Article In Brief

Residency program administrators focus on the standards they apply in in search of out neurology residents within the absence of conventional grades.

As extra medical colleges transfer away from utilizing conventional grades to evaluate college students—opting as a substitute for a pass-fail system—neurology program administrators are hard-pressed to make choices about candidates for his or her residency applications.

In interviews with Neurology Today, some administrators mentioned they welcomed the shift towards evaluating candidates primarily based on letters of advice, analysis expertise, and neighborhood service, whereas others expressed issues over introducing new biases into the equation. Some administrators are additionally placing much less weight on outcomes of the United States Medical Licensing Examination (USMLE) in choosing first-year residents.

“I really look at so much more than just grades when evaluating applicants, especially as clinical grades are so subjective,” mentioned Rebecca E. (Fasano) Matthews, MD, affiliate professor of neurology and neurology residency program director at Emory University School of Medicine in Atlanta, which switched to pass-fail grading within the medical section in March.

“Instead of clinical grades, I like to look at the comments made by faculty who supervised students on rotations. For example, did a student work hard and seek out feedback? There’s always a lot of information in those comments,” she mentioned.

Dr. Matthews, an epileptologist, mentioned the brand new system will enable college students “to focus more on learning on the wards rather than trying to speak the loudest, speak the most on rounds, or impress faculty or residents to get ‘honors’ grades.”

In addition, the brand new supplemental software to residency applications has been useful as a result of it offers college students the chance to explain pivotal life experiences, such because the obstacles they’ve overcome. “I feel that these experiences reveal a lot of information about a student’s tenacity and ability to succeed,” Dr. Matthews mentioned.

Surmounting obstacles is a key issue thought-about by the choice committee on the Perelman School of Medicine on the University of Pennsylvania, mentioned Raymond Price, MD, FAAN, professor of medical neurology and director of its neurology residency program.

Some medical college students have demonstrated that they will deal with adversity properly. For occasion, Dr. Price mentioned, challenges could embrace overcoming poverty, managing private well being points, being a caregiver for a member of the family, or working a number of jobs whereas attending school or medical college.

By distinction, traditionally, specializing in medical grades and standardized take a look at scores resulted in “flawed” strategies of evaluating candidates’ potential and “can set up inequities.” An outgoing character could assist cowl for deficiencies in information, whereas good test-taking expertise can stem from getting access to the most effective assets for preparation, Dr. Price mentioned. Overall, “we don’t really have the ideal way to evaluate what makes a great physician or outstanding clinician,” he added.

“Instead of clinical grades, I like to look at the comments made by faculty who supervised students on rotations. For example, did a student work hard and seek out feedback? Theres always a lot of information in those comments.”—DR. REBECCA (FASANO) MATTHEWS

However, Dr. Price famous that the overemphasis on grades and take a look at scores can result in elevated nervousness, stress, and burnout for medical college students. It can also trigger heightened competitors, which works towards the fundamental idea of working towards medication in a collaborative setting.

Grades from one establishment will be vastly completely different than these given by one other, mentioned Charles C. Flippen II, MD, FAAN, FANA, Richard D. and Ruth P. Walter Professor of Neurology, vice chair for schooling, and director of the neurology residency program on the David Geffen School of Medicine at UCLA, which makes use of a pass-fail grading system for all courses.

“There is a lot of grade inflation out there, where a third or half of a class gets honors in a given school, whereas in another school only a quarter or a fifth receive honors in the same subject,” Dr. Flippen mentioned, including, “Who is to say they’re not graded more harshly? The grades are hard to adjudicate between schools, so it’s important to look at people as individuals.”

Students’ work habits and private traits are a lot larger predictors of success, he mentioned. In these conditions, letters of advice and clerkship evaluations assist present much-needed perception.

“We look at leadership qualities because those people tend to be self-starters and are usually naturally curious and innovative,” mentioned Dr. Flippen. “That’s not to say that we don’t need an assessment of knowledge acquisition and knowledge base. But if they are able to pass the USMLE, that proves that they have this requisite knowledge.”

It’s uncommon to come across a resident who lacks this fundamental requirement. More generally, he identified, the problems that will pose difficulties are ineffective communication fashion, lack of ability to work with others, and problems with professionalism resembling timeliness in finishing duties.

“Those are the things that most often cause problems during residency,” Dr. Flippen mentioned, whereas noting that his program does not have a cutoff rating on the USMLE.

A Holistic Approach

Considering all candidates and avoiding using a cutoff rating on the USMLE has fostered a holistic strategy within the evaluation course of throughout the previous couple of years on the University of Miami Miller School of Medicine, mentioned Leticia Tornes, MD, FAAN, affiliate professor of medical neurology and affiliate director of the neurology residency program. (The medical college is utilizing a pass-fail system for sure programs, however not all.)

“Not having the Step scores will not affect the current screening process,” mentioned Dr. Tornes, who can be chief of neurology on the Miami VA Healthcare System. In addition, having an excessive amount of weight on a Step rating is problematic because it will not be consultant of the candidate as an entire.”

When selecting first-year residents, the choice committee considers scholar’s efficiency in medical college, management positions, analysis expertise, publications, service and volunteer actions, ardour for neurology primarily based on the aforementioned components and private assertion, letters of advice, evaluation of the candidate in a medical college efficiency analysis (MSPE), and a rating of pass-fail on the USMLE/COMLEX.

Although the dearth of medical grades could make it tougher to check functions between a number of college students from the identical medical college, it is nonetheless doable to take action if the decision-makers put extra effort into the method, Dr. Matthews mentioned. Considering letters of advice, analysis expertise, and neighborhood service is vital.

Fostering Diversity

Looking past grades can be important in fostering range and making certain equity alongside the best way. In Dr. Matthews’ expertise, the subjective nature and implicit biases related to medical grades harmed college students from underrepresented backgrounds.

“I have always felt that minority students are graded more harshly, so I have always discounted grades as a factor when evaluating minority students,” she mentioned, including that the brand new system ought to promote range, “as long as program directors don’t put more stock in other factors that are biased against minorities,” resembling standardized take a look at scores—as an example, Step 1 of the USMLE.

Transitioning away from counting on summative scores and examination efficiency is an try and encourage a holistic evaluation of candidates and promote range of residency candidates at Wake Forest University School of Medicine in Winston Salem, North Carolina, mentioned Emily Poole Pharr, MD, MS, affiliate professor of neurology and neurology residency program director. (The medical college has not transitioned to a full pass-fail system.)

“Diversity in recruitment is crucial for the future of medicine and the field of neurology,” mentioned Dr. Pharr, who can be director of the Comprehensive Multiple Sclerosis Center. She hopes that residency program administrators will contemplate the significance of recruiting a various group of trainees quite than emphasizing a rating cutoff.

That mentioned, she identified that the dearth of goal information could unknowingly compel residency and fellowship applications to rely on subjective opinions about candidates.

“We are forced to rely more on the reputation of the medical school, personal recommendation from colleagues, and comments from supervising faculty within rotation evaluations—all of which have the potential for implicit bias.”

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“There is a lot of grade inflation out there, where a third or half of a class gets honors in a given school, whereas in another school only a quarter or a fifth receive honors in the same subject. Who is to say theyre not graded more harshly? The grades are hard to adjudicate between schools, so its important to look at people as individuals.”—DR. CHARLES C. FLIPPEN

Dr. Pharr mentioned the committee seems to be at every candidate’s software broadly. “We review their life experiences—their educational pathway, their work, research, and volunteer experiences,” she mentioned. “We review their personal statement to understand what drives their passion for neurology. We review the data provided in the dean’s letter, any pass-fail results, scores, and comments provided. And finally, we review the applicant’s letters of recommendation.”

However, Dr. Pharr added that a powerful efficiency on standardized exams can elevate a candidate’s software if different points—analysis, experiences, and repair—are usually not as robust.

Overall, such a complete software evaluation is difficult due to the big quantity of candidates who apply. “It is time consuming to review each application fully,” she mentioned.

“For better or worse, scores and grades provide a framework for application review. Without objective scores, we are relying to a greater degree on comments from faculty with whom the candidate worked on clinical rotations and the thoughts shared by letter writers. This has the potential to introduce bias and tips our assessment toward a more subjective review.”

Dr. Price identified the pitfalls of receiving “universally positive letters” of advice, so it is vital to evaluation them “with a discerning eye.” The resolution: “You have to look for the degree of superlatives,” he mentioned. Even so, it is not unusual for a letter of advice to specify {that a} medical scholar is within the 5 % of scholars with whom the professor has ever labored. Another letter could point out {that a} scholar is within the prime 10 % of scholars with whom the professor has even labored.

“These are all degrees of what should be viewed with as outstanding,” Dr. Price mentioned. “I’ve never seen a letter that says anything other than this is the top 25 percent or better.” Even that’s “vanishingly rare. “The majority say top 10 percent or better in the letters of recommendation if they decide to quantify it this way.”

As a outcome, “I would argue that the removal of grades to reduce biases in the grading system is replaced with a different bias in the letter writing system,” he mentioned. “There are unintended consequences of moving to the pass-fail system for residency selection. This introduces more randomness.”

In addition, there’s a potential for bias when colleges are assessed primarily based on obtainable rating techniques such because the one by U.S. News & World Report. A previous expertise with a resident from a selected medical college could inadvertently decide whether or not future candidates from that establishment are seen in a constructive or adverse mild.

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“I would argue that the removal of grades to reduce biases in the grading system is replaced with a different bias in the letter writing system. There are unintended consequences of moving to the pass-fail system for residency selection. This introduces more randomness.”—DR. RAYMOND PRICE

“You tend to treat students from the same institution homogeneously,” Dr. Price mentioned, “whether one could have been the best student that institution ever had or the worst they ever had based on random experience.”

Dr. Flippen mentioned members of the residency choice committee attempt to display candidates in addition to they will with letters of advice and the interview course of that ensues. “We’re left to the mercy of the candor of the people who write letters of recommendation and complete performance evaluations on students during medical school,” he mentioned. “That’s why letter writing and evaluations are not insignificant activities.”

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