A Retrospective Analysis of Medical Student Performance Evaluations, 2014-2020: Recommend with Reservations.

BACKGROUND: The Medical Student Performance Evaluations (MSPE) is a cornerstone of residency applications. Little is known regarding adherence to Association of American Medical Colleges (AAMC) MSPE recommendations and longitudinal changes in MSPE content. OBJECTIVES: Evaluate current MSPE quality and longitudinal changes in MSPE and grading practices. DESIGN: Retrospective analysis. PARTICIPANTS: Students from all Liaison Committee on Medical Education (LCME)-accredited medical schools from which the Stanford University Internal Medicine residency program received applications between 2014-2015 and 2019-2020. MAIN MEASURES: Inclusion of key words to describe applicant performance and metrics thereof, including distribution among students and key word assignment explanation; inclusion of clerkship grades, grade distributions, and grade composition; and evidence of grade inflation over time. KEY RESULTS: MSPE comprehensiveness varied substantially among the 149 schools analyzed. In total, 25% of schools provided complete information consistent with AAMC recommendations regarding key word/categorization of medical students and clerkship grades in 2019-2020. Seventy-seven distinct key word terms appeared across the 139 schools examined in 2019-2020. Grading practices markedly varied, with 2-83% of students receiving the top internal medicine clerkship grade depending on the year and school. Individual schools frequently changed key word and grading practices, with 33% and 18% of schools starting and/or stopping use of key words and grades, respectively. Significant grade inflation occurred over the 6-year study period, with an average 14% relative increase in the proportion of students receiving top clerkship grades. CONCLUSIONS: A minority of schools complies with AAMC MSPE guidelines, and MSPEs are inconsistent across time and schools. These practices may impair evaluation of students within and between schools.

Evarts Ambrose Graham, empyema, and the dawn of clinical understanding of negative intrapleural pressure.

The concept of negative intrapleural pressure is fairly new. Although the phenomenon had already been described, Wirz provided the first definitive analysis of its significance to the mechanics of breathing in 1923. By contrast, empyema has been known since antiquity; from the time of Hippocrates, treatment has consisted of open drainage. Open drainage was often successful and did not result in pneumothorax, because most cases of empyema were associated with adhesions and thickened visceral pleura that prevented the lung from collapsing. The epidemic of group A streptococcal pneumonia in military camps in 1917-1918 was associated with the rapid and early accumulation of empyema fluid and was the catalyst for renewed study of empyema. Use of open drainage to manage this illness resulted in a high immediate mortality rate, probably because patients developed pneumothorax. The work of Evarts Graham and the Empyema Commission married physiological understanding of pleural mechanics with rational clinical treatment and paved the way for further advances in thoracic surgery.