Tulane Internal Medicine Residency, Program Information

Evaluations and Milestones

For as good as our residents are, every resident deserves to have personal guidance and strategic planning for how he/she can become even better. And if you’ve read this far into the website, it shouldn’t come as a surprise to you that the Tulane Team has its own philosophy when it comes to evaluations!

You’ll find that when it comes to evaluations and self-improvement…. Tulane’s “system has driven the function.” Read through again the structure of Tulane’s program… and you’ll find that the system has been perfectly designed to maximize the time each intern has with his resident, each resident has with her interns, and each team has with its attending. Even the best evaluations are not going to be very effective if your attending isn’t around to see you practice the art… or if your resident is perpetually in a different place than you are (i.e., shifts, running to clinic, etc.)  The Tulane system has been designed to optimize team-contact time, and that in turn provides for exceptional feedback and evaluation.

So how does the evaluation system work? There are six components, but in all cases, the focal point of the evaluation is not on stratifying who is better than someone else… the focal point is on giving you counsel as to how you can improve your weakest area… we believe that for as good as you might be, there is always something to improve. That’s how good becomes great!  

1. Mid-block evaluations. Near the mid-point of the month, your attending will give you a piece of paper and two pennies. On that piece of paper will be ten skills that make for a great intern…. Not abstract, ACGME-new-speak… tangible skills like data organization, time management, talking with patients, interacting with nurses, etc. She’ll ask you to put your penny on what you think your weakest area might be, and then she’ll do the same. Your time together will be about strategies to improve those areas (infinite play), not wasted time on commentary on how “well” you have done on the block (finite play).

2. End of block evaluations:  Every resident receives evaluations each month… But to optimize the infinite game, it will come from the team, not merely from the attending. At the end of the block, the team (attending, resident, interns, students) will sit in a room. One by one, team members will leave the room, and the remaining team will discuss the areas where the person could most improve. That person will come back in the room, and the next person will leave. Once everyone has left and returned, the attending will provide the summary comments to each individual person. The method rewards how well a resident has done in making other team members better (infinite play) vs. just looking impressive himself (finite play).

3. Nurse evaluations. On a quarterly basis, one of our residents will meet with the nursing team in a room. Picture of all of the residents who have been on that ward in the preceding three months will be shown to the nurse team. The nurses will then collectively answer this question, “How could this resident improve?”   In a separate room, the resident team be doing the same… reviewing pictures of the nurses with whom they have worked, collectively answering that same question, “How could this nurse improve?” Because the evaluations are team-based, they emphasize interpersonal relationships, and because each team is tasked with answering the question of “How could he improve?”… the emphasis is on infinite play.

4. Ambulatory evaluations also occur on a quarterly basis, and follow the exact model of the nurse evaluations. The precepting team of attendings will review each resident, tasked with answering that same one question, “How can this resident most improve?”

5. Patient evaluations come in two forms. Throughout the year, you’ll be asked to give patients of your choosing an evaluation form to complete. In addition, your teaching hospitalist (by virtue of being a hospitalist) will often round on your patients a second time during the day. During these visits when only she (the teaching hospitalist) is in the room, is the opportunity to ask the patients what they think of the care you have provided them.

6. Finally, as described in the Firm System, you will be assigned a firm when you enter the Tulane Team. Each firm is tasked with assigning members from its firm to staff its ward, ICU, CCU, etc. duties. When you go to one of these rotations, you will be going with a resident from your firm. Over time, the senior residents on the firm (PGY 2 and 3) will collectively become very knowledgeable about the interns in their firm (since they will have collectively worked with you throughout the year). On a quarterly basis, the senior residents in the firm will evaluate each intern in their firm… using the exact methodology as the ambulatory and nurse evaluations…. One question… “How can this intern most improve?” And… the interns on that firm will reciprocate with their own session, evaluating the residents on their firm. Once again, the evaluation system is designed to optimize and reward interpersonal relationships, and to give you meaningful feedback as to how to become even better (as opposed to that tired-old…“She was a 4 out of 5… great working with her… Read more.”  Useless… as if you were on the fence as to whether you should read more or read less.)

But once again… the point of evaluations should not be to compile an “official record” of scores in the E-value system. There is no grade-point average in residency. The point of the evaluation should be to improve you, and to make sure that what evaluation does occur immediately translates into giving you personal counsel as to how to make that improvement. And that’s where having personal coaches makes all the difference.

Twice a year, you’ll have a private meeting with your assistant coaches (chief resident and associate program director). Even though you’ll have received immediate feedback from evaluation strategies 1 and 2 above, they’ll review those with you in addition to the summary comments from evaluation components 3, 4, 5 and 6. But know this…. This is not about telling you if you are an “A” resident or a “B” resident… it is not about how “well you did.” Regardless of how well you did (the finite focus), you can improve (the infinite focus)…. And the focus will be on designing plans for continued improvement along the milestones to greatness. 

Gone are the days of “who’s honors and who’s high pass.” We can do more for out patients as a team than we can as individuals. Learning how to be a great team player, though, requires a new way of thinking… and without evening knowing it, your time with the Tulane Team will teach you to think in a new way… a way that is about winning the infinite game….  Now is the time for identifying the weakest area in your portfolio of talents, and designing strategies to improve those areas. Welcome to the rest of your life… we’re happy to walk the next few miles of that road right along with you!


A Deep Foray Into the Philosophy that Underlies Tulane’s Evaluations/Feedback Platform…

(Enter at your own risk!)

To understand our philosophy on evaluations, it’s worth a foray into John Carse’s book, “Finite and Infinite Games.” (One of the readings for the residents’ CAS sessions). I’ll say from the outset, that this might mess you up a bit… it’s some pretty deep philosophy. But here goes…

In the book, Carse describes the “finite game” as being comprised of the following components: 1) There is a finite beginning, and a finite end, 2) Players in a finite game are “abstractions of themselves”…. That is to say, they are playing a “role,” that may or may not approximate who they are as people. 3) The goal of the finite game is to win the game, 4) If something is not explicitly prohibited, it is implicitly allowed (i.e., short cuts/work-arounds/cheating) and 4) The utility/value of any action is measured by how much it helps you in winning the game.

The infinite game (aka, your life), on the other hand, is comprised of the following: 1) There is no end… your life keeps going, 2) Players are themselves, and they see each other as people… and these people-people relationships are fostered to persist long after any “finite game” has come to a conclusion, 3) The goal of the infinite game is to keep playing… and to include as many other players as wish to play, 4) The utility/value of an action is measured by how it enriches your life and your relationships with others, regardless of whether it helps/hurts winning a finite game.

Told you… this gets a little deep….

Your whole life, you have been socialized into “finite games.” Semesters in college… blocks/clerkships in medical school… are just a few examples. Each had a finite beginning and a finite end… in each you were playing a role (i.e., “today, the role of ‘third year medical student’ will be played by (insert your name)”)… and in each, the goal was to “win the game” (i.e., get honors, get the A, etc.). Now... there is nothing wrong with a finite game, nor is there anything wrong with winning a finite game…. Indeed, if you don’t… you don’t get to keep playing.

Where it becomes wrong, however, is when the finite game starts to compete with the infinite game. Case in point, did you ever have the temptation to share your class noted with a colleague (knowing that someone had to get the “B” if someone was to get the “A”)…. To teach a colleague when you knew you had limited time to study for a final exam yourself… to spend more time with a patient on the wards instead of going to a coffee house to study for the shelf exam…. or merely to learn about something that you knew wasn’t going to be on the exam when you knew you had limited time to cram for the exam?  In all cases, the decision to do or not do the action was influenced by the stakes of the finite game. The actions of teaching, sharing, spending time with a patient, learning… these are all people-people skills, and their utility/value extends even after the finite game is long gone. But the harsh reality is that finite games often get in the way of the infinite games, and that has consequences… the most tangible of which is that the finite games can start to erode personal relationships (i.e., throwing people under the bus) and to stunt your own personal growth (i.e., asking for meaningful feedback gives way to posturing to look better than you are, covering your mistakes, hiding what you don’t know, etc.). But more distally, becoming the slave to the finite game erodes happiness and fulfillment. As a rule, the importance of a finite game progressively dissolves after the game is over. Think about it… that “A” you worried so much about in college… does that matter to you now? How about the friend you met as a part of being in that course in college… yes, that relationship (i.e., infinite game) brings a degree of happiness that sustains itself.

So here we go… when you are dealing with people (like you and me) who have been socialized to play finite games, you have to be very carful in how evaluations are designed, lest you end up creating new finite games (i.e., who had the higher score… who’s the “8 out of 10” vs. the “9 out of 10.”… who’s at “milestone 4 vs. milestone 5” etc.). The Tulane Team has put great effort into ensuring that we didn’t build new finite games. The things we learn as a team should be for the sake of learning, not for the finite purpose of reaching a higher score on the in-service exam. The things we do as a team should be about optimizing interpersonal relationships (infinite games), not rewarding competition/one-ups-manship.