ABSTRACT
OBJECTIVES: Internal medicine clerkship grades are important for residency selection, but inconsistencies between evaluator ratings threaten their ability to accurately represent student performance and perceived fairness. Clerkship grading committees are recommended as best practice, but the mechanisms by which they promote accuracy and fairness are not certain. The ability of a committee to reliably assess and account for grading stringency of individual evaluators has not been previously studied. METHODS: This is a retrospective analysis of evaluations completed by faculty considered to be stringent, lenient, or neutral graders by members of a grading committee of a single medical college. Faculty evaluations were assessed for differences in ratings on individual skills and recommendations for final grade between perceived stringency categories. Logistic regression was used to determine if actual assigned ratings varied based on perceived faculty's grading stringency category. RESULTS: "Easy graders" consistently had the highest probability of awarding an above-average rating, and "hard graders" consistently had the lowest probability of awarding an above-average rating, though this finding only reached statistical significance only for 2 of 8 questions on the evaluation form (P = .033 and P = .001). Odds ratios of assigning a higher final suggested grade followed the expected pattern (higher for "easy" and "neutral" compared to "hard," higher for "easy" compared to "neutral") but did not reach statistical significance. CONCLUSIONS: Perceived differences in faculty grading stringency have basis in reality for clerkship evaluation elements. However, final grades recommended by faculty perceived as "stringent" or "lenient" did not differ. Perceptions of "hawks" and "doves" are not just lore but may not have implications for students' final grades. Continued research to describe the "hawk and dove effect" will be crucial to enable assessment of local grading variation and empower local educational leadership to correct, but not overcorrect, for this effect to maintain fairness in student evaluations.
ABSTRACT
BACKGROUND Management of atrial fibrillation (AF) with rapid ventricular rate in the setting of submassive pulmonary emboli (PE) has not been well defined in the literature. It is challenging as the hemodynamics caused by a PE can change the management of AF. We report a case of bilateral PE masked by new-onset AF with rapid ventricular rate that was treated pharmaceutically and mechanically, with thrombectomy. CASE REPORT An 85-year-old man presented with gradual dyspnea and was found to be in AF with rapid ventricular rate (~160-180 bpm). The patient had tachypnea and hypoxia requiring oxygen administration. On physical examination, he had euvolemia. Chest X-ray did not reveal pulmonary vascular congestion. He was started on standard AF management with atrioventricular nodal blockers. Laboratory tests revealed a normal troponin level but mildly elevated B-type natriuretic peptide and lactate. Because his dyspnea was out of proportion to the physical examination, radiographic, and laboratory findings, a D-dimer level was obtained and was elevated. Computed tomography with pulmonary angiogram showed extensive bilateral PE. An echocardiogram (TTE) showed evidence of right ventricular failure. The patient underwent mechanical thrombectomy with clot retrieval, deterring the risk of hemodynamic collapse that would have ensued with atrioventricular nodal blockers monotherapy. On repeat TTE, right ventricular dysfunction was completely resolved and the remaining hospitalization was uneventful. CONCLUSIONS In patients with concomitant AF with rapid ventricular rate and submassive PE, the use of mechanical thrombectomy, in addition to the standard AF management, could be beneficial in deterring the risk of hemodynamic collapse.
