 117)...
7. Hold a long interview...three or four hours, at least...not for criticism, but for help
and...everybody[‘s]...better understanding...
8. Figures on performance should be used not <strong>to</strong> rank the people...that fall within the system, but
<strong>to</strong> assist the leader <strong>to</strong> accomplish improvement of the system...(118)
...Running a company on visible figures alone (counting the money). One can not be successful on
visible figures alone...he that would run his company on visible figures alone will in time have
neither company nor figures.
...the most important figures...are unknown and unknowable..., but successful management must
nevertheless take account of them. Examples.
Fallacies of reward for winning in a lottery. A man in the personnel department of a large
company came forth with an idea, held as brilliant...<strong>to</strong> reward the <strong>to</strong>p (274) man of the month on
a certain production line (the man that made the lowest proportion defective over the month) with
a citation. There would be a small party on the job in his honor, and he would get half a day off.
This might be a great idea if he were indeed an unusual performer for the month. There were 50
men on the production line.
Do the results of inspection of their work form a statistical system...? If the work of the group
forms a statistical system, then the prize would be merely a lottery...if the <strong>to</strong>p man is a special
cause on the side of low proportion defective, then he is indeed outstanding. He would deserve
recognition, and he could be a focal point for teaching men how <strong>to</strong> do the job.
There is no harm in a lottery...provided it is called a lottery. To call it an award of merit when the
selection is merely a lottery...is <strong>to</strong> demoralize the whole force, prize winners included. Everybody
will suppose that there are good reasons for the selection and will be trying <strong>to</strong> explain and reduce
differences between men. This would be a futile exercise when the only differences are random

deviations, as is the case when the performance of the 50 men form[s] a statistical system.
(Deming 1986 275) [5]
In a similar vein, Ierodiakonou and Vandenbroucke term medicine a s<strong>to</strong>chastic art:
Ancient Greek philosophers thought that medicine was an art with peculiar characteristics, and
they called medicine a s<strong>to</strong>chastic art. A doc<strong>to</strong>r might treat a patient conscientiously according <strong>to</strong>
all learned precepts; yet the patients' condition might deteriorate. Another patient might be treated
rather carelessly by another doc<strong>to</strong>r; yet the patient might regain full health. Thus, in medicine
there exists unpredictability between means and ends. By contrast with other arts a diligent
execution of the tasks does not guarantee a good outcome, and vice versa...
...we have long witnessed a debate on the right way <strong>to</strong> measure the quality of medical care: should
we use outcome or process criteria?...For instance, a few years ago, (542) a series of outcome
investigations was started in the USA. Presumably, some administra<strong>to</strong>rs had been convinced that
even in health care, quality of performance should be measured according <strong>to</strong> strict outcome
criteria, as is practised in the Japanese car industry, for example. The simplest outcome measure
was mortality in hospital. Third party payers such as the Health Care Financing Administration,
which administrates Medicare, started <strong>to</strong> rank hospitals according <strong>to</strong> mortality rates for specific
procedures. The mere idea sent ripples of alarm through the American Medical Association
(AMA). Do not we intuitively know that medical centres with the highest reputation attract
patients whose illnesses are close <strong>to</strong> being beyond rescue? Advanced epidemiological techniques
have proved that differences in hospital mortality can be explained away by adjustment for
differences in patient mix. To use outcome as a means <strong>to</strong> moni<strong>to</strong>r quality would necessitate
continuous evaluation of all individual patient characteristics. This process would be a gigantic
research effort, close <strong>to</strong> the examination of treatments in randomised controlled trials, and would
defy all realistic efforts at quality assurance. The whole armamentarium of epidemiology and
statistics, such as randomisation, matching, blinding, placebo-procedures, strict selection criteria,
and modelling, aims at mastering the s<strong>to</strong>chastic elements that confound our judgment...[6]
Why should the performance of trainees be deterministic, not s<strong>to</strong>chastic, inasmuch as the
s<strong>to</strong>chastic vagaries of patient-characteristics (case-mix) must influence it, in any individual
instance? The difference is that hospital-administra<strong>to</strong>rs have an influential voice in such
decision-making. The individual trainee does not.
Under pervasive fear of rating, the trainee dares not ask a question that he thinks that the rater
might think foolish. He has <strong>to</strong> confine his questions only <strong>to</strong> what he considers “intelligent,” posed
with the purpose in mind of impressing the rater with his insight and wisdom, beyond his years.
The good regard of the rater is the trainee's life-preserver, on a s<strong>to</strong>rmy sea of insecurity. The
trainee walks on eggshells, fearing that his every move, his every word is an element in a
cumulative body of chit-marks that may eventually <strong>to</strong>rpedo his reputation. If he should get a black
mark against him, for any reason, and the rater learns of it, the trainee shall thereby have lost the
rater's support and enter career free-fall. Accordingly, he pre-edits all questions for acceptability
before letting them out of his mouth. If he can't think of a zinger of a question, he'll most likely
stay mum and live in ignorance about a broad variety of subjects, out of fear of asking a “stupid

question.”
MIT Cal Tech and other high-prestige institutions have experimented with a pass-fail grading
system because they unders<strong>to</strong>od the inherent absurdity of grading-systems, with their arbitrary
cut-off points for each letter-designation. That represented a rejection of the very notion of
grading. I'm not certain of the status at those institutions at the moment. Maybe their graduates
have had difficulty translating their academic performance in<strong>to</strong> terms that other institutions, that
recognize grading, understand, so maybe they've gone back <strong>to</strong> grading.
4. Improper substitute for “where do I stand”
Coens and Jenkins deplore performance-appraisals and, by implication, also LORs:
At a recent quality conference, a CEO was questioned as <strong>to</strong> why his organization continued <strong>to</strong> use
appraisals after shifting <strong>to</strong> a quality management culture of system and process
improvement...“We think we owe it <strong>to</strong> people <strong>to</strong> let them know where they stand.”...(27)
What people really want is access <strong>to</strong> the knowledge and information that influences the
organization's pay, promotion, and status systems and how these affect or apply <strong>to</strong> them...People
are insatiably curious about Where do I stand? because, in most organizations, this query is
decided with a maze of unspoken rules, inscrutable political influences and other dynamics of
organizational life. Appraisal is not the system that drives pay, careers, and status; it is an
incidental effect of those dynamic systems. Appraisal is...the paper-shuffling that sanctifies
decisions already made.(28)[7]
The cognate of pay and promotion, in the corporate setting, is gaining acceptance in<strong>to</strong> a “<strong>to</strong>p”
(whatever that might mean) training program, in the medical-educational setting.
Too often, a trainee finds out, <strong>to</strong> his surprise or shock, where he stands only when he reads his
retrospective performance-appraisal/LOR and, by then, it's <strong>to</strong>o late <strong>to</strong> do anything about it. LORs
and performance-appraisals have an especially pernicious affect on medical students, at that
vulnerable stage in their development, but they're bad for any trainee and for any person.
5. Inaccuracy:
a. misapplication of the Likert-scale
“Likert” seems an unlikely choice for naming the method, since Likert used the scale in canvassing
members of population-samples <strong>to</strong> obtain aggregate ratings of their attitudes in his
1932-article[8], the presumed basis of the eponym. Likert, himself, had the good sense not <strong>to</strong>
apply such rating scales <strong>to</strong> important matters that could affect people's livelihoods, though his
predecessors already had and his successors still do. Likert[9] credited prior authors, Fechner and
Gal<strong>to</strong>n, without citing a reference, for the origination of such questionnaires, circa 1888. Scott
introduced the system <strong>to</strong> the United States Army in the early part of the last (20th) century[10].
Paterson, an employee of the Scott-Company, described a later adaptation of Scott's

method[11,12] for “objective” evaluation of job-performance, the purpose of interest here.
With no apparent insight in<strong>to</strong> the inherent vagueness of the method, Paterson claimed <strong>to</strong>
distinguish objective from subjective qualities without doing so:
objective qualities . . . “efficiency,” “originality,” “perseverance,” and “quickness” . . . subjective
qualities . . . “courage,” “cheerfulness” and “kindliness.” . . .[12]
The criteria he cited for rating workers were similarly vague:
Ability <strong>to</strong> Learn, Quantity of Work, Quality of Work, Industry, Initiative, Co-operativeness,
Knowledge of Work[13]
Strangely, Paterson disregarded the opportunity for evidence-based assessment of the criterion
most amenable <strong>to</strong> objective evaluation, namely quantity of work, in terms, say, of number of units
the worker produces per unit-time. Instead, the instructions bade the rater give a worker on that
criterion a rating-score, presumably <strong>to</strong> foster “uniformity”[14] with ratings of other criteria, not
amenable <strong>to</strong> objective assessment.
Other authors described errors and pitfalls inherent in the method. Thorndike first described the
halo effect as a
. . . constant error <strong>to</strong>ward suffusing ratings of special features with a halo belonging <strong>to</strong> the
individual as a whole[15]
He found even the most capable rater
unable <strong>to</strong> treat an individual as a compound of separate qualities and <strong>to</strong> assign a magnitude of
each . . . in independence of the others.[16]
As a countermeasure <strong>to</strong> minimize the halo-effect, he exhorted:
. . . the observer should report the evidence, not a rating, and the rating should be given on the
evidence <strong>to</strong> each quality separately without knowledge of the evidence concerning any other
quality in the same individual.[16]
Thorndike did not explain how a rater could avoid having knowledge of ratings he had given on
other criteria listed on the same form. The “evidence” Thorndike had in mind consisted in vague
descriptive adjectives, similar <strong>to</strong> those that Paterson cited,[17] that the rater had a general
impression might apply <strong>to</strong> the ratee.
Kingsbury addressed accuracy:
. . . ratings as ordinarily made are . . . unreliable, and . . . only under what may be called ideally
favorable conditions will they approximate accuracy, even on a scale so gross as one of five

divisions. (18)
Kingsbury enumerated those allegedly ideal conditions:
Ratings, <strong>to</strong> be reliable, necessitate (1) averaging three independent ratings, each made on an
objective scale; (2) these scales must be comparable and equivalent, made in conference under
expert supervision; (3) the three raters must be competent <strong>to</strong> rate.[18]
Paterson joined, with slightly different wording, in affirming Kingsbury's ideal conditions (2) and
(3) and in thus implicitly alluding <strong>to</strong> pitfalls of the method:
. . . Ratings should be accepted and filed for use only from those who have proved themselves
capable of accurately judging human qualities. . . a rating scheme will not work au<strong>to</strong>matically. It
must be closely supervised preferably by trained personnel research workers who must continually
subject the ratings <strong>to</strong> critical analysis and assist in training executives in proper use of the method.
There is no escape from this requirement.[19]
Paterson and Kingsbury omitted mention of what specifics the training they proposed for the
personnel-research workers should comprise and accomplish but they presumably intended,
among other things, that the trained supervisors should somehow ensure separate evaluation of
labeled traits <strong>to</strong> exclude Thorndike's halo-effect; then, by averaging, fine-tuning, adjustment and
manipulation of the scores from at least three raters, all of whom knew how <strong>to</strong> provide accurate
ratings (presumably assessed by the raters' mutual agreement on each candidate's score on each
criterion) obtain a set of ratings consistent with the aggregate global impression each candidate
made on the raters (the candidate's halo). The circularity of the rationale seems inescapable.
Prior <strong>to</strong> receiving requests <strong>to</strong> fill out forms consisting of Likert-scale ratings on others'
performance, I have never received any of the extensive training or testing <strong>to</strong> prove myself
“capable of accurately judging human qualities,” nor, I daresay, has any appraiser of my
performance received such training and testing, <strong>to</strong> my knowledge. The origina<strong>to</strong>rs of such forms
seemed <strong>to</strong> assume that the rating scemes would “work au<strong>to</strong>matically,” contrary <strong>to</strong> Kingsbury's
admonition.
Rugg may have had more insight:
. . . The unordered -- yes, the chaotic -- character of the judgments appears, irrespective of what
traits are considered or of what kinds of scales are compared. I now believe that the evidence
establishes the futility of obtaining single “ratings” on point scales of such dynamic qualities as
“intelligence,” “personal qualities,” “general work,” and the like.[20]
Paterson cautioned and predicted:
These rating methods should not be looked upon as perfect or final. Further research is necessary,
and industry will profit . . . as progressive, experimentally minded executives realize the scope of
the problem and engage in the necessary research . . . <strong>to</strong> develop newer and more reliable methods

than we now possess.[21]
The progress Patterson envisioned has been slow in developing, as the medical-education
evaluation-literature amply shows [22- 28]. The Likert-scale remains alive, well and unimproved
since Paterson, Kingsbury and Thorndike fretted over it and <strong>to</strong>rtured it and since Rugg dismissed
it as inherently invalid over eighty years ago.
Rating-criteria in medical education continue <strong>to</strong> be as vague as Paterson's, e.g., “general medical
knowledge (1-5),” “procedural skill (1-5),” “rapport with patients (1-5),” “rapport with nurses
(1-5),” “overall general impression (1-5)” (the most global “halo”-criterion of all) and the like.
Many,[22-28] though not all[29,30] current users and discussants of the Likert-scale treat it as an
axiomatically good and self-explana<strong>to</strong>ry scheme.
In current medical-education usage, men<strong>to</strong>rs rate trainees and trainees rate men<strong>to</strong>rs without any
expert supervision - in disregard of Kingsbury's ideal conditions[18], Paterson's precautions[19]
and Rugg's skepticism[20] -- perhaps in imitation of Likert[8], who may have felt justified in
ignoring the precautions, conditions and invalidity of the method for objective evaluation because
he pursued only subjective attitudes rather than purportedly objective traits. Yet, those who
publish studies based on Likert-scale “data” apply the numerical scores derived as if they were
facts and manipulate them with parametric statistics as if they were not ordinal[ 22-28] .
Guilford[30] appears <strong>to</strong> equate Likert-scales with formal psychometric tests by including them in
his book, entitled, “Psychometric Methods.” Worse, many seem <strong>to</strong> follow Thorndike[9] in
attributing traits <strong>to</strong> ratings, a tendency Tryon deplores, even for psychological tests, which are
more formal than Likert-ratings, yet purveyors of Likert -ratings attribute traits <strong>to</strong> them:
The test-trait fallacy [consists in presuming] that test scores provide measures of enduring and
generalized characteristics of the person, called traits. . .
The test-trait fallacy begins with the assumption that test scores are trait measures. The second
assumption is that trait measures are basic properties of the person. It easily follows that test
scores reflect basic properties of the person. . . hence a measurement is reified in<strong>to</strong> a causal force.
. . the unsound logic of drawing inferences about ability on the basis of observed performance is
integral <strong>to</strong> the test-trait fallacy. . .[32]
Traits are alluring because they are . . . compatible with the stimulus-organism-response paradigm
<strong>to</strong> which virtually all psychologists subscribe. . . To presume that psychological tests . . . measure
organismic traits and <strong>to</strong> further presume that such traits are the basic properties that cause
behavior is <strong>to</strong> place the psychologist in an attractively powerful theoretical and clinical position.
The volume of psychological tests . . . is evidence of their allure for clinicians and researchers
alike.[33]
Authors even apply statistical methods <strong>to</strong> aggregate number-scores from a group of raters,
compute inter-observer correlations and the like. Literature-approval of Likert-scale “data”
encourages decision-makers <strong>to</strong> attach unwarranted worth <strong>to</strong> Likert-scale merit-ratings and

serenely <strong>to</strong> apply them in life-altering decisions <strong>to</strong>uching subordinate trainees,[22] such as
recommendation for certifying examinations, and employment, and even in promoting
faculty-members[25].
Albanes[34] suggests that “real life” ratings, presumably of qualified physicians, are objective and
based on outcomes, yet Carey[35] asserts that evaluations of physician-faculty must be subjective.
Codman[36] and his spiritual successors[37-41] have called for outcome-based rating of
performance and, by extension, of competence, but physicians and hospitals have pointed the
deficits of that method and prevented its spread, <strong>to</strong> date, by citing the multiplicity of fac<strong>to</strong>rs,
unrelated <strong>to</strong> institutional or physician-competence, that determine outcome.[42]
The champions of rating attribute two roles <strong>to</strong> it, evaluative or summative (entailing punitive and
deterrent purposes) and formative.[42] Paterson <strong>to</strong>uted the formative purpose:
I. Rating methods have been developed because of a recognition of the educational value of
ratings . . .
a. . . . on those who make the ratings. . . insures the analysis of subordinates in terms of the traits
essential for success in the work.
b. . . . on the employee. . . encourages self-analysis and provides an incentive for
self-improvement in . . . traits in which he is weakest.[35]
As educational feedback, rating fails <strong>to</strong> fulfill Ziegenfuss' proposed criteria for adequacy and
efficacy:
. . . the art of feeding back quality-related data is a critical point of quality improvement work. . .
Feedback is effective when the following conditions are met:
1. Clarity of Purpose. Data can be used for development or for rendering judgment (formative
versus summative . . .). . . for . . . organizational development, . . . the purpose is . . . formative . .
. Learning and change <strong>to</strong> improve processes is the goal. A judgmental purpose (summative) offers
a . . . grade of pass or fail and is designed for accountability. . .[45]
Since “accountability” entails punishment[46], it does not belong in any workplace.[4] In
education, by definition, the only appropriate purpose of feedback is the formative one. The
Likert-rating, in its cus<strong>to</strong>mary application, succeeds in the summative, punitive goal of criterion 1
but fails in its formative goal.
2. Clear and Specific Data. Data . . . must be . . . relevant <strong>to</strong> the . . . recipient.[45]
The vague expression, “general medical knowledge, 3” (or any other number) is unclear and
non-specific, so rating fails criterion 2 and is not relevant <strong>to</strong> the recipient (see criterion 5).

3. Descriptive, Not Evaluative. Useful feedback describes what is happening but does not offer an
evaluative judgment (unless that is the intended purpose). The presenters must not rush <strong>to</strong>
judgment without some interactive discussion with the audience.[45]
The Likert-scale rating substitutes for relevant evidence and thus fails criterion 3.
4. Timely. How close <strong>to</strong> the action . . . reviewed are the data describing the events? The golden
rule is quick feedback . . . Old data is useful for his<strong>to</strong>rical and longitudinal purposes but is not
supportive of behavior change in the near term.[45]
The team, employed long-term, may <strong>to</strong>lerate a monthly, quarterly or semi-annual feedback-cycle.
The medical student or other trainee, who often has monthly rotations in clinical departments,
needs a shorter feedback-cycle. Feedback should be continuous, its formal aspect should be at
least weekly, and, preferably, daily. The commonest Likert-rating comes <strong>to</strong> the ratee's attention as
a summative, end-of-rotation event, delivered <strong>to</strong>o late for him <strong>to</strong> implement improvement, so it
fails criterion 4.
5. Limited. How great is the scope of the data? . . . tailor and focus the data <strong>to</strong> fit the specific,
targeted needs of users. . .[45]
A Likert-rating, e.g., “general medical knowledge, 3,” is <strong>to</strong>o vague and global <strong>to</strong> serve a ratee's
needs. It invites the so-called halo-effect and fails criterion 5.
6. Comparative. . . To leave out comparative information is <strong>to</strong> deprive the recipients of
knowledge about their progress or lack thereof. . .[45]
Albanes[34] deplored the rater's “failure <strong>to</strong> discriminate” among trainees in awarding them equal
marks. He thereby pursued a similar goal of making distinctions for distinctions' sake alone and
disregarded the “lottery”-nature of rating people who operate “within the system,”[5]
Kingsbury likewise suggested:
. . . we do have <strong>to</strong> make distinctions between people . . .
. . . and the rater should realize that it is not so disastrous <strong>to</strong> make some employees 2 who are not
much worse than some he marks 3, as it is <strong>to</strong> mark them all alike <strong>to</strong> avoid seeming <strong>to</strong> magnify the
difference. . .[47]
As Deming eloquently explains,[5] it's disastrous for an individual <strong>to</strong> suffer a low rating. A low
rating may be especially crushing <strong>to</strong> a medical student, accus<strong>to</strong>med such a tender soul often is,
from the experience of a lifetime, <strong>to</strong> high academic ratings.
If two or more employees or trainees perform equally well and very well, say, 5 of 5, they would
deserve equal marks because equality of their performance reflects truth. The company, <strong>to</strong> which
marking two or more employees alike, e.g. 5 of 5, may seem disastrous, can stand the gaff more

easily than an individual arbitrarily marked down, despite his best effort, merely <strong>to</strong> “make
distinctions between people.” Neither Albanes[34] nor Kingsbury[47] justified the need <strong>to</strong> make
such distinctions. He presumably considered the principle axiomatic and self-evident.
Since the end-of-rotation Likert-scale rating provides no progressive comparisons and since
men<strong>to</strong>rs might balk at the administrative burden of completing Likert-scale ratings more often
than once monthly, it provides no sequential comparison and fails criterion 6.
7. Participative Interpretation. . . . final . . . analysis can[not] be conducted without audience
involvement. Joint interpretation is consistent with the developmental/formative purpose, as
<strong>to</strong>gether we discuss meaning and follow-up action . . .[45]
In the medical-education context, the Likert-scale rater rarely discusses his rating with his ratee(s)
prior <strong>to</strong> entering it. It comes most often <strong>to</strong> the recipient's attention as a fait accompli, <strong>to</strong>o late for
him <strong>to</strong> improve it. The Likert-scale rating fails criterion 7.
8. Safety and Security. Receiving performance feedback is . . . technical and . . . psychological . . .
We need first <strong>to</strong> have the data correct (technical). . . Presenters must be sensitive <strong>to</strong> the
psychology of the process and offer language and behavior that protect the recipients.[45]
The Likert-scale rating inherently fails the technical criterion, since it consists of a set of numerical
scores which obscures the evidence that purports <strong>to</strong> form its basis. Various errors, <strong>to</strong> wit, the
halo-effect (supra) and tendency <strong>to</strong>ward the mean[48,49] inhere in the Likert-scale.
As applied, it most often fails the psychological criterion since the social-control function, which
Albanes[34] advocated is crucial <strong>to</strong> its deterrent/punitive function. To pull a punch at the moment
of delivery would diminish or annihilate the crushing impact the rater can otherwise accomplish.
9. Practical and Action Oriented. To be useful, the data should suggest some followup action and
should be practical enough <strong>to</strong> be used by professionals in the field. . . [32,50]
Having received a rating of, e.g., “general medical knowledge, 3,” the recipient can discern no
idea from the rating how <strong>to</strong> improve. The Likert-rating fails criterion 9.
The evidence seems clear that ratings fail all of Ziegenfuss's rational criteria for effective feedback.
b. inevitability of rating-inflation
A universal human conceit holds that everybody's a fool and a moral pervert except for thee and
me and I'm not so sure about thee. The individual expects others <strong>to</strong> rate him in a manner
consonant with the intrinsic, superlative characteristics that he attributes <strong>to</strong> himself. When
men<strong>to</strong>rs, in a medical-education setting, rate him harshly, he feels helpless and often non-plussed
and feels an urge <strong>to</strong> press his raters <strong>to</strong> improve his rating.
Some years ago, Sissela Bok, philospher and wife of Derek Bok, former President of Harvard

University, addressed merit-ratings on “fitness-reports” in the US Army. Her context was “lying”
and her example of a liar was the supervisor who rated his subordinates <strong>to</strong>o highly on traits, such
as “leadership,” “appearance,” etc., which are at least as nebulous as entities that raters in
medicine attempt <strong>to</strong> address, e.g., “general medical knowledge,” “rapport with staff,” etc. They're
all manifestations of the great tendency <strong>to</strong> generalize from skillful execution of a narrow scope of
activities, such as getting high scores on tests, <strong>to</strong> global “excellence,” “outstandingness” or
“bestness,” in general.
Bok's description shows that your observation that “excellent” is a third-tier rating has a his<strong>to</strong>ry:
...Those who rate officers are asked <strong>to</strong> give them scores of “outstanding,” “superior,' “excellent,”
“effective,” “marginal,” and “inadequate.” Raters know...that those who are ranked anything less
than “outstanding” (say “superior” or “excellent”) are then at a great disadvantage, and become
likely candidates for discharge...superficial verbal harmlessness combines with the harsh realities
of the competition for advancement and job retention <strong>to</strong> produce an inflated set of standards <strong>to</strong>
which most feel bound <strong>to</strong> conform. (Bok 73)
...The US Army tried <strong>to</strong> scale down evaluations by publishing the evaluation report...cited. It
suggested mean scores for the different ranks, but few felt free <strong>to</strong> follow these means in individual
cases, for fear of hurting the persons being rated. As a result, the suggested mean scores once
again lost all value. (Bok 74) [51]
Professor Bok, writing as a member of the establishment. LORs and performance-evaluations
cause little <strong>to</strong> no worry <strong>to</strong> her and her husband, who have made it <strong>to</strong> the <strong>to</strong>p of the academic
heap, from which pinnacle, they may comment on us, herebelow:
In elite . . . organizations, the evaluation model tends <strong>to</strong> be elitism. Two lines of argument are
involved. First, since the organizations have selected the best people, evaluation of performance is
irrelevant. After all, if the best people could not succeed, who could do better? Second, since the
quality of the organizations and their output is determined primarily by the equality of their
people, attention <strong>to</strong> system, methods, or management is inconsequential. It follows that, if the
organizations already have the best people, “the opportunities for increased productivity in them
are small and come slowly.” Finally, . . . elitism tends <strong>to</strong> create self-perpetuating closed circles
whose members are exempt from review except by peers within.
Converting work problems in<strong>to</strong> people problems is a process of denying organizational
accountability. It is a process of establishing a hierarchy of special privilege and immunity <strong>to</strong> rank
with the hierarchy of authority. It is a process of maintaining the status quo; it denies both the
need for change and the possibility. (27)[52]
Accordingly, Professor Bok focused on the “lies” perpetrated <strong>to</strong> help the plebeian but omitted any
mention of organization dishonesty: the rumor-grapevines, chiefly by telephone, which leave no
paper-trail, and which circumvent and subvert the normal channels of committed, transparent,
written communication, <strong>to</strong> which subjects of ratings on LORs might obtain access.[53]
Personnel-managers use such underhanded means <strong>to</strong> evade legal liability for defamation of

character <strong>to</strong> find out from former employers “what applicants are really like.”
You wrote in your article[1] in nearly identical terms of the inevitable tendency <strong>to</strong>ward rating
inflation, your “hierarchy of superlatives,” the Lake Wobegon effect, in which everybody is
“above average,” and the tendency <strong>to</strong>ward rating-fragmentation <strong>to</strong> permit raters <strong>to</strong> distinguish the
"is one of the finest medical students of the year," "...one of the best medical students I have ever
worked with," "richly deserves the honors awarded in the rotation," or "receives my highest
recommendation",[54] from among the best and those who are the very best in the past year, the
best ever, etc., etc. Speer et al cited grade-inflation in internal medicine as well:
. . . a significant number of clerkship direc<strong>to</strong>rs (43%) felt that we are unable <strong>to</strong> appropriately
identify students with failing performances. The implication for our ability <strong>to</strong> certify students as
clinically competent is concerning. . . (116)[55]
That's evidently not their concern. They express more concern with labeling trainees clinically in
competent.
. . . faculty were the key <strong>to</strong> both the cause and solution. (116)[55]
That is a truer statement than Speer et al perhaps realized, though faculty would probably prefer
<strong>to</strong> blame the trainee-victims.
Yet, clinical medicine simply doesn't contain tasks of sufficient sophistication that trainees could
perform that would enable a trainee could distinguish himself from his fellows <strong>to</strong> the extent
depicted in all the finely nuanced and ever mounting expressions of enthusiasm. The difficulty
would be quite similar <strong>to</strong> the difficulty of rating a patient in similar terms, according <strong>to</strong> his
response <strong>to</strong> treatment. Objectively, he either gets better, stays the same or gets worse. It's difficult
<strong>to</strong> imagine that an evalua<strong>to</strong>r of patients could find rational criteria for appraising a patient's
recovery as “excellent,” “outstanding,” one of the best on the ward,” “one of the best in the past
year,” “the best ever,” etc. If a rater can't do it for a patient, how can he do it for a trainee?
Gould attributed the fallacy of confusing objects with labels <strong>to</strong> John Stuart Mill:
The tendency has always been strong <strong>to</strong> believe that whatever received a name must be an entity
or being, having an independent existence of its own. And if no real entity answering <strong>to</strong> the name
could be found, men did not for that reason suppose that none existed, but imagined that it was
something peculiarly abstruse and mysterious.[56]
Gould cited the fallacy in noting that Benet, origina<strong>to</strong>r of IQ, intended none of the social elitism <strong>to</strong>
which it has given rise.[56] Such reification of jargon is a prominent feature also of rating
practice.
c. popularity-contest
What feats of clinical derring-do can a trainee, at any level, perform that would make him so much

etter than any of his contemporaries that he would qualify for such sterling and distinctive
accolades as "is one of the finest medical students of the year," "is one of the best medical
students I have ever worked with," "richly deserves the honors awarded in the rotation," or
"receives my highest recommendation",[54] in contradistinction <strong>to</strong> his fellows, whose
performance might rate a mere “excellent”?
Did pediatric resident A miraculously heal a girl with Friedrich's Ataxia so she never progressed
and even achieved a normal gait? If so, how did he do it? By Divine Intervention? By Black
Magic? By weird science? Miracle-healing, if accomplished, would obviously exceed cus<strong>to</strong>mary
expectations and be well the upper control-limit of performance that Deming defines as “within
the system.” Miracle-healing may thus warrant the highest accolades but even outstanding
residents rarely <strong>to</strong> never perform it.
The only realistic answer that comes <strong>to</strong> my mind is that the highly regarded trainee manufactures
his high regard by ingratiating himself, through force of intrinsic personality or insidious, political
means, in<strong>to</strong> the rater's favor. The rater then comes <strong>to</strong> like the trainee personally so much that he's
willing <strong>to</strong> go out on a limb for him with various superlative terms of enthusiasm, presumably
assuming his performance be at least adequate. In other words, rating of trainees for
personnel-records and the LOR are popularity-contests. Who has the bubbliest personality? Who
is the most “well liked?”[57]
Such a system could select for those who go along <strong>to</strong> get along and who may rate pleasing their
administrative superiors <strong>to</strong> enhance the chance of their own advancement as more important than
performing what's right for a patient, perhaps contrary <strong>to</strong> the will of his superiors. Such disregard
of objectively correct performance may lead <strong>to</strong> deterioration of quality of patient-care, ostensibly
the opposite of rational goals for a health-care system.
d. mismeasure of “excellence”
Mere prattle without practice doesn't necessarily tranfer well <strong>to</strong> good real-world outcomes.
Howard Zinn spoke of “the best and the brightest”:
The New York Times did a survey of high-school students <strong>to</strong> see how much his<strong>to</strong>ry they knew.
They do this every few years. They do a survey of young people <strong>to</strong> prove how dumb they are and
<strong>to</strong> prove how smart are the givers of the tests and so they gave this test <strong>to</strong> high-school seniors and
corroborated what they thought. Young people don't know anything about his<strong>to</strong>ry. They asked
questions like, “Who was the President during the War of 1812?” “Who was the President during
the Mexican War?”...We're in a great quiz-culture...“What came first the Homestead Act or the
Civil Service Act?” You recognize questions like that because those are the questions that appear
on tests which enable you <strong>to</strong> get in<strong>to</strong> graduate-school. You can go very far if you know enough of
those answers. You'll be Phi Beta Kappa. You'll become an advisor <strong>to</strong> the President of the United
States. You remember the book, The Best and the Brightest, which was precisely about that
point, that the people surrounding the President were...the people who got the highest scores.
They were Phi Beta Kappa and they were the architects of the War in Vietnam.[58]

Holman cited an analogous problem related <strong>to</strong> inflated self-esteem, the ‘excellence' deception in
medicine[59].
Simpson addressed the examination-system but his remarks apply at least as well <strong>to</strong> any rating
system:
...the traditional examination system...achieves...pseudo-precision, for it has chosen the accurate
measurement of the barely relevant in preference <strong>to</strong> the less precise measurement of the most
highly relevant...our cultural bias <strong>to</strong>wards believing that anything expressed in numbers must be
significantly more true than the same thing expressed in words...allows the student <strong>to</strong> accumulate
a sequence of numerical ascriptions and grades, often of very dubious reliability and
validity...added <strong>to</strong>gether and averaged <strong>to</strong> help us guess at whether he is fit <strong>to</strong> leave medical
school. This is as logical as making a pre-operative surgical assessment by adding and averaging
your patient's haemoblobin, potassium, urea and blood sugar levels. It produces results...of little
or no predictive validity and...neither tell the student who has passed the exam why he has done
well (so that we can be reasonably sure he can do it again) nor tell the student who has failed
anything of much use <strong>to</strong> him in avoiding further failure...[60]
e. men<strong>to</strong>r-inattention
The descriptions of how recipients of LORs perpetrate Mill's reification-fallacy in an attempt <strong>to</strong>
attach specific meanings <strong>to</strong> various phrases that the phrases themselves don't necessarily
denote[61], seems especially anomalous in a context in which the author may be a
department-chairman who may even concede that he has never had any contact with the trainees,
about whom he has a duty <strong>to</strong> write LORs, not have even what Albanes called
The episodic, fragmented, and...small amount of contact that clinical faculty have with
students...(Albanes 653)[34]
Albanes claimed that that circumstance
...leaves them [raters] reluctant <strong>to</strong> make ratings that would call attention <strong>to</strong> students' performance
deficits...(Albanes 653)[34]
In those circumstances, faculty-members' reluctance <strong>to</strong> make ratings of any sort , at all, would
bespeak their simple honesty. Yet, somehow, most faculty-members, whether in good conscience
or not, rate their students and other trainees after clinical rotations and later when they write
LORs for them.
Kefalides affirms faculty-expectations and complains that insurance-rules newly require
faculty-members <strong>to</strong> take care of patients and thus provide golden opportunities for clinical
teaching, which he seems <strong>to</strong> disparage.[62]
Cydulka et al present time-cosuming, close observation of trainees as a startling new
departure.[63]

In the industrial setting, in which TQM arose, nobody could ever confuse the manufactured
product with the worker whose efforts produce it. In another article,[64] Albanes did just that. He
attempted <strong>to</strong> apply TQM <strong>to</strong> medical education but, in the process, he conflated students as human
beings with students as objects, products of the education-process and got his ideas twisted. As a
result, in one section of his article, grading is good, while in another, it's bad. The very fact that
Academic Medicine published his article indicates the likelihood that the thinking, among many
academics, about rating and evaluating the performance of trainees and others is confused.
f. self-fulfilling prophecy
Bosk noted:
One striking feature of the clinical judgment of residents is how easily the whole process may turn
in<strong>to</strong> self-fulfilling prophesy ( sic )....good reputations exercise a protective or deviance-reducing
effect while bad ones generate a destructive or deviance-amplifying one. If a resident is considered
trustworthy, moni<strong>to</strong>ring by attendings is decreased. Therefore, deficiencies are less likely <strong>to</strong> be
discovered. Conversely, if a resident is suspect, moni<strong>to</strong>ring increases. Convinced that they are
there for the finding, an attending is more likely <strong>to</strong> find evidence of sloppy work. When found,
these only increase surveillance, which again increases the probability of mistakes. Clearly
suspicion does not create residents who are unfit-- after all, something creates the suspicion.
Nonetheless, being suspect is for a resident a very vulnerable and demoralizing position. Not only
that, being above suspicion gives a fair amount of protection, especially when mistakes need not
be seen as innocent error. Given these dynamics, it is not surprising that those who fall on the
short end of evaluation (or their at<strong>to</strong>rneys) often characterize it as arbitrary and capricious.[65
Strangely, when a physician so abuses ancillary personnel that they lose their self-confidence in an
analogous manner, he becomes a “disruptive physician,”[66] fit only for expulsion. Yet, in the
setting of medical education, such abuse is <strong>to</strong>lerable, even cus<strong>to</strong>mary.
g. Absence of evidence-basis
Rating/evaluation is particularly vulnerable <strong>to</strong> charges of resting on an inadequate evidence-basis:
...In perusing the folders of the residents in the training program that I studied, I found only one
evaluation that mentioned a specific incident. This leads me <strong>to</strong> suspect that residents who are
dismissed from programs could easily argue that their “due-process rights” were violated, which
raises a very thorny issue. Surgery <strong>to</strong> a large degree rests on peer trust, and it is unclear what
degree of formal, concrete evaluation is consistent with that trust. (12)[67]
Two pediatric core-curricula have come out for emergency-pediatrics,[68,69] one for pediatric
interventional cardiology,[70] one core-content inven<strong>to</strong>ry for adult emergency-medicine[71] and a
retrospective inven<strong>to</strong>ry of diagnoses encountered in internal-medicine residency.[72]
Other core-curricula may exist in other specialties, yet, in no specialty, do recommendations for
the LOR relate in any manner <strong>to</strong> specific elements of any defined core-curriculum. If the LOR is

supposed <strong>to</strong> reflect job-performance, what justification is there for omitting any mention of
job-performance criteria, delineated in national core-curricula, core-content statements or
otherwise?
In all the literature on LORs and evaluations, none that I've seen suggest including the cumulative
statistics on clinical outcomes of patients under the care of the subject of the LOR. Yet, without
such evidence of actual job-performance, in terms of numbers and proportions of patients saved,
lost and improved, the rest is nothing.
The medical literature is replete with accounts of physicians' inaccurate performance-appraisals of
their colleagues and of trainees.[73-86] Those accounts render the idea of entrusting
performance-appraisal of anyone <strong>to</strong> physicians patently absurd.
Perhaps the most concrete, objectively verifiable category is “procedural skills.” The trainee either
succeeds at the lumbar puncture by obtaining CSF or not, succeeds in intubating a patient or not.
No performance-evaluation I've ever seen has any space devoted <strong>to</strong> citing the specific number of
procedures that the men<strong>to</strong>r observed the subject performing, far less a score-card that documents
how many he performed successfully and in how many he failed. What would be the distinction in
a rating of 3/10 vs. a rating of 7/10 in the category, “procedural skills?” One might imagine that
the evaluee succeeded in 30% or 70%, respectively, of the procedures he performed during a
clinical rotation. Did a month-long rotation provide even ten opportunities for each of, say three
trainees, <strong>to</strong> perform lumbar punctures or intubations? It seems unlikely.
If the trainee's score was low, where is the documentation of the help that the men<strong>to</strong>r provided <strong>to</strong>
the trainee <strong>to</strong> improve his performance? I've never seen it and the proposed standard <strong>Letter</strong> of
Recommendation (SLOR), in emergency-medicine, omits mention of anything like it.[54,63]
Where is the documentation of the progress in the trainee's score during the month? Was his score
2 of 10 at the beginning of his rotation and 8 of 10 at the end? I've never seen anything like that,
either, possibly because a trainee may have one opportunity <strong>to</strong> perform one clinical procedure in a
month, if he's lucky. The cus<strong>to</strong>mary evaluation is post hoc, delivered as a summative accolade or
condemnation, long after the trainee can do anything about his scores.
What was the quality of his performance? What did he do <strong>to</strong> succeed in the procedure, if he
succeeded? Did he fracture teeth of patients he intubated? If so, how many each? How many of
the patients on whom he performed a lumbar puncture required a blood-patch afterwards <strong>to</strong> stem
post-procedure CSF-leakage? I've never seen any such evaluation in writing.
How many of the procedures that the evaluee performed did the men<strong>to</strong>r personally observe?
SLOR has no space for any such entry[54,63]. Is the rating based on a “general impression” of the
evaluee's procedural skill, as an intrinsic trait, derived from rumor? If so, upon what specific
evidence or criteria did the evalua<strong>to</strong>r base the score that he assigned?
Is one of the men<strong>to</strong>r's considerations his own anxiety over giving the evaluee a big head? Did the
evaluee, rather, need a low score <strong>to</strong> give him a harsh dose of “reality?” If so, on what evidentiary

criteria did the evalua<strong>to</strong>r base his concept of “reality,” such that a low rating would give the
evaluee a dose thereof and, in some sense (what sense?) improve the evaluee's outlook? Did the
evalua<strong>to</strong>r apply his dose of reality <strong>to</strong> all evaluees consistently? If not, why not? Did he condemn
those whom he personally disliked (perhaps because they asked him <strong>to</strong>ugh questions <strong>to</strong> which the
men<strong>to</strong>r felt embarrassed at not knowing the answers) and favor those whom he personally liked
(perhaps because they never asked him any <strong>to</strong>ugh questions)? If he applied his dose of reality
consistently, without regard <strong>to</strong> the evaluee's actual performance (which the evalua<strong>to</strong>r may never
have observed -- my consistent experience, throughout “training”), isn't that practice arbitrary,
unreasonable and capricious, i.e., a manifestation of chaos and irrationality, in a setting where
rational thought is supposed <strong>to</strong> prevail?
Most important, what does the rating score tell the relevant candidate about what he should do <strong>to</strong>
improve his performance?
One might argue that success in procedures, like medicine, itself, is a s<strong>to</strong>chastic matter[5,6], i.e.,
that some procedures fail even in the best of hands and some succeed even in the worst of hands,
in whatever sense of “best” and “worst” one might choose <strong>to</strong> apply. I would reply that that's
correct. Success in procedures is, at least <strong>to</strong> some extent what Deming terms a lottery,[5] no
question. Given that truism, what's the point of making “procedural skills a ratable category, in
the first place?
h. glittering generalities
Greenburg et al wrote, in relation <strong>to</strong> LORs:
Brevity and generality...come across as distinctly negative features, causing the reader <strong>to</strong>
wonder...whether the writer actually knows the applicant. (197)[87]
Yet, the evaluation-criteria, upon which LORs are most often based, rely upon brevity and
generality, presumably in the assumption that evalua<strong>to</strong>rs' general opinions of candidates reflect the
truth. No evidence supports that proposition and my personal observation is that it is false. If
brevity and generality be negative features of a LOR, how can the same features be acceptable in
the underlying evaluation-criteria?
Bosk terms vague indices of “quality” of the candidate, such as “general medical knowledge,”
“rapport with staff” and the like “essentially-contested concepts.”[67] They are summative,
glittering generalities, intended <strong>to</strong> make the evaluation-form brief, that have no necessary
evidentiary relation, either <strong>to</strong> the subject-physician's actual performance, clinical acumen or <strong>to</strong>
clinical outcomes of his patients.
In the field of academic emergency-medicine, Harwood et al referred <strong>to</strong> various elements of
evaluative jargon:
Of the applicants submitting SLORs <strong>to</strong> our EM residency program, 49% or more received the
superlative response in the categories of "commitment," "work ethic," and "personality." In

contrast, only 35% of the applicants received the superlative response regarding their "differential
diagnosis ability." The "global assessment" operated similarly, with 37% of the applicants
receiving the superlative response. The least common superlative response was the "match
rating," with only 23% of the applicants receiving a "guaranteed match."
These data can serve as a reference for both interpreting and writing SLORs. The data show that
EM applicants least commonly receive the superlative response in the categories of "differential
diagnosis ability," "global assessment," and "match rating," making these key categories for
residency selection committees. These results suggest that authors can justifiably evaluate most
applicants in the highest categories of personal traits, but that they should be more discerning with
assessing "differential diagnosis ability," "global assessment," and "match rating."[88]
Harwood et al seem <strong>to</strong> pretend as if ratings were objective facts, rather than what they are,
subjective appraisals based on the author's claimed but unverifiable (and probably negligible)
familiarity with the trainee.
In the foregoing passage, Harwood et al urged institutional authors of SLORs (standardized
letters of reference) <strong>to</strong> manipulate their performance-appraisals in various sections of the SLOR,
on the premise that the evidentiary basis of such appraisals don't matter, with a view <strong>to</strong> pandering
<strong>to</strong> the selection-committees for emergency-medicine residencies and manipulating the outcomes
of their deliberations over trainee-selection. Harwood et al seem <strong>to</strong> ignore the possibility that
fewer authors rate trainees highly in the glittering-generality categories of "differential diagnosis
ability," "global assessment," and "match rating" than in the glittering-generality categories,
"commitment," "work ethic," and "personality" because the authors could be inappropriately
ungenerous with their ratings in the first three categories, most likely because those categories are
the clinically oriented ones and authors would very likely believe that they weren't performing
their watchdog/gatekeeper function properly (<strong>to</strong> keep bad doc<strong>to</strong>rs from practicing
emergency-medicine) unless they had condemned a certain quota of trainee-candidates with each
batch that left their respective institutions. Hea<strong>to</strong>n depicts that practice in terms of what he calls
the “basic process”:
The Basic Process
The basic process of an individual in a hierarchy is <strong>to</strong> avoid mistakes. . . individuals are rated by
their errors, for their tasks are predetermined. There is no premium for achievement outside
assigned hierarchical tasks but there are penalties for every shortfall from perfection.
The normal distribution in a hierarchy includes a percentage of failures, so grading on a curve
means that students making the most mistakes are given failing grades. . . When failing students
are eliminated, those next above them succeed <strong>to</strong> the failing category. The rule of thumb is for
one-third <strong>to</strong> leave between the fifth and twelfth grades, . . . The next third become
failure-threatened, declining in rank regardless of effort or improvement. Apprehension then
blocks learning so there can only be unskilled repetition. Thus this middle third is taught
submission and place within the hierarchy. . . (32)

Is it true or false that for every winner there has <strong>to</strong> be a loser? False – there has <strong>to</strong> be a continuing
supply of losers if a winner is <strong>to</strong> keep on winning. In schools, grading on a curve . . . means that
the A student needs an F student at the other end of the normal distribution; then annually or
more often, when the F student is eliminated or drops out, another student must be pushed in<strong>to</strong>
the failing position. . . companies seem <strong>to</strong> survive only by establishing a large pool of marginal
workers who can be picked up when needed and dropped when business is slow. . .
. . . Schools in exclusive suburbs do not produce so many failures . . . Instead they assume their
students are mostly in the upper half of a normal (59) distribution. . . there are schools which
assume their students are mostly in the lower half of a normal distribution. In one vocational high
school in New York, no teacher could give a grade above C without special approval by the
principal. In a ghet<strong>to</strong> high school a department head <strong>to</strong>ld me that only one student in a . . . class of
twenty was capable of learning. I knew the students were capable and interested, but sure enough,
nineteen dropped out and failed. . . grading in schools is a process that produces failures and
accomplishes rejecting.
Winners are cus<strong>to</strong>m-made, but losers are mass-produced. . . (62)[52]
Pursuing a similar line of “reasoning,” raters in medical education may believe that they can
enhance the reputation and credibility of their respective institutions by making a big show of
being “<strong>to</strong>ugh graders” and the clinically oriented rating criteria are the most attractive targets for
that sort of behavior.
i. dis<strong>to</strong>rtion from “confidentiality,” under perpetual tension.
In both edi<strong>to</strong>rial peer-review and performance-appraisal/LOR, the thesis is that the rater cannot
deliver an “honest and accurate”[89] rating unless he labors under the protection of
“confidentiality,”[61,89,90] meaning that everybody except for the subject, gets <strong>to</strong> see the rating.
Decades of organizational oppression, in which ratees had <strong>to</strong> <strong>to</strong>lerate the in<strong>to</strong>lerable, finally
prompted the US Congress <strong>to</strong> enact the enlightened Buckley Amendment, a federal law that
requires schools that receive federal funding <strong>to</strong> make student records available for viewing by
parents and the students themselves if they are 18 or older.[89,91] Accordingly, even though
federal law mandates that the trainee should be able <strong>to</strong> see his rating, those in medical education,
prefer the old oppression. They recommend that the organization should compel the trainee <strong>to</strong>
“waive” his legal right, under the Buckley-Amendment, <strong>to</strong> see his rating, in the interest of
“honesty”,[1,90] “authenticity,”[89] and “objectivity” (read freedom of the rater <strong>to</strong> give an
adverse rating with the security of knowing that the ratee cannot learn of it and therefore not have
grounds for retaliation) of the letter and of its “value”[1] <strong>to</strong> the receiving institution.
In edi<strong>to</strong>rial peer-review, the author receives the rating but not the identity of the rater. In
performance-appraisal, the trainee knows the identity of the rater but, ideally, not the rating.
Yet, dissenting voices resist such organizational oppression, and for good reason, in my view:

...One of our wisest and most experienced faculty members, <strong>Dr</strong>. Douglas Lindsey, offers <strong>to</strong> write
letters for every medical student. He writes them honestly. He then shows the student the letter. It
is up <strong>to</strong> the student <strong>to</strong> decide wether it is sent. This is an excellent policy of a great teacher.
Unfortunately, it is probably unique. (320)
A few students have been asked <strong>to</strong> sign statements that they have not seen their reference letters.
This is ridiculous and unenforceable. Don't sign...it is common practice for students <strong>to</strong> be asked <strong>to</strong>
sign a waiver of their right <strong>to</strong> request <strong>to</strong> see referee letters. If you are forced in<strong>to</strong> this type of
situation, you may have <strong>to</strong> sign it and hope for good letters. If possible you do want <strong>to</strong> see those
letters before they go out. (321)[53]
The practice of “confidentiality,” under compulsion and under false color of “honesty,” in the
rater, may thus spawn duplicity and dishonesty in the ratee.
On the subject of so-called honesty, one naturally wonders whether the “honesty” will be
even-handed or biased. A few obvious questions spring <strong>to</strong> mind:
Will the rater be as “honest” about how he himself prioritized the needs of trainees lower than his
own personal needs and therefore devoted insufficient time <strong>to</strong> the those in need of guidance <strong>to</strong>
foster their improvement as he claims <strong>to</strong> be about the shortcomings of those trainees, whom the
rater thus abandoned? Will he be honest about his own failures <strong>to</strong> implement and incorporate core
content of his specialty (e.g., emergency-medicine) in training and rating his trainees? Will he be
honest about his own failure <strong>to</strong> provide daily feedback <strong>to</strong> trainees <strong>to</strong> keep them informed of what
specific performances they needed <strong>to</strong> demonstrate the following day <strong>to</strong> show improvement? Will
the rater be honest about his own failure <strong>to</strong> document daily or weekly improvement or otherwise
and reasons therefor in his rating-comments? Will the rater be honest about his own failure <strong>to</strong>
define behavioral educational objectives,[92] <strong>to</strong>ward which the trainees might strive? Will the
rater be honest about how he exchanged gossip with other faculty about various trainees and
thereby formed a collective, united, homogenized opinion of trainees, insteade of expressing his
own opinion, based on his personal observations? Will the rater be honest about casting the
evaluation in terms only of the trainee's failures, not in terms of systematic failures of the
institution?
Tonesk provides a twisted view of objectivity vs. subjectivity and authority-relationships in
medical education.[93]
In the realm of edi<strong>to</strong>rial peer-review, Walsh et al found referees more considerate and courteous
<strong>to</strong>ward authors if their names attached <strong>to</strong> their reports[94]. What's wrong, therefore, with
accountability in LORs?
Flacks wrote:
. . . maintaining the confidentiality of the contents of evaluations and letters of reference would
[not] improve the quality of such assessments. On the contrary, . . . I've become convinced . . .
that the reverse is true. New state laws and university regulations have opened the process . . --

and the results . . . have been good. Faculty members and departments now have the opportunity
<strong>to</strong> respond <strong>to</strong> negative reviews . . . timely . . . and with some understanding of the arguments that
may merit rebuttal. The review process is now more cumbersome, but it is . . . less Kafkaesque. . .
A new law that would require full disclosure has passed the legislature but is being contested in
the courts by the University. I am quite sure that the . . . motivation for the University's resistance
is not so much <strong>to</strong> protect the quality of the review process as it is <strong>to</strong> protect the discretionary
powers of the administration.
. . . The need for open evaluations is not simply that such openness promotes due process. The
due process argument applies <strong>to</strong> all institutions in their treatment of workers. . . open access helps
ensure that each member can benefit from critical feedback and also ensures that criticisms are
made in a way that is responsible <strong>to</strong> canons of scholarly objectivity. . .[95]
Fashing wrote:
. . . If we allow people <strong>to</strong> require anonymity as the price for the exercise of candor and
professional responsibility, then surely we encourage a pernicious form of cowardice. Are our
sensibilities so delicate that they cannot contend with the requirement <strong>to</strong> render our negative
judgments openly and honestly with whatever risk that entails? And if they are, should we
continue <strong>to</strong> encourage such delicacy or should we begin <strong>to</strong> require a modicum of courage <strong>to</strong> go
with our “candor”? I for one believe we should. . . the requirement of anonymity raises serious
questions of credibility in its own right. Why should we believe that anonymity is the price of
honesty any more than that it is an opportunity for dishonesty? . . .
. . . there are compelling reasons for confronting intellectual, professional, and . . . personal
differences as a minimal requirement for the development of any serious sense of community. This
will no doubt produce some unpleasant moments in the context of whatever conflicts surface, but
what group that constitutes a serious community, or perhaps more importantly, a community <strong>to</strong>
be taken seriously, especially in intellectual terms, is without conflict? That consensus about all
issues is unnecessary <strong>to</strong> the maintenance of a healthy community is recognized by all but the most
resolutely conservative members of the academy. To address such differences and <strong>to</strong> resolve
them, or in the case of intellectual differences, <strong>to</strong> provide a climate in which debate and conflict of
opposing ideas are a catalyst for intellectual growth and creativity, strikes me as the essence of
academic community and a primary requirement for intellectual and academic freedom. In this
sense disclosure should promote rather than retard intellectual excellence. (222)[96]
6. The ultimate goal: communion of “<strong>to</strong>p” talent in “<strong>to</strong>p” institutions
The counter-argument <strong>to</strong> the foregoing is that the most competitive programs have <strong>to</strong> select the
most competitive trainees.
Why? Even assuming that the selection-process be valid, a dubious proposition, what ultimate
utility is there in aid of quality of patient-care in concentrating “<strong>to</strong>p talent” in “<strong>to</strong>p institutions?”
Isn't that just elitism run amock? What about spreading the wealth, if that's what it is (a dubious
proposition), around a little? Wouldn't the “non-competitive” trainees gain from exposure <strong>to</strong> “<strong>to</strong>p

institutions” and wouldn't “competitive trainees,” if they offer any genuine advantage over
non-competitive trainees, be able <strong>to</strong> work their magic in institutions in more humble locations?
I've interacted with finished physicians from a broad range of institutions and I'm constantly
impressed with how alike they are. Physicians from Harvard, Yale and other Ivy League
institutions are no great shakes and some of the most impressive come from the hinterlands. What
was all the fuss about during education and training, then?
7. Illustrative anecdote which is more typical than it should be
When I worked as a civilian in the ER of the military hospital, Fort Stewart, GA, my military
supervisor, a Major in the Army Medical Corps, liked me pretty well at first but seemed <strong>to</strong> dislike
me more and more as time went on, evidently because of conflicts that swirled around me.
He criticized my handwriting, so I brought in a word-processor <strong>to</strong> write up my charts and make
them optimally legible. He didn't s<strong>to</strong>p me from doing that but, long after I'd left there, I obtained
copies of my personnel-records, including documentation of his commentary on the episode.
Without explaining what he intended, he put an exclamation after the statement, “he brought in a
word-processor!” I gather he disapproved of my constructive response <strong>to</strong> his criticism, yet he
suggested no other alternative. What did he want from me? Did he expect me suddenly <strong>to</strong> develop
handwriting like his? He never explained.
In perhaps the emblematic episode of my tenure there, I pissed off one of his fellow Army-officers
by calling him in at night <strong>to</strong> attend a female patient of his by admitting for her evaluation and
moni<strong>to</strong>ring of her chest-pain that I suspected had a cardiac origin. He chewed me out for
disturbing his sleep and wanted me <strong>to</strong> release her home without forcing him <strong>to</strong> come in and
examine her. He claimed <strong>to</strong> know her so well that he KNEW that her chest-pain was not cardiac
but, instead, was from her COPD. The rules, not of my making, required him <strong>to</strong> come in and
examine a patient whom the ER-physician suspected of requiring admission. Under protest, he
came in, chewed me out some more in front of nurses and other personnel and released her home.
A few weeks later, her cardiac catheterization at Fort Gordon revealed severe coronary artery
disease. I had committed an unpardonable sin: being right when an army-doc<strong>to</strong>r was wrong.
It's not as if this were a diagnostic coup. It could hardly have been more stereotypical. She had
chest-pain, reminiscent of cardiac chest-pain. It was bread-and-butter medicine. She needed
admission for the sake of safety. The officer fulfilled his paper-duty under protest by getting out
of bed and examining the patient. He failed in his duty <strong>to</strong> admit her for moni<strong>to</strong>ring.
I pissed off a pediatrician by calling him in at night a few times <strong>to</strong> attend febrile infants who I
thought might need admission, as a posted directive required me <strong>to</strong> do. Whether the patient's
condition is serious enough <strong>to</strong> warrant admission is a matter of judgment and, if I think the patient
needs admission, the pediatrician may disagree. I assumed that <strong>to</strong> be in the realm of disagreement
among reasonable people. He evidently disagreed, even with that principle, probably because he
was the pediatrician on call and fulfilling his duty required him <strong>to</strong> exert unwelcome effort. He
impugned my “judgment,” as a tactic in his campaign. He sent all the patients I referred <strong>to</strong> him

home, possibly as a way of accumulating incompetence-points against me. Those incidents
illustrate the principle, universal, in my observation, that hospital-personnel pay abundant
lip-service <strong>to</strong> concern for quality of patient-care but their actions bespeak only concern for their
own convenience.
Thus, I accumulated “complaints” against me but the hospital never preferred any charges against
me or offered me a peer-review hearing for me <strong>to</strong> rebut such charges, presumably because the
notion would have been absurd, even <strong>to</strong> Army-brass.
Hypothetical charge 1: diagnosing chest-pain as cardiac which later proved <strong>to</strong> be cardiac but
pissing off Army-Officer in the meantime by calling him in at night <strong>to</strong> do his duty. Charge 2:
complying with posted hospital-directive by calling in Army-Officers in relevant specialties
“unnecessarily,” and thereby pissing them off, on nights when they're on call <strong>to</strong> attend patients,
possibly appropriate for admission, and <strong>to</strong> render their opinions.
Instead of taking a formal route, they chose a typical bureaucratic route: my supervisor completed
consecutive evaluation-reports in secret and never discussed them with me. The personnel-records
I obtained years later, exhibited an unmistakeable halo-effect: In all components, from “medical
knowledge” and “rapport with staff” <strong>to</strong> “health” and “appearance,” the ratings descended in
parallel from 9 or 10 of 10, steadily downward, <strong>to</strong> end at about 3 or 4 out of 10, under the
influence of multiple complaints of pissing off Army-physicians by asking them <strong>to</strong> do their duty.
That is, each evaluation-cycle, my supervisor assigned all components the same rating: all 9s, all
8s, all 7s, all 6s and so forth. Yet, my “appearance” and “health” were verifiably the same
throughout that time: fine and stable. He presented not a scintilla of evidence of my deteriorating
health, for example, yet he “documented” its deterioration in his numerical ratings. This person
had an MD-degree!
Thereupon, enough poor pseudo-ratings had accumulated against me <strong>to</strong> “justify” my termination
and <strong>to</strong> provide an ironclad “paper-trail,” in case I should have decided, at some point, <strong>to</strong> contest
my termination legally.
LORs that I requested from Fort Stewart stated only the dates of my employment there but made
no mention whatever of my performance, e.g., my thoroughness and my diligence, for the benefit
of patients, against the odds of dysfunctional military-bureaucratic obfuscation. Those LORs
illustrate a fundamental principle of all LORs: LORs accommodate the needs of the ambient
power-hierarchy, not of the subject thereof. That makes them inherently inaccurate. If the
academic is honest with himself, he will concede that academic power-hierarchies exhibit similar
manifestations.
I could provide other anecdotes with similar import but I've gone on far <strong>to</strong>o long already, so I'll
s<strong>to</strong>p.
When will decision-makers cop themselves on <strong>to</strong> the inherent unfeasibility of rating human
beings?