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Abstract: Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students' individual needs and goals., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Scientific research has been changing medical practice at an increasing pace. To keep up with this change, physicians of the future will need to be lifelong learners with the skills to engage with emerging science and translate it into clinical care. How medical schools can best prepare students for ongoing scientific change remains unclear. Adding to the challenge is reduced time allocated to basic science in curricula and rapid expansion of relevant scientific fields. A return to science with greater depth after clinical clerkships has been suggested, although few schools have adopted such curricula and implementation can present challenges. The authors describe an innovation at Harvard Medical School, the Advanced Integrated Science Courses (AISCs), which are taken after core clerkships. Students are required to take 2 such courses, which are offered in a variety of topics. Rather than factual content, the learning objectives are a set of generalizable skills to enable students to critically evaluate emerging research and its relationship to medical practice. Making these generalizable skills the defining principle of the courses has several important advantages: it allows standardization of acquired skills to be combined with diverse course topics ranging from basic to translational and population sciences; students can choose courses and projects aligned with their interests, thereby enhancing engagement, curiosity, and career relevance; schools can tailor course offerings to the interests of local faculty; and the generalizable skills delineate a unique purpose of these courses within the overall medical school curriculum. For the 3 years AISCs have been offered, students rated the courses highly and reported learning the intended skill set effectively. The AISC concept addresses the challenge of preparing students for this era of rapidly expanding science and should be readily adaptable to other medical schools., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Grading committees give excessive weight to standardized-examination scores., Purpose: Understanding that biases are often ingrained in grading processes, we sought to assess the influence of a structured grading policy in limiting this effect., Methods: All 7 clerkship grading committees derived students' clinical scores while blinded to examination scores. Scores were combined to yield a final rank order, which was used to derive grade cutoffs. Logit regression was performed to assess the contribution of clinical and examination scores to final grades. Results were compared to a similar analysis where committees were not blinded to examination scores., Results: In contrast to prior findings, grading committees consistently assigned greater weight to clinical-performance scores in assigning final grades when blinded to examination scores., Conclusions: Grading committees may be unaware of the extent to which they discount clinical assessments when they are at odds with the results of standardized examinations. This can be addressed with a procedure that blinds grading committees to examination scores.

Context: Grades in clinical clerkships are typically based on a combination of clinical assessments from teachers, as well as results of more reliable (but perhaps less valid) scores on standardised tests of knowledge. It is not clear how these scores are combined in practice to yield a final summative grade., Methods: Our subjects were 83 students who rotated through five clinical clerkships during a single year. After computing univariate correlations between clinical assessment scores and standardised examination scores, we performed logistic regression analyses for each clerkship to predict the final grade from these two variables. We compared actual grade with predicted grade under various hypothetical policies for combining these two variables. Finally, we assessed whether some students would systematically benefit from these policies., Results: Clerkships varied in their univariate correlations between scores on clinical assessments and scores on standardised examinations. Clerkships with the lowest correlations tended to give more weight to standardised examination scores. Grading committees adjusted a substantial minority of grades to account for factors that were not reflected in either score. There did not appear to be a systematic bias in grading committee effect across the five clerkships., Conclusions: These results suggest a number of testable hypotheses about the cognitive processes by which evaluators combine various pieces of information to yield a summative performance score.

Background: Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students., Objective: To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance., Design: Observational study over 1 year., Participants: Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems., Primary Outcome: Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores., Main Results: Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34)., Conclusions: Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.

Purpose: Standardized end-of-clerkship examinations typically occur on the last day of the clerkship. However, recent trends toward time-varying competency-based medical education have offered students more test scheduling flexibility, creating an opportunity to study the impact of student-selected examination timing., Method: Starting with the graduating class of 2018, students took the required standardized end-of-core clerkship examinations at any available time they chose during their clinical years. Before this change, these examinations were administered to all students on the last day of the clerkship. Students' examination dates relative to clerkship completion were analyzed between 2017 and 2020 (inclusive of before and after flexible exam timing) to assess the impact that student-selected exam timing had on test performance on National Board of Medical Examiners shelf clinical science examinations for required core clerkships., Results: Data on 146 medical students in 2017 (fixed exam timing) and 466 medical students between 2018 and 2020 (flexible exam timing) were included. Among students offered flexible exam timing, between 2.7% (internal medicine) and 14.6% (psychiatry) took their exam before actually taking clerkship, while between 22.7% (psychiatry) and 40.0% (surgery) took their exam more than 90 days after the clerkship ended. Exam scores were statistically higher for those who took the exam at a time of their choosing compared with those who were required to take it at the end of individual rotations and when the exam scores were combined (fixed exam timing mean = 73.9, standard deviation [SD] = 7.8; flexible exam timing mean = 77.4, SD = 6.0, P < .001). The percent of students with passing scores was statistically higher in internal medicine, pediatrics, and psychiatry., Conclusions: Self-selection of shelf exam timing appears to increase shelf exam scores. As more medical schools transition to competency-based medical education, providing scheduling flexibility appears not to negatively affect student achievement., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Progress testing is an assessment method in which an examination reflecting competencies at graduation is regularly administered to students over multiple years, thereby facilitating self-directed learning. However, the significance of the objective structured clinical examination as a progress test in undergraduate education, needs to be determined. This study provides evidence of the role of the objective structured clinical examination for progress testing and optimal scoring methods for assessing students in different academic years. Methods: We conducted a sequential explanatory mixed-methods pilot study. Participants were assessed using the Item Rating Scale, the year-adjusted Global Rating Scale, and the Training Level Rating Scale. The characteristics of each scale were compared quantitatively. In addition, the influence of the objective structured clinical examination as a progress test on learning attitudes was examined. Qualitative data from a post-examination questionnaire were analyzed, using content analysis to explore influences on self-directed learning. Results: Sixth and fifth year clinical students (n = 235) took the objective structured clinical examination progress test. The total Item Rating Scales were recorded (%) as 59.03 ± 5.27 and 52.64 ± 5.08 (p < 0.01); Training Level Rating Scale was 3.94 ± 0.39 vs 3.22 ± 0.42 (p < 0.01); and the year-adjusted Global Rating Scale was 4.25 ± 0.44 vs 4.32 ± 0.52 (no significant difference), for the sixth and fifth year students, respectively. The correlations across stations and the reliability of each station were satisfactory. Four categories were identified in the qualitative analysis: "motivation to learn during the clinical clerkship was promoted," "dissatisfied with being asked about things they had not experienced," "confusion about being unable to use conventional test-taking strategies," and "insufficient understanding of competencies at graduation." The scores indicated significant differences in performance according to training year. Conclusions: This study provides evidence that the objective structured clinical examination can be used as a progress testing tool for undergraduate clinical clerkships. Further enhancement of training opportunities and dissemination of performance competency goals in clerkship curricula are required if we intend to promote self-directed learning through progress testing. [ABSTRACT FROM AUTHOR]

In this paper we outline the key design principles of our clinical reasoning curriculum and share student evaluations of the DR course along with an audit [[7]] of the longitudinal clinical reasoning curriculum. The clinical reasoning curriculum features spaced sessions anchored by the diagnostic reasoning (DR) course at the end of an 18 month pre-clerkship curriculum. Curricular integration The reasoning curriculum features multiple opportunities for students to engage with clinical reasoning concepts from the beginning of medical school with increasing complexity (spiral learning) as students progress in their training [[33]]. Keywords: clinical reasoning; curriculum; diagnosis; diagnostic errors; undergraduate medical education (UME) EN clinical reasoning curriculum diagnosis diagnostic errors undergraduate medical education (UME) 265 273 9 05/12/22 20220501 NES 220501 Introduction The 2015 National Academy of Medicine report I Improving Diagnosis in Health Care i raised the profile of diagnostic error as a major quality and safety issue [[1]]. [Extracted from the article]

Background: Faculty and students debate the fairness and accuracy of medical student clerkship grades. Group decision-making is a potential strategy to improve grading.Objective: To explore how one school's grading committee members integrate assessment data to inform grade decisions and to identify the committees' benefits and challenges.Design: This qualitative study used semi-structured interviews with grading committee chairs and members conducted between November 2017 and March 2018.Participants: Participants included the eight core clerkship directors, who chaired their grading committees. We randomly selected other committee members to invite, for a maximum of three interviews per clerkship.Approach: Interviews were recorded, transcribed, and analyzed using inductive content analysis.Key Results: We interviewed 17 committee members. Within and across specialties, committee members had distinct approaches to prioritizing and synthesizing assessment data. Participants expressed concerns about the quality of assessments, necessitating careful scrutiny of language, assessor identity, and other contextual factors. Committee members were concerned about how unconscious bias might impact assessors, but they felt minimally impacted at the committee level. When committee members knew students personally, they felt tension about how to use the information appropriately. Participants described high agreement within their committees; debate was more common when site directors reviewed students' files from other sites prior to meeting. Participants reported multiple committee benefits including faculty development and fulfillment, as well as improved grading consistency, fairness, and transparency. Groupthink and a passive approach to bias emerged as the two main threats to optimal group decision-making.Conclusions: Grading committee members view their practices as advantageous over individual grading, but they feel limited in their ability to address grading fairness and accuracy. Recommendations and support may help committees broaden their scope to address these aspirations. [ABSTRACT FROM AUTHOR]

Background:Medical school evaluations typically rely on both language-based narrative descriptions and psychometrically converted numeric scores to convey performance to the grading committee. We evaluated inter-rater reliability and correlation of numeric versus narrative evaluations for students on their Neurology Clerkship. Design/Methods:50 Neurology Clerkship in-training evaluation reports completed by their residents and faculty members at the University of Rochester School of Medicine were dissected into narrative and numeric components. 5 Clerkship grading committee members retrospectively gave new narrative scores (NNS) while blinded to original numeric scores (ONS). We calculated intra-class correlation coefficients (ICC) and their associated confidence intervals for the ONS and the NNS. In addition, we calculated the correlation between ONS and NNS. Results:The ICC was greater for the NNS (ICC = .88 (95% CI = .70–.94)) than the ONS (ICC = .62 (95% CI = .40–.77)) Pearson correlation coefficient showed that the ONS and NNS were highly correlated (r = .81). Conclusions:Narrative evaluations converted by a small group of experienced graders are at least as reliable as numeric scoring by individual evaluators. We could allow evaluators to focus their efforts on creating richer narrative of greater value to trainees. [ABSTRACT FROM PUBLISHER]

BACKGROUND: Since the 2011 Accreditation Council of Graduate Medical Education (ACGME) work hour rules for residents were implemented, 24-30 h call for interns has been replaced by shift work, including night-float. The impact of these changes on undergraduate medical education experiences in internal medicine has not been described. OBJECTIVE: We aimed to determine the current status of medical students' overnight experiences in Internal Medicine clerkships and sub-internships, and to assess internal medicine educators' perceptions of the importance of overnight work during internal medicine rotations. DESIGN AND PARTICIPANTS: In May 2014, the Clerkship Directors in Internal Medicine (CDIM) conducted its annual survey. Twenty-eight questions about student participation in overnight work and perceptions of the importance of overnight work (rated on 1-5 Likert scale, 1 = very unimportant and 5 = very important) were included. Descriptive statistics were used to summarize responses. Free text results were analyzed qualitatively. KEY RESULTS: The response rate was 78 %. A minority of respondents reported students having any overnight experience during the clerkship (38.7 %) or the sub-internship (40.7 %). Only 5 % of respondents reported having students assigned to night-float rotations outside of clerkships or sub-internships. Respondents agreed that overnight experiences were more important during the sub-internship than the clerkship, 4.0 ± 1.1 vs. 3.2 ± 1.2, p < 0.001. Admitting new patients, following their course and responding to emergencies were rated as important overnight tasks for both clerkship and sub-internship students. CONCLUSIONS: Overnight experiences offer students additional educational opportunities. Clerkship directors felt that the overnight experience for the sub-intern in particular was an important chance to practice providing emergency cross coverage and other intern roles. In the era of ACGME duty hours, there is a need to further examine whether there is a role for increased overnight hospital experiences for medical students. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical education topics including the function of medical mentors in evaluating a physician's performance, the pedagogical significance of patient feedback and the evaluation of clinical clerkships.