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

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