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

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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]
Page 1 and 2: DR. ERIC N GROSCH - A new approach
Page 3 and 4: i. distortion from
Page 5 and 6: they were inferior. It is unfair, a
Page 7 and 8: Another Irving Langmuir? Can Americ
Page 9 and 10: deviations, as is the case when the
Page 11 and 12: method[11,12] for “objective” e
Page 13 and 14: than we now possess.[21] The progre
Page 15 and 16: 3. Descriptive, Not Evaluative. Use
Page 17: University, addressed merit-ratings
Page 21 and 22: In the industrial setting, in which
Page 23 and 24: criteria did the evaluato</
Page 25 and 26: Is it true or false that for every
Page 27 and 28: and the results . . . have been goo
Page 29: home, possibly as a way of accumula

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

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