Anonymous Evaluations: Helpful or Hurtful?

If you are in medicine, you are probably quite familiar with the process of writing and collecting online evaluations that are anonymous and generally unhelpful. (I’m sure this is true of many other professions too, but my only experience with them is in medicine.) They do form the bulk of our MSPEs (short for medical student performance evaluations) and later for other self-promotion when looking for a job, but are they actually helpful in practice?

First, let’s talk about why positive evaluations are nice but not helpful. Everyone gets to cherry pick their best comments to showcase how great they are when sending them out for review, so out of the many applications I’ve read for both med school and residency candidates, I’ve seen one mildly negative comment. One. Ever. And they framed it in a way that showed the person had addressed a shortcoming based on in-person feedback, so in the end it was actually nice and demonstrated how important real life communication is. The anonymity of online evaluations does nothing to improve performance, and by their nature it is difficult to use them to stratify applicants. If the evaluation is written about you, it makes you feel good about yourself for a minute and maybe even a little complacent, but the vast majority of evaluations are generic and non-specific, something along the lines of “Elizabeth has an excellent fund of knowledge for her level of training and was a pleasure to work with on a busy service.” We’ve all gotten that exact comment on more than one occasion, and according to the numerical component of our evaluations we are all above average. But that’s just not how math (or life) works!

I know I am not alone in my frustration about the Embarrassment of Riches awarded to medical trainees in that they are difficult to wade through and often rather superfluous. The linked article comes from the Journal of Pediatrics (Rockney, 2014) and is written by someone who is both a clerkship director and a residency selection committee member. What are we achieving with our overabundance of positive comments?

Conversely, negative evaluations given behind a veil of secrecy have the power to be really hurtful. Although I’ve been fortunate to mostly avoid negativity in evaluations I’ve received, I exist in the real world and therefore there have been occasions where I’ve been on the receiving end of rude or thoughtless criticism. They come from people I’ve worked with who haven’t given me any face-to-face feedback but then weeks or months later drop an anonymous comment that makes me feel really terrible about myself, just because there is a compliance deadline and they feel some sort of clerical urge to put pen to paper. It’s confusing when all other evaluations from the rotation are positive and then this one person takes it upon him or herself to let you know they think you suck. It leaves you wondering who you rubbed the wrong way and makes you wary of anyone who could have been the author. It has the potential to poison you against a large group of people and that is not a healthy dynamic to create between people working together to save lives.

Regardless of the positive or negative nature of the feedback, in written documentation, there is also some gender bias and differences in terminology used based on the gender of the student being described. There was a very interesting article published recently in Academic Medicine (Riese et al, 2017) discussing the differences between the way male and female medical students are described, in addition to the differences between the way male and female evaluators grade their students differently.

This year I stopped turning in evaluations about my co-residents and our fellows/attendings and I am not apologizing for it. It has really given me more confidence in giving face-to-face constructive criticism and genuine compliments to the people I work with for up to 80 hours a week at a time, and I would encourage more individuals and programs to consider supporting this approach. It also gives me the feeling of a clean conscience when one of my co-residents receives a negative evaluation – they know it wasn’t from me and they know if there was something I felt I needed to address with them that I would have respected them enough to have done it without hiding behind the internet. I’ve also made the decision to stop reading things that are written about me, with the expectation that the people I work with would have a similar level of respect for me and would help me improve my patient care skills by having meaningful human interaction. (As a bonus, I save a lot of time staring at a computer screen.)

What do you think? How do you handle rude commentary from someone you’re supposed to trust and feel supported by? Do the potential benefits of written performance evaluations truly outweigh the cons of secretive and generic feedback practices?

Creating Your Rank List

This post is for all the current and future fourth years out there who are making a rank list – it’s an overwhelmingly important decision and you’re almost certainly going to second guess yourself at least a little. Although I definitely had more flexibility in my free time and really enjoyed the absence of regular testing in MS4, I think I was just about as anxious as I had been throughout medical school just because so much feels like it’s being left up to fate, and that was kind of tough to deal with! There’s nothing left to do but decide where you’d like to spend the next 3-7 years of your life and then to wait and hope that it works out the way you want it to. The good news is that it ends pretty well for most everyone I know!

The biggest piece of advice I got and will give is that you need to trust your gut. I was actually interviewing at U Chicago when my now-program director was chatting with us and told us about how she’d created spreadsheets on spreadsheets of things that she like and didn’t like about the various programs she’d visited, but in the end decided to trust herself about what she wanted and picked what felt right. At the time of that conversation, I was about halfway through interviews and had definitely been making some spreadsheets of my own. What I realized was that I was tweaking some of the things I was putting into each column to make the programs move into the order I wanted them to be in based on my gut reaction. After that I ditched the spreadsheet and just put them in the order that felt right to me.

I would also encourage you to put literally anything into the NRMP the day it opens just so that something is on the books in case you get put into a coma or get kidnapped until the deadline. You can always change things around after you certify, but you might find that putting in a list early and quickly is actually the least stressful way possible to do it.

In terms of actual program selection, there are probably a million factors that are unique to each applicant and to each program, so I imagine my reasons for choosing pediatrics at U Chicago are probably very different from someone choosing ortho at Rush, even though we’re in the same city. I’ll share with you some of the things I considered, just to give you a sense of my thought process.

  1. Program size and catchment. When I was applying to programs, I really thought I wanted to be in a medium-sized program and in a city that had only one children’s hospital. While interviewing I realized there was such a thing as too big, but there was also such a thing as too small and that shifted a few larger-than-medium programs higher up my list. I also realized it didn’t really matter to me if there were other children’s hospitals in the city, as long as we weren’t constantly shipping our patients out to them. There are a few really large children’s hospitals in the Chicagoland area, but ours is the only one on the South Side, so I’ve sent a grand total of 2 interesting patients to other hospitals for very specific indications.
  2. Location. I was terrified of Chicago when I came to interview, but had a great weekend touring the city and felt a pull to come here. It was nice to know that if I ended up hating it, it would only have been a 3 year commitment and then I’d have a definitive endpoint where I could leave without anyone being surprised or disappointed. It has been an excellent decision for me to have left my home state and I’m glad I didn’t stay in NC for training.
  3. Underserved population. If you don’t want to work with underserved patients, please please please be honest with yourself about this. I have interviewed numerous candidates here at U Chicago who really didn’t seem to get that taking care of children with disadvantaged backgrounds is a huge privilege and honor and should not be taken lightly. It is absolutely ok not to want to do that – everyone needs access to care, including the rich! Being in a hospital where our payor mix is 80% Medicaid/Medicare presents some unique challenges and is often not very glamorous. This is where my heart lies and I can’t really see myself doing anything else, but if that’s not you, don’t pick a program where you will not be happy just because it seems cool to say you take care of the underserved.
  4. Co-residents. I really enjoyed meeting the residents at almost every single program where I interviewed, but there was something about the “Comer family” that felt really right to me. They were a little less saccharine than the average pediatrician, and I felt like my sometimes-snarky commentary on life would fit in better here than anywhere else. I also really liked the program leadership here – most PDs gave a powerpoint about why we should choose their program and ours just had a really honest conversation with us. I loved that!
  5. Resident-driven program. I interviewed at a couple larger programs that were largely fellow-driven and could definitely see the appeal, but moreso the appeal for being a fellow there. I like that we have a mix of specialties with and without fellows here, but even on services that have fellows, it’s almost always the resident making decisions (with their support and teaching) and not the other way around. I have a ton of autonomy here and I absolutely love that, but if you want more supervision, consider a program where you are less likely to be making decisions on your own.

There were obviously many other factors that were probably more specific to my own goals and needs, but I hope there’s a pearl in there that someone might find useful when creating a rank list! Comment below if you have any other tips that a 4th year might need to know!

A Day in the Life: Pediatrics Clinic

Although at some point I’ll post a review of the rotation as a whole, I thought I’d share what a day looks like for me when I’m in primary care clinic as a resident pediatrician! Let me know in the comments what questions you have or what you’d like me to talk about in my review later!

06:30: wake up and feed my diva dog who demands his kibble be mixed with water and wet food. He’s a great and affectionate alarm clock and it’s pretty difficult to snooze. Pour coffee into my body and try to put on enough mascara and concealer to not look like death.

07:32: leave to make sure I get a good parking spot at work.

07:44: actually leave, will not get a great spot but will show up exactly on time.

08:00: morning report starts, which is often a case-based session led by one of the chiefs, an attending/fellow/resident, or, on occasion, me!

09:00: head up to clinic and look at the list for my morning preceptor. Check any labs or imaging I ordered recently and call families as needed to give results. Find a patient to see and let my preceptor know where I’m headed!

  • typically I run the whole visit at this point in my training as “the” doctor, with attending backup. It’s a great way to learn to be efficient and pick up tips on things to improve, but always with the knowledge that when I don’t know something I have an immediate support.
  • I don’t usually give SOAP style presentations anymore since they take up a lot of time. Especially with well child checks, I’ll let my preceptor know what the parents’ concerns were, what the child’s concerns were, what my concerns were, and then my plan, but otherwise report only the most pertinent positives and negatives.
  • What’s really fun is when either a) my preceptor checks on the patient after I’m completely done just to “bless” the encounter, or b) my preceptor goes with me into every visit and watches me see every patient on the schedule. The first is fun because it really feels like it’s my own clinic, and the second is fun because I get real-time feedback from an experienced pediatrician, with actual time constraints on the appointment that I’ll have in real life as an attending.

12:00: wrap up my last encounter, then head down to grab lunch to take to noon conference. This tends to be a bit more didactic and is likely to be a lecture from an attending. Sometimes we also use this hour for housestaff meetings or ethics conferences.

13:00: at this point I have a few possibilities: go back to clinic (usually with a different preceptor), drive to my own continuity clinic at an FQHC a few blocks away, head to a seminar for my leadership program, or find a quiet space to get some work done on my quality improvement project. Occasionally I get the afternoon off to read which I sometimes do from home in order to spend more time with Auggie! (Not that he’s spoiled…)

18:00: clinic ends and I go home to make dinner and study! I like reading from Nelson’s or Peds in Review about something I saw that day. I also usually have at least two books going so I’ll spend some time reading, and I have to admit that most nights I turn the TV on for a while too, mostly for some noise.

That’s pretty much it! What would you like more details about?

 

Step 1 Studying

This post contains an affiliate link.

This is one of my most requested topics through instagram DMs. I’m writing this down as a stream-of-consciousness once so that I can send this link to anyone who asks for it… but I don’t want to talk about it a lot more than that! Everyone’s step 1 experience is tortuous in its own special way, and although I’m very hopeful that mine was one of the worst so that I can console myself into believing that not every single doctor out there is as traumatized by this exam as I was, I’m fairly certain this is wishful thinking.

One disclaimer is that I knew I wanted to do something primary-care related, and since the average step 1 score for ob/gyn (which I was thinking about at the time) was somewhere around 226 vs. neurosurgery at 244, there was a lot more cushion and a lot less pressure on me to go nuts aiming for a 280. If I’d changed my mind later to doing something more competitive, there were certainly other aspects of my application that in combination with the score I did end up receiving would have likely made me successful candidate in any specialty, but my approach was definitely an “I don’t want any roadblocks to residency but more than enough seems superfluous” one and that might not be the very comfortable for someone who knows ahead of time they need a high score.

Another disclaimer is that this is not a post about how to approach the exam as an IMG. I get that question from a lot of instagrammers as well and honestly, I don’t have expertise in that area and would feel bad trying to give advice about it!

So, now that I’ve written disclaimers that are probably a lot longer than the actual content of how I studied, here it is:

  1. Do well in medical school. This doesn’t necessarily mean make 100s on every exam, but it means studying like someone’s life depends on it, because at some point someone’s life will probably depend on how hard you studied in medical school. This also has the benefit of making step 1 studying a review rather than a crash course in all of medicine, which would be physically impossible to do.
  2. Pathoma. Either get this or Goljan’s and stick with it. You can use it during the preclinical years, but definitely pay more attention to your lecturers in real life since just knowing the pathology is not the only key to success as a physician.
  3. First Aid. Obviously. I would advise against buying this as a first year and maybe not even until the second semester of MS2 if you’re at a school that still has 4 preclinical semesters. Over-annotating will be wholly counterproductive and you’ll seriously get lost in the woods if your whole book is covered in something you just knew would be helpful when you started reviewing. It won’t be. My favorite tip for this book was to get it unbound and 3-hole-punched so you could put it into separate binders. One small section at a time somehow feels one million times less intimidating than the entire thousand-page volume. Also see bonus #11 for disposal techniques.
  4. UWorld. UWorld UWorld UWorld. If you know everything in all of the answer explanations, you probably will score beyond your wildest dreams.
  5. Strategize timing. I know most people probably can’t do this one, but for me it worked really, really well. I had built up some elective time during MS1/MS2 (thank you Spanish and alternative medicine) that meant I had a LOT of free time in MS4, so I moved my first MS3 rotation into MS4 and took an extra 6 weeks of at the end of MS2. I finished a couple of projects I’d been working on, went on vacation with my family, did MS3 orientation with the rest of my class, and then started studying. I only studied for about 3 weeks in total before taking another 3 weeks off. It was a little weird seeing the rest of my classmates get started on the wards, but in hindsight is now absolutely a decision I’d make over and over again to protect my mental health.
  6. Find a a good study spot. I went home to my parents’ house and let my mom drive me to my undergrad library every morning when she went her work nearby. This meant I couldn’t call it quits early if I was getting bored of studying since I had no way to get home. I had the perfect study carroll and the librarians all started bringing me coffee and giving words of encouragement because they’d literally never seen anyone study so hard. #UNCWproblems
  7. Flashcard study walks! I know all of the pharmacology that I know only because I took pre-made flashcards of drugs on short walks 2-3 times per day. Thankfully the campus where I was studying was really safe/car-free so it worked out pretty well that I could walk and read at the same time. After a certain point my body just needed to stand up, but I am the type of person who needs studying momentum and even a 15 minute break can derail my train of thought, so this was a good happy medium. It felt like a “break” to me but I would advise using this technique with caution if you are of the mindset that a real break entails actually stopping studying.
  8. Take evenings off. If you have already studied 9 hours in the library all day, how productive is your brain actually going to be at home? Just enjoy time with family or friends and try not to think about anything important.
  9. Let loved ones know you’re not feeling like yourself. This was key – despite the relatively low-stakes nature of my exam prep and the overall way I approached the test, I was beside myself with fear 99.9% of my waking hours, and that manifested itself as me not being totally emotionally stable. Now, looking back, I know my strategy paid off and I shouldn’t have been as anxious as I was, but one of the best things I did for myself was to surround myself with support and to let them know that this was at least somewhat par for the course, since at the time I would have probably crumbled if it wasn’t for my parents. There was one night the week of my exam where I freaked out to the point of a panic attack, sobbing and practically screaming that I “knew nothing,” so my mom literally turned every single page of First Aid saying “do you know something about what’s on this page?” and when I answered yes, she wrote something down and at the end did some really phony math that demonstrated I knew 98% of everything in First Aid. Obviously I didn’t, but I needed that morale boost and I think everyone could use that kind of cheerleader who doesn’t judge you or ask questions but just helps during the hell that is step 1.
  10. Don’t study the day before the test! I think this is pretty obvious, but relax and just try to remember how to breathe. My mom came to the rescue again with this one… she found a friend with a yacht and got me invited to spend the afternoon and evening on the water so that I literally could not get access to my books no matter how hard I tried.
  11. Bonus: shoot First Aid. My dad took me to a shooting range after the test was over and I unloaded 15 rounds into the front cover. This was incredibly cathartic and though I usually do not condone gun use now as a pediatrician, I would make a special exception for anyone wanting to exact revenge on an inanimate object such as First Aid, as long as it’s done with adequate eye and ear protection and safe shooting technique and environment.

I guess step number 12 would be to almost immediately start studying for step 2, which I found much more pleasant and actually applicable to real life as a physician. I can do a separate post about it later, but for now check out OnlineMedEd which is what I used and loved. It helped boost not just my numerical score (average step 2 CK is much higher at baseline) but my actual percentile. It also helped me look good on the wards!

That’s pretty much it. Writing this all down actually brought back a strange amount of emotion… so glad I don’t ever really have to think about this again!