By Tim Lacy

Working in the Office of Medical Student Learning Environment, I find it a good practice to draw a bright line between a person’s feelings about grades and evaluations, on the one hand, and their own assessment of a course’s or clerkship’s learning environment on the other. It’s important to separate questions of mistreatment from critical feedback and lower-than-expected grades.

This is, admittedly, a difficult distinction to make when one is in the midst of the curriculum. It’s hard to parse one’s feelings and draw appropriate lines when an individual course is ongoing, or even after a course or clerkship is complete. Even so, one must resist thinking of a poor grade, or critical feedback, as abuse or mistreatment. Our reactions to assessments of performance, whether in a course or on the job, traffic heavily in emotion. It is very human to see low scores or a critical assessment (even when conveyed constructively) and take it hard. Disappointment is natural. When you are or have been a good student, your expectations do not always line up with reality. Let downs are difficult.

With those points in mind, let’s work through the issues.

Situation #1:  Help!  I just received a negative evaluation, and I’m worried/upset/confused. What are my options?

After an initial stage of reaction, however, you have choices.

  • Accept the assessment and move on. You figure out what went wrong, resolving to not repeat the mistake in the future. This may involve further feedback from the instructor, a test review session, and practice toward correction. The latter is, in essence, voluntary remediation. Remediation can also be required by an instructor if mastery is crucial.
  • Ignore the assessment. There are legitimate reasons for doing so. Perhaps you know it was a one-time negative performance based on circumstances. You suspected during the test that you weren’t at your best. The numbers confirmed it, and you’re disappointed, but you’re moving on. You may also reject the assessment because it doesn’t fit your narrative about yourself. If you’ve had success and rarely experience failure, you can read the bad grade as a statistical anomaly—bound to happen but nothing about which to fret. It is right, it seems, to ignore the event as an unusual occurrence.
  • Reject the assessment, grade, and feedback because you feel it was made in error. Errors happen. Sometimes these are easy to see, objective, and quickly remedied. You take the error to your instructor, it’s acknowledged, and a correction is made. Sometimes there is an element of subjectivity in the perception of error. You bring the perceived error to the instructor, but the instructor counters with a plausible argument about instructions not being followed, particulars being overlooked, or another reasonable way to read the question (i.e. issues of emphases and judgment in determining a hierarchy of factors). Instructors have a great deal of leeway to determine what is reasonable in the context of a course.

This underscores the issue of perception, one related to rejection that leads to difficult feelings about assessments. Even curricula based on science, medicine, and technology contain many points of subjectivity. This is especially true in the clerkship years, where questions of human interaction, and perceptions about them, are most prominent.

Then you add another layer of interpretive issues surrounding ‘professionalism’. This subject is taught during one’s doctoring courses and put into practice during the clerkship years. In those situations your professionalism is assessed and critiqued. Issues arise. One person’s candidness, for instance, is another’s bluntness. One person’s succinctness feels deficient in relation to conveying understanding to patients and students. One person’s sense of objectivity and professional distance is coldness to another—inhumane. And there is no denying that an individual’s sense of professionalism is conditioned by cultural factors.

These difficult issues of assessment and perception—of differing views about how humans should interact in medicine—often touch on learning environment problems in medical education. One person’s view of negative behavior can be, at times, another’s mode of operation. The problem, however, is that only some negative behaviors constitute mistreatment or create a suboptimal learning environment.

Situation #2: I don’t feel like I was treated fairly. Is it mistreatment?

Points of reference:

  • AAMC examples of mistreatment include: public embarrassment; public humiliation; threatening with physical harm; physically harming someone; requiring a subordinate to perform personal services; making sexist remarks; denying of training or rewards based on race, gender, or ethnicity; giving lower evaluations or grads based on race, gender, or ethnicity; sexual harassment; unlawful racial discrimination; or subjecting someone to unwanted sexual advances.
  • Other examples: verbal abuse, using threatening behaviors or words; directing profanities, obscenities, or pejoratives at a student or in a student’s presence; unwarranted exclusion from reasonable learning activities; ignoring institutional policies; encouraging unethical behavior; and pressuring or requiring students to work beyond established hours.
  • Here are examples of “sub-optimal learning environments”: instructors or supervisors inviting students (or vice versa) into romantic or sexual relationships; singling out students for higher expectations relative to the student’s cohort; assigning duties as punishment rather than education; intentional neglect or lack of communication; and allowing students to witness mistreatment toward fellow students or patients. A complete list of examples of negative behaviors and sub-optimal learning environment issues are available at this link.

While these lists constitute a wide range of negative behaviors in the context of one’s learning environment, only a few touch on grades or evaluations directly: giving lower grades based on one’s identity; unwarranted exclusion from reasonable learning activities; ignoring institutional policies (on assessment); and singling out students for higher expectations relative to others in the student’s cohort. Publicly posting grades is not allowed under FERPA if the posting contains non-coded, publicly identifiable links to individual students. [Peer assessments and grading are not covered under FERPA until they are collected and recorded by the instructor.]

More factors related to grading and assessment:

  • Two things that are implied but not explicitly addressed in these lists are (1) unannounced departures from the syllabus and (2) the lack of timely feedback. While these contribute to a sub-optimal learning environment, they can and should be addressed through the grade grievance process. The University of Illinois College of Medicine’s “Academic Grievance” process is discussed at this link.
  • Verbal abuse is sometimes confused with critical feedback when the latter feels harsh, especially if it is delivered succinctly or pointedly, or in an urgent and/or intense situation. A student may feel singled out due to the social nature of medical education settings. But would the same feedback have been given to another student in the same situation? You may feel embarrassed, and the setting was public, but was it a purposed public embarrassment meant to harm you, or others? Getting clear, unambiguous answers to these questions can be difficult.

Disclaimer: I raise these issues and questions not to say that grades, assessments, and evaluations are not sites of mistreatment. They most certainly can be. I have seen cases where the student’s reaction and resolve about what happened were absolutely correct. Verbal abuse, purposed public embarrassment, and public humiliation do occur in the context of assessment.

In sum, assessments are a place in the curriculum where confusion occurs. It is important to remember that feelings about, and reactions to, critical assessment do not mean that mistreatment occurred. Time is needed for discernment and clarification. And one should discuss, when possible, ambiguities with the offending party. Those professional conversations can provide clarity and help you discern the best next steps. I am happy to assist with any issues you may have in this arena.