Moving from Performance to Authenticity: Reflections on Grading Students in the Real World

Most of my medical student teaching takes place during patient care. The student and I care for the patient together, and the patient is both the mission and the lesson. Students usually speak with and examine patients first, and often know patients best. Faculty evaluate medical students not only on their written exam performance, but also on their ability to recall medical knowledge quickly and apply it by developing specific patient care plans. Students are also expected to consistently demonstrate a positive attitude, compassion, and a willingness to work hard.

The high value placed on clinical performance is changing the structure of medical education. Students are being placed in clinical settings earlier, in the first and second years rather than in the later years of their education. As they compete for residency positions, clinical evaluations are critically important. Assessment of real-world performance is not unique to health education, but there are few other areas of higher education where it is emphasized so comprehensively or valued so highly.

There are good reasons for teaching and evaluating clinical performance. When immersed directly in patient care, students learn lessons that could never be captured in a classroom or simulation. In my office, students learn principles of preventive care by counseling patients to quit smoking—sometimes with success. Medical students learn how to spend long hours in the office or hospital and stay up all night when their patients need them. They also experience loss, grieving for suffering patients and families. Patient care teaches students the profound sense of responsibility that comes with making decisions that change the course of people’s lives.

However, the constant evaluation of medical students in clinical settings has a cost. There are few studies of grading in clinical care, but it is believed to be subject to bias and inherently unreliable. Supervising physicians have individual ways of evaluating students, so differences between teachers can be as important as differences between students in determining final grades. Because these assessments are informal, they are not always transparent; students might not be aware of the “real” grading criteria until they learn that they are doing poorly.

Clinical grades can also be driven by the personality of the student, rather than by skills. Certain personality characteristics, such as extraversion, correlate with greater success in clinical evaluations.[1] Clinical assessment can also be impacted by students’ attractiveness, gender, race, or sexual orientation. For example, in one study, Asian-American and African-American medical students were rated lower in communication skills than Caucasian students.[2]

Finally, students who are always being evaluated on performance are always performing. Their decisions, perceptions, and actions have much less of an impact on patient care than mine do, but they are evaluated much more stringently, on a moment-to-moment basis, than I am. This endless performance can be soul-crushing, for it creates an environment in which they compete with their peers and cannot be vulnerable in front of their teachers. During one of the most stressful transitional periods of their lives, they have no immediate, non-judgmental sources of support by their side. This can create a deep sense of isolation, and this isolation likely contributes to the extremely high rates of depression experienced by medical students.

We, their teachers, know that students’ well-being is always more important than any grade. But because our students have learned to stay relentlessly “enthusiastic,” we might not know how they are doing emotionally. A few years ago, one of my students committed suicide. The event was devastating for the entire institution, but especially for those who surrounded her during the last weeks of her life. She had been in the midst of her psychiatry rotation, working side-by-side with psychiatrists, but had not asked for help.

It is also difficult for students to let their guard down and open their minds to learning, except for those moments when their evaluators—who are also their teachers—step out of the room. I often wish I could persuade my students to “take off the mask,” be their authentic selves, and simply enjoy the immersive process of clinical education. Unfortunately, I have not found a way to create a truly nurturing environment for medical students within the patient care context.

Clinical assessment is an essential part of medical education, and has clear benefits. Moving beyond the classroom and into “real-world” settings is essential for developing learners with practical skills, not only in medicine but also in all areas of higher education. However, assessing learners in the real world should be approached cautiously because it is subject to bias that creates a lack of fairness. In my opinion, although clinical assessment plays a crucial educational role, it should not outweigh exam or simulation performance in determining student grade

Students immersed in real-world assessment also need extra support because, for them, every day is a test. Although medical student distress has gained increased recognition, sources of emotional support for medical students remain inadequate, especially when students leave the lecture hall and begin the real work of patient care.

I am not aware of learning methods that both preserve real-world assessment and allow students to stop performing. It is possible that other disciplines have succeeded where medicine has not. If so, perhaps the medical profession could learn from alternative approaches to assessment already present in other academic fields

[1] Doherty EM, Nugent E. Personality factors and medical training: a review of the literature. Medical education. Feb 2011; 45(2): 132-140.

[2] Fernandez A, Wang F, Braveman M, Finkas LK, Hauer KE. Impact of student ethnicity and primary childhood language on communication skill assessment in a clinical performance examination. Journal of general internal medicine. Aug 2007; 22(8): 1155-1160..