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Academic Medicine:
doi: 10.1097/ACM.0b013e318285f4bc
Letters to the Editor

Why Reforms Must Be Made to Make the Dean’s Letter Useful

Alexander, Erik K. MD; Osman, Nora Y. MD; Walling, Jessica L.; Mitchell, Vivian G. MD

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Medicine clerkship director and director of medical student education, Brigham and Women’s Hospital, Boston, Massachusetts; ekalexander@partners.org.

Associate clerkship director, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Clerkship coordinator, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Associate clerkship director, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

In Reply to Weissman: Dr. Weissman succinctly delineates the adverse consequences of extreme variation and imprecision in present-day clerkship grading. Although such imprecision affects many downstream events, the most notable may be the quality and content of the “dean’s letter” and the fairness to internship and residency applications. However, the problem goes beyond postgraduate training. State licensing boards, internal promotions or disciplinary boards, honorary societies, and even the students themselves are equally affected.

As we stated in our report, the importance of clear and consistent educational objectives and of fair and transparent evaluation has been addressed by the Liaison Committee on Medical Education (LCME).1 There are 47 educational directives that clerkship directors are expected to understand and apply to their courses. Educational Directive 1 addresses the need for core content and consistent course objectives, defined in part by public expectations of a physician’s competency. Educational Directive 30 states that clerkship directors must also design and implement a system of fair and timely evaluation for each course. What is notably not addressed is the expectation of consistency in evaluation and grading terminology. Even among U.S. medical schools using the same grading systems, we documented impressive differences in the proportions of medical students awarded the top grade. Among LCME-accredited medical schools, we found that this percentage ranged from 2% to 92%.2

Dr. Weissman urges leaders of academic medicine to hold a national conference that charges all stakeholders to develop a strategy and timetable for grading reform. We agree, and we believe that LCME accreditation should recommend use of a single and consistent grading system throughout all the schools it accredits, much as content exposure to internal medicine, surgery, pediatrics, obstetrics, and psychiatry are mandated. Those tasked with creating and implementing any standardized grading system should reflect on the fact that our analysis2 suggests it would be detrimental to create excessive grading categories. Our data suggest that grading systems with fewer available grade options demonstrate less grade inflation while simultaneously reducing interschool variation.2

We hope the Association of American Medical Colleges and the LCME will respond to Dr. Weissman’s request, one echoed by an increasingly vocal constituency. There is arguably little downside to standardizing grading terminology and structure, but there is tremendous opportunity to further improve the best medical training system in the world.

Erik K. Alexander, MD

Medicine clerkship director and director of medical student education, Brigham and Women’s Hospital, Boston, Massachusetts; ekalexander@partners.org.

Nora Y. Osman, MD

Associate clerkship director, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Jessica L. Walling

Clerkship coordinator, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Vivian G. Mitchell, MD

Associate clerkship director, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

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References

1. Liaison Committee on Medical Education. . Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. http://www.med.unc.edu/ome/lcme/Sub-Committees/lcme-documents/LCMEFunctionsStructMS10-11.pdf. Accessed December 31, 2012

2. Alexander EK, Osman NY, Walling JL, Mitchell VG. Variation and imprecision of clerkship grading in U.S. medical schools. Acad Med. 2012;87:1070–1076

© 2013 Association of American Medical Colleges

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