Personal View: The ticking box travesty
Authors: Neville Goodman
Journal: BMJ (2006)

Ihave organised the teaching of anaesthetics to groups of medical students for more than 20 years. Not much about this is anaesthetics: they need to practise cannulation, learn about the airway, understand perioperative fluid balance, and know how to prescribe analgesia. We are lucky in Bristol; students are with us for three weeks, which allows for six sessions each week, one-to-one practical teaching in theatre, and plenty of small group tutorials.

At one time, we had to grade each student on a scale of A-E for half a dozen criteria, including knowledge, practical skills, attendance, and so on. It was never easy because each student was taught by a number of different consultants during their attachment. I was much happier when the criteria and gradings were abandoned and the medical school simply wanted a brief statement that each student had completed their attachment satisfactorily.


I refuse to destroy my or my students' probity by sending tripe to the medical school


Such a sensible paper-free situation was unlikely to survive the current mania for assessment. A form appeared, headed “Professional Behaviour Assessment.” It has to be filled in for every student, for every clinical attachment. The only criteria shared with the previous grading system are related to punctuality; skills and knowledge are not included, and the other 14 require us to judge the students' attitudes and behaviour. For each criterion, a tick is needed to indicate “satisfactory,” “some reservations,” or “unsatisfactory.” There is also space for free text.

I have always taken it as part of a teacher's job to ensure that students behave properly, and to help them if they seem wayward. Rarely does someone in authority need to know about their behaviour. Over the years I have made sensitively worded phone calls and written discreet letters for a few students. I hope they were helped, either within their medical careers, or to realise that medicine was not for them.

How would filling in the new forms have helped for all the others? There are 250 students in each year. If they do six attachments each year, this totals 1500 forms filled with meaningless ticks, taking up space somewhere in someone's office.

I have personally looked after more than 400 students. I cannot remember any who worried me because they did not have “Respect for patients from all cultures and backgrounds.” Other new criteria include “Helpfulness towards others, including fellow students” and “Respect for needs of other students during teaching.” Yes, these are important, though there are always students who are more forthcoming than others. One teaching skill is to make sure that all students get their chance. By the time students reach me, they are in their fourth year. If these omissions have not been flagged up by then, there are serious deficiencies in the first three years of the course.

I cannot understand the need for the new forms. It might be worth reminding clinical tutors every now and again of the behaviour we expect from students, which is the behaviour expected from doctors, and surely we know what that should be. Perhaps we are not trusted to alert the medical school to students who may have problems unless we have a form to fill in. Or perhaps it is some sort of legal safeguard, so that if the medical school is sued in the future it can blame the supervising clinician.

Both tutor and student are supposed to sign the assessment. I told my current students that I would have nothing to do with these idiotic forms. They laughed, and said that previous tutors had just ticked all the “satisfactory” boxes. What a waste of time. More worryingly, two of the criteria are just about impossible for us to judge. I am asked to judge whether a student has “Respect for patient confidentiality,” but I do not see the students when they are outside the hospital, which is where abuse of that confidentiality is most likely. I am also asked to assert that a student “Does not show evidence of abuse of alcohol or other drugs”: on what grounds am I expected to make that judgment?

Filling in these meaningless forms compromises one's probity—an attribute that is assessed in the standard form for consultant appraisal. To paraphrase the doctor and writer Theodore Dalrymple: no matter how asked or answered, the question destroys the probity of appraisee and appraiser; an honest man does not proclaim his honesty, but if he has no probity to be destroyed then he will happily lie; the appraiser's probity is destroyed because he knows the answer is either humiliating, or an evasion. In another article, Dalrymple commented that “nothing is more destructive of people's ability to resist than forced acquiescence to what they know is tripe.”

I refuse to destroy my or my students' probity by sending tripe to the medical school, though I will always be on the lookout for students who seem unsuited to being doctors, as will all tutors. But, assessment forms or not, some inappropriate students will still qualify, and I do not see how the forms will help prevent this.