Does evaluation of medical students produce any positive feedback?
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* Shelley Spaner

Examination time . . . the thought of preparing for yet another in a seemingly endless stream of examinations is enough to increase anxiety levels in even the most relaxed of all medical students. “The marks are posted” . . . that short phrase is enough to cause a slight tachycardia in even the most confident of all student interns. “An acceptable academic record” . . . the simple written words, displayed prominently in the *Canadian Resident Matching Service Program Directory Guide*, are enough to cause even the most gifted clinical clerk to question if he or she is actually good enough. Really, what is good enough? Why does it always seem that the medical student’s ideas of the important and necessary concepts always seem to be markedly different from those of examiners?

As a student at the University of Alberta, where the nine-point scoring system is as dreaded as the fear of being called upon to speak at noontime rounds, when the only reason you attended was for the free lunch, I am one of many who question the necessity of a bell curve to separate 120 students who frequently score within 15% of each other on standardized examinations.

I still recall the frustration that was visible in the eyes of many of my classmates when this very question was posed to the faculty in an information session during our first few days of “Phase I.” We were informed that the nine-point system was necessary because there must be a way to rank the class. “Don’t worry,” we were told, “30% of you will graduate with first-class honours.” Doesn’t anyone in the Dean’s office realize that 100% of us entered medical school with first-class honours? Don’t any of the administrators realize that when they casually mention that “you must be in the top 20% of your class to be considered for certain residency spots,” their words bring real feelings of fear and despair into the hearts of students who always seem to find themselves on the “wrong” side of the cutoff when the stanines are assigned? Doesn’t anyone in the faculty office realize that, as the stakes are perceived to rise with each rise in grade point, the positive feelings of camaraderie and teamwork more frequently than not give way to feelings of competition and a “win at all costs” attitude, as students try to look out for their own best interests. It is, indeed, worth noting that the members of the Class of ’96 at the University of Alberta often speak with great longing and envy when the subject of a pass/fail grading system is mentioned. There is something inherently wrong with a grading system that consistently causes students to remark upon receiving an evaluation, “I wonder if this is any good. . . . What’s the average?”

I truly believe that evaluation is an important and necessary part of medical school. It gives students the incentive that they require to study and to learn the material that is fundamental to their future roles as physicians. I also believe that the current system in use at the University of Alberta does not serve its intended purpose. To be effective, any system, be it judicial or academic, must appear to be fair and relevant. On too many occasions, I feel that the current evaluation system has only caused grief and frustration among many of my classmates. It is not uncommon to hear my future colleagues remark “who cares any more? I’ve given up!” In terms of evaluating procedures, there is no doubt that the change from straight “exam-bank drawn” multiple-choice tests, common in the first 21⁄2 years of medical school, to the current system that focuses on Objective Structured Clinical Examinations and ward performance is more relevant. This system rewards both clinical skills and diligent effort. However, it has its drawbacks also. Often the subjective component of ward performance is not taken seriously by the preceptors entrusted with the responsibility of evaluating a student’s performance. Many times the student’s grade or evaluation depends not upon how hard the student works or upon how knowledgeable the student is. Instead it depends on who the preceptor is. Some preceptors are known to give extraordinarily high marks to every student they supervise. Conversely, others give the same average score to every student intern, the explanation being, of course, “That’s what I always give.” In terms of evaluation, things are definitely better on the ward, but they are still far from perfect.

In my opinion, the role of the evaluation procedure is to let the medical student know if he or she is competent and capable of dealing with real people who present with medical problems. I believe that the evaluation system that would best accomplish this is one that does not rank students. Does anyone really benefit from the ranking procedure? Is there really any difference between the student who finishes 40th in the class and the one who winds up 100th? Eventually won’t all become doctors? I believe that the ultimate evaluation system would be one that recognizes areas of deficiency in either knowledge or technical ability and provides remedial help to those who require it. The ultimate evaluation system would help to foster teamwork and the sharing of ideas and information that is so vital to the practice of medicine. The ultimate evaluation system would be one that strives to ensure that every student graduates from medical school with a solid knowledge base and an ability to work competently as a PGY-1. By eliminating the need to memorize every page of thick textbooks, in a misguided effort to obtain that one extra percentage point that might result in one extra grade point, students could spend more time talking to patients, working alongside their residents and practising the skills that they will need when marks no longer control their destiny.

Does evaluation produce any positive feedback? I would still answer yes. However, this affirmation needs some clarification. There must be a sense of relevance and fairness in any ranking system for students, especially students who are as academically aware as medical students. The system must reward hard work and diligent study. Written examinations must be seen to reflect concepts that are important and relevant, not as ones designed to “lower the average” or to “increase the spread.” There is little doubt in the minds of many of the medical students of the University of Alberta Class of ’96 that the nine-point system is neither necessary nor relevant. Clearly, a more positive evaluation would be one that points out deficiencies in competency while fostering the much-needed attributes of cooperation and teamwork. In the current era, when students must choose their residency positions so early in their careers, the focus on marks is certainly intense. Perhaps it would be wiser for educators to evaluate students and ultimately choose residents based on students’ abilities to communicate and cooperate, and on their basic level of competency, rather than on their ability to write tests well. To me, the best evaluation that a student intern can receive is to be told by a patient “Thank you. . . . You’re going to make a great doctor.”

## Footnotes

*   * MD, May 1996

*   Accepted February 29, 1996.