Setting standards to determine core clerkship grades in pediatrics

Clerkship Grading and the U.S. Economy: What Medical Education Can Learn From America's Economic History

Clerkship grades (like money) are a social construct that function as the currency through which value exchanges in medical education are negotiated between the system's various stakeholders. They provide a widely recognizable and efficient medium through which learner development can be assessed, tracked, compared, and demonstrated and are commonly used to make decisions regarding progression, distinction, and selection for residency. However, substantial literature has demonstrated how grades imprecisely and unreliably reflect the value of learners. In this article, the authors suggest that challenges with clerkship grades are fundamentally tied to their role as currency in the medical education system. Associations are drawn between clerkship grades and the history of the U.S. economy; 2 major concepts are highlighted: regulation and stock prices. The authors describe the history of these economic concepts and how they relate to challenges in clerkship grading. Using lessons learned from the history of the U.S. economy, the authors then propose a 2-step solution to improve upon grading for future generations of medical students: (1) transition from grades to a federally regulated competency-based assessment model and (2) development of a departmental competency letter that incorporates competency-based assessments rather than letter grades and meets the needs of program directors.

What Defines an Honors Student? Survey of Pediatric and Internal Medicine Faculty Perspectives

OBJECTIVE

Although considerable emphasis is placed on the attainment of honors in core medical school clerkships, little is known about what student characteristics are used by attending physicians to earn this designation. The purpose of this study was to evaluate what values and characteristics that attending physicians consider important in the evaluation of Pediatrics and Internal Medicine clerkship students for clinical honors designation.

METHODS

This cross-sectional survey study was framed around Accreditation Council for Graduate Medical Education (ACGME) competencies. It was administered at three tertiary care hospitals associated with one large medical school in an urban setting. Teaching ward attendings in Pediatrics and Internal Medicine who evaluated third-year medical students between 2013 and 2016 were surveyed.

RESULTS

Overall, Pediatric and Internal Medicine faculty demonstrated close agreement in which competencies were most important in designating clinical honors. Both groups believed that professionalism was the most important factor and that systems-based practice and patient care were among the least important factors. The only competency with a significant difference between the two groups was systems-based practice, with Internal Medicine placing more emphasis on the coordination of patient care and understanding social determinants of health.

CONCLUSIONS

Professionalism, communication skills, and medical knowledge are the most important characteristics when determining clinical honors on Pediatrics and Internal Medicine clerkships.

Identifying High-Performing Students in Inpatient Clerkships: A Qualitative Study

OBJECTIVES

Examine fundamental behaviors and characteristics that attending physicians in inpatient settings utilize to identify high-performing clerkship students.

METHODS

We employed written comment data from a cross-sectional survey of Internal Medicine and Pediatrics attending physicians at a single academic medical center in the southern USA. Free-text responses regarding factors that faculty consider when assigning honors grades were analyzed by four trained researchers (interrater agreement 0.87) using conventional content analysis to identify themes.

RESULTS

Seventy-nine of 141 (56%) attending physicians who were surveyed provided 90 comments.Four major theme areas for recognizing higher performing clerkship students were identified: Taking Ownership of Patient Care (35%), Medical Knowledge and Clinical Reasoning (20%), Team Orientation (15%), and Awareness of Opportunities for Growth and Progress (13%).

CONCLUSION

Internal Medicine and Pediatric attending physicians identified characteristics that contributed to four themes in the determination of a high-performing medical student. These findings are particularly salient, as they highlight that commitment to patients, application of clinical knowledge and skills, teamwork, and awareness of growth and progress are valued by attending physicians for identifying top performing students in inpatient settings.

Faculty development effects on clerkship grades

BACKGROUND

Faculty member assessment of clerkship students' clinical performance has been noted as a consistently problematic issue within most medical student clerkships, and thus a worthy target of faculty development. One of the primary challenges in such faculty development is creating a change that improves the clinical assessment of students in a meaningful way.

METHOD

In the current study we evaluated the effects of a pair of brief interventions designed to facilitate greater use of the 'Not observed' option in faculty member assessments of clerkship students (as opposed to use of 'Meets expectations' for skills actually not observed by the rater) within a psychiatry rotation for third-year medical students in the USA.

RESULTS

The intervention demonstrated statistically significant effects, both intentional and unintentional. Specifically, faculty members rated themselves as having increased their own understanding and confidence regarding the use of the assessment forms after the intervention. With regard to actual ratings of clerkship students, faculty members were less likely to use the 'Not observed' option after the intervention. Also, the mean rating increased slightly, and to a greater degree than could be explained entirely by the shift away from using 'Meets expectations' when 'Not observed' was more appropriate. Faculty member assessment of … students' clinical performance [is] a consistently problematic issue DISCUSSION: Results are discussed with regards to suggestions for implementation of the intervention in other programmes, specifically with regard to proposed improvements and issues to consider and monitor.

Combating Grade Inflation in Nephrology Clinical Rotation Evaluations Using Faculty Education and a 5-Point Centered Rating Scale

Background From 2010 to 2011, more than 70% of the clinical rotation competency evaluations for nephrology fellows in our program were rated "superior" using a 9-point Likert scale, suggesting some degree of "grade inflation." Objective We sought to assess the efficacy of a 5-point centered rotation evaluation in reducing grade inflation. Methods This retrospective cohort study of the impact of faculty education and a 5-point rotation evaluation on grade inflation was measured by superior item rating frequency and proportion of evaluations without superior ratings. The 5-point evaluation centered performance at the level expected for stage of training. Faculty education began in 2011-2012. The 5-point centered evaluation was introduced in 2012-2013 and used exclusively thereafter. A total of 68 evaluations, using the 9-point Likert scale, and 63 evaluations, using the 5-point centered scale, were performed after first-year fellow clinical rotations. Nine to 12 faculty members participated yearly. Results Faculty education alone was associated with fewer superior ratings from 2010-2011 to 2011-2012 (70.5% versus 48.3%, P = .001), declining further with 5-point centered scale introduction (2012-2013; 48.3% versus 35.6%; P = .012). Superior ratings declined with 5-point centered versus 9-point Likert scales (37.3% versus 59.3%, P = .001), specifically for medical knowledge, patient care, practice-based learning and improvement, and professionalism. On logistic regression, evaluations without superior scores were more likely for 5-point centered versus 9-point Likert scales (adjusted odds ratio [aOR] = 8.26; 95% CI 1.53-44.64; P = .014) and associated with faculty identifier (aOR= 1.18; 95% CI 1.03-1.35; P = .013), but not fellow identifier or training year quarter.

CONCLUSIONS

Grade inflation was reduced with faculty education and the 5-point centered evaluation scale.