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

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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
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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
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Page 23 and 24: criteria did the evaluato</
Page 25 and 26: Is it true or false that for every
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Eric Grosch, Letter to Dr. Morgenstern on LOR - Semmelweis ...

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