“We Co-Created This Mess”: Letters Between UME and GME

Dearest UME,

Over the holidays I watched one of my favorite movies—Love Actually. While this classic (and problematic) 2000s romantic comedy features multiple fraught relationships, I found myself sobbing every time one particular dysfunctional marriage was featured. Emma Thompson and Alan Rickman play a long-married couple who have drifted apart, culminating in Rickman seeking infidelity. On the surface, their relationship seems idyllic, but in truth, communication between them had withered and they lost trust. My dear UME, I was sobbing because I fear we have become Thompson and Rickman.

I remember so clearly when I entered your life back in 1919.¹ We were so young and fancy free. Our relationship felt casual and even seemed easy once we met The Match in 1951.² But now things feel strained. Difficult. I’m under constant pressure as the number of applicants you send me has grown. I love these applicants—they are incredible humans who often become fantastic physicians, and they deserve to be treated fairly and equitably by both of us. But you are making the process impossible for me.

I am trying my hardest to review every applicant holistically,³ but it’s a Herculean task given the quantity and quality of information you send me. What should I make of an Honors or Pass grade? You don’t use these labels consistently across (or within) institutions,^4,5 and grades don’t tell me what an applicant can or cannot do, nor where they might need extra help.⁶ Many times you rank your students explicitly, and other times you use code words and complicated graphs, as if you are making the Medical Student Performance Evaluation a puzzle I have to solve. I am really trying to be competency-based and holistic in recruiting, but you are actively making this more difficult.

I also feel like you’re not being honest with me.^7,8 So many times I have had learners join me, only to find out that you knew they were struggling and needed help but didn’t tell me. That doesn’t help anyone; it only hurts the learners and me. My trust in you has evaporated.

I’m writing you this letter because I’ve tried to have this conversation with you so many times, but you don’t seem to listen. Maybe writing things down is the best way to break through. I’m getting so frustrated. And now, other people are noticing our problems, too.⁹ I don’t mean to lay all of the blame on you, but you have to admit, it’s mostly on you. Right? We can do better if we try.

Please write me back. Let’s work this out.

With care,

GME

Dear GME,

First, we at least agree that Love Actually is a great holiday movie. But that may be where our agreement ends. You are the one who has not been listening to me. Your letter bemoans the types of data that I send you about applicants (to whom, I might add, I have dedicated multiple years of my life). Do you know why I send you “ambiguous” grades and “meaningless” class rankings? Because for decades, you asked for it! And in many cases, you continue to do so to make your life easier! By the way, the increasing number of applicants you’re seeing is not my doing; it’s game theory at play as medical students navigate the high stakes of residency application in a world with lower cost to attend virtual interviews.^10,11

I truly appreciate your attempt at a more competency-based and holistic approach to applicant selection. I have been trying similarly to evolve. My most prized measure, the United States Medical Licensing Examination Step 1, recently shifted to pass/fail.¹² Several of my medical schools are moving toward competency-based assessment systems, reducing (or eliminating) normative rankings, and dropping traditional grading frameworks for criterion-based approaches.^13,14 You and I are evolving in parallel. But let’s not pretend that our current situation is purely my fault. You have begged me to give you rankings and scores: anything to help quickly sort the deluge of applicants knocking on your door. Even now, several of your programs have expressed frustration and skepticism with the idea of holistic review given the scope and scale of data to be reviewed. Not to mention the wails of lament when Step 1 was changed to pass/fail.¹⁵ Our current situation is not my fault—we co-created this mess.

And let’s discuss for a moment how you can’t trust me any longer. How you think I obfuscate the truth about my learners. First, let’s both acknowledge that assessment is really hard. Given the wide variability in clinical settings and assessor development, I will never know every aspect of my learners’ competence, and so there will always be surprises in what they can or cannot do when they arrive at your program. Second, competence is contextual and dynamic,¹⁶ so it’s very possible that the data I am sending you is truly reflective of their performance in medical school contexts, but things change when they reach residency. Third, so much of the data that I send you is from a learner’s third year in training. By the time they reach you, those data are nearly a year old and may not accurately reflect the inevitable competence decay that happens during a fourth year that is often, shall we say, less-than-challenging.¹⁷ Finally, many of my assessors are afraid to provide critical feedback to learners because, despite the inherent hierarchy, they worry about reprisal in learners’ assessments (which can be tied to financial compensation or academic promotion).¹⁸ In other words, I’m doing my best, but assessment is a difficult and inexact science.

By the way, maybe I do zhuzh up some of my learner’s files. But what would you do if your learners (who had poured their hearts, souls, and dollars into years of extremely hard work) were facing a moment of impossibly high-stakes selection that determined their future careers? You wouldn’t present them in the best possible light? Don’t you do that now with the fellowship match or when you write letters of recommendation for your graduates’ future jobs?¹⁹ You don’t need to answer that because we both know it’s true. We both know what these learners sacrifice for our profession and we don’t want to let them down. Not to mention the fact that the rising cost of education and accreditation focus on learner satisfaction has turned medical training into a commodity,^20,21 and I have to treat my students as customers. If they aren’t happy, I lose their enrollment, and I’m in peril. The whole system becomes in peril.

So, let me know if you need help getting down off your high horse. We got into this mess together, and we have to get out of it together. Let me know when you actually want to make a change and find some novel solutions.

Respectfully but firmly,

UME

Dear UME,

Wow. All I can say is touché. I didn’t realize how much pressure you have been under. And I didn’t think about how my behaviors were affecting you. If I’m being honest, you’re right. I do secretly like class rankings and Step 1 scores, even though I know in my heart that they do not predict performance in residency,²² and that they reflect biases inherent in our society.²³ It’s just… I’m under a lot of pressure too. If I match a learner who is struggling and needs extra help, I don’t always have adequate resources to help them. My best educators are overstretched, my residents are burning out and struggling to find energy for the deliberate practice needed for improvement, and I have a finite amount of time before I have to graduate them (which I sometimes do even if I’m unsure they’re ready).^24,25 So, even though I shouldn’t care about rankings and shouldn’t try to only find the “best” applicants, I can’t help it! I don’t want to fail someone who might need extra support when they come to my programs. As you said, these learners have invested so much of themselves. I can’t bear letting them down. What do we do?

Humbly,

GME

Dear GME,

I appreciate your candor. Our current situation is something we have co-created, so it’s not all your fault. I have to admit that I am not only motivated by student well-being. Several people in my camp worship at the altar of school rankings and our Match rates. Institutions must put on airs to attract the next group of students in a saturated UME marketplace. So you asked, what do we do? I have some ideas. First, keep working together, and continue to call out the pressures that have incentivized us into our current situation.¹¹ Second, what if we tried the following:

• Eliminate normative comparisons (between learners and between institutions)

• Use criterion-referenced assessment and set the bar of “pass” high enough that rankings such as “best” and “worst” become irrelevant because everyone who graduates is truly ready to join you.¹¹ Progress is already being made setting that bar,^26,27 but implementation is still early.

• Build programmatic assessment that spans the gap between us using aligned frameworks²⁸

• Improve transparency in what you’re looking for in your holistic review of applicants²⁹

• Co-create a post-Match learner handover^30,31

• Stop letting our incentives drive our behavior (eg, rankings, risk avoidance, etc) and reground our work in the needs of patients and society³²

These are big ideas, but if we are going to save our relationship, I think we have to try. If you’re up for it, why don’t we have a Love Actually watch party next week? We can start our work after.

With hope,

UME

Dear UME,

I’ll bring popcorn and my laptop. I’m excited and hopeful that we can save this relationship. See you next week.

Also with hope,

GME

Fictional Editor’s Note

The Journal of Graduate Medical Education editorial team recently procured [fictional] personal correspondences between undergraduate medical education (UME) and graduate medical education (GME) that were written during a tense time in the relationship between the 2. JGME has chosen to publicize these letters in hopes of shining a light on how open communication can save a strained relationship.