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First impressions can influence rater-based judgments but their contribution to rater bias is unclear. Research suggests raters can overcome first impressions in experimental exam contexts with explicit first impressions, but these findings may not generalize to a workplace context with implicit first impressions. The study had two aims. First, to assess if first impressions affect raters' judgments when workplace performance changes. Second, whether explicitly stating these impressions affects subsequent ratings compared to implicitly-formed first impressions. Physician raters viewed six videos where learner performance either changed (Strong to Weak or Weak to Strong) or remained consistent. Raters were assigned two groups. Group one (n = 23, Explicit) made a first impression global rating (FIGR), then scored learners using the Mini-CEX. Group two (n = 22, Implicit) scored learners at the end of the video solely with the Mini-CEX. For the Explicit group, in the Strong to Weak condition, the FIGR (M = 5.94) was higher than the Mini-CEX Global rating (GR) (M = 3.02, p < 0.001). In the Weak to Strong condition, the FIGR (M = 2.44) was lower than the Mini-CEX GR (M = 3.96 p < 0.001). There was no difference between the FIGR and the Mini-CEX GR in the consistent condition (M = 6.61, M = 6.65 respectively, p = 0.84). There were no statistically significant differences in any of the conditions when comparing both groups' Mini-CEX GR. Therefore, raters adjusted their judgments based on the learners' performances. Furthermore, raters who made their first impressions explicit showed similar rater bias to raters who followed a more naturalistic process.

Understanding which factors can impact rater judgments in assessments is important to ensure quality ratings. One such factor is whether prior performance information (PPI) about learners influences subsequent decision making. The information can be acquired directly, when the rater sees the same learner, or different learners over multiple performances, or indirectly, when the rater is provided with external information about the same learner prior to rating a performance (i.e., learner handover). The purpose of this narrative review was to summarize and highlight key concepts from multiple disciplines regarding the influence of PPI on subsequent ratings, discuss implications for assessment and provide a common conceptualization to inform research. Key findings include (a) assimilation (rater judgments are biased towards the PPI) occurs with indirect PPI and contrast (rater judgments are biased away from the PPI) with direct PPI; (b) negative PPI appears to have a greater effect than positive PPI; (c) when viewing multiple performances, context effects of indirect PPI appear to diminish over time; and (d) context effects may occur with any level of target performance. Furthermore, some raters are not susceptible to context effects, but it is unclear what factors are predictive. Rater expertise and training do not consistently reduce effects. Making raters more accountable, providing specific standards and reducing rater cognitive load may reduce context effects. Theoretical explanations for these findings will be discussed.

Learner handover (LH), the process of sharing of information about learners between faculty supervisors, allows for longitudinal assessment fundamental in the competency-based education model. However, the potential to bias future assessments has been raised as a concern. The purpose of this study is to determine whether prior performance information such as LH influences the assessment of learners in the clinical context. Between December 2017 and June 2018, forty-two faculty members and final-year residents from the Department of Medicine at the University of Ottawa were assigned to one of three study groups through quasi-randomisation, taking into account gender, speciality and rater experience. In a counter-balanced design, each group received either positive, negative or no LH prior to watching six simulated learner--patient encounter videos. Participants rated each video using the mini-CEX and completed a questionnaire on the raters' general impressions of LH. A significant difference in the mean mini-CEX competency scale scores between the negative (M = 5.29) and positive (M = 5.97) LH groups (P < 0.001, d = 0.81) was noted. Similar findings were found for the single overall clinical competence ratings. In the post-study questionnaire, 22/28 (78%) of participants had correctly deduced the purpose of the study and 14/28 (50%) felt LH did not influence their assessment. LH influenced mini-CEX scores despite raters' awareness of the potential for bias. These results suggest that LH could influence a rater's performance assessment and careful consideration of the potential implications of LH is required.

There is an increasing focus on factors that influence the variability of rater-based judgments. First impressions are one such factor. First impressions are judgments about people that are made quickly and are based on little information. Under some circumstances, these judgments can be predictive of subsequent decisions. A concern for both examinees and test administrators is whether the relationship remains stable when the performance of the examinee changes. That is, once a first impression is formed, to what degree will an examiner be willing to modify it? The purpose of this study is to determine the degree that first impressions influence final ratings when the performance of examinees changes within the context of an objective structured clinical examination (OSCE). Physician examiners (n = 29) viewed seven videos of examinees (i.e., actors) performing a physical exam on a single OSCE station. They rated the examinees' clinical abilities on a six-point global rating scale after 60 s (first impression or FIGR). They then observed the examinee for the remainder of the station and provided a final global rating (GRS). For three of the videos, the examinees' performance remained consistent throughout the videos. For two videos, examinee performance changed from initially strong to weak and for two videos, performance changed from initially weak to strong. The mean FIGR rating for the Consistent condition (M = 4.80) and the Strong to Weak condition (M = 4.87) were higher compared to their respective GRS ratings (M = 3.93, M = 2.73) with a greater decline for the Strong to Weak condition. The mean FIGR rating for the Weak to Strong condition was lower (3.60) than the corresponding mean GRS (4.81). This pattern of findings suggests that raters were willing to change their judgments based on examinee performance. Future work should explore the impact of making a first impression judgment explicit versus implicit and the role of context on the relationship between a first impression and a subsequent judgment.

Competency-based assessment is placing increasing emphasis on the direct observation of learners. For this process to produce valid results, it is important that raters provide quality judgments that are accurate. Unfortunately, the quality of these judgments is variable and the roles of factors that influence the accuracy of those judgments are not clearly understood. One such factor is first impressions: that is, judgments about people we do not know, made quickly and based on very little information. This study explores the influence of first impressions in an OSCE. Specifically, the purpose is to begin to examine the accuracy of a first impression and its influence on subsequent ratings. We created six videotapes of history-taking performance. Each video was scripted from a real performance by six examinee residents within a single OSCE station. Each performance was re-enacted with six different actors playing the role of the examinees and one actor playing the role of the patient and videotaped. A total of 23 raters (i.e., physician examiners) reviewed each video and were asked to make a global judgment of the examinee's clinical abilities after 60 s (First Impression GR) by providing a rating on a six-point global rating scale and then to rate their confidence in the accuracy of that judgment by providing a rating on a five-point rating scale (Confidence GR). After making these ratings, raters then watched the remainder of the examinee's performance and made another global rating of performance (Final GR) before moving on to the next video. First impression ratings of ability varied across examinees and were moderately correlated to expert ratings (r = 0.59, 95% CI [-0.13, 0.90]). There were significant differences in mean ratings for three examinees. Correlations ranged from 0.05 to 0.56 but were only significant for three examinees. Rater confidence in their first impression was not related to the likelihood of a rater changing their rating between the first impression and a subsequent rating. The findings suggest that first impressions could play a role in explaining variability in judgments, but their importance was determined by the videotaped performance of the examinees. More work is needed to clarify conditions that support or discourage the use of first impressions.

We introduce a post-entry liquidity constraint to the standard model of a …rm with stochastic cash ‡ow and irreversible exit decision. We assume that a …rm with no cash holdings and negative cash ‡ow is forced to exit regardless of its future prospects. This creates a precautionary motive for holding cash, which must be traded off against the liquidity cost of holding cash. We characterize the optimal exit and dividend policy and analyze numerically its comparative statics properties. The …rm pays dividends when it is in a sufficiently strong position in terms of cash ‡ow and cash holdings, and the …rm almost surely exits voluntarily to pre-empt forced exit. The direct effect of the liquidity constraint is to impose inefficient exit, but in industry equilibrium it also creates a price distortion that leads to ineffi cient survival. (D81, D92, G35)

Growth in the field of medical education is evidenced by the proliferation of units dedicated to advancing Medical Education Research and Innovation (MERI). While a review of the literature discovered narrative accounts of MERI unit development, we found no systematic examinations of the dimensions of and structures that facilitate the success of these units. We conducted qualitative interviews with the directors of 12 MERI units across Canada. Data were analyzed using qualitative description (Sandelowski in "Res Nurs Health" 23:334-340, 2000). Final analysis drew on Bourdieu's ("Outline of a theory of practice." Cambridge University Press, Cambridge, 1977; "Media, culture and society: a critical reader." Sage, London, 1986; "Language and symbolic power." Harvard University Press, Cambridge, 1991) concepts of "field," "habitus," and "capital", and more recent research investigating the "field" of MERI (Albert in "Acad Med" 79:948-954, 2004; Albert et al. in "Adv Health Sci Educ" 12:103-115, 2007). When asked about the metrics by which they define their success, directors cited: teaching, faculty mentoring, building collaborations, delivering conference presentations, winning grant funding, and disseminating publications. Analyzed using Bourdieu's concepts, these metrics are discussed as forms of capital that have been legitimized in the MERI field. All directors, with the exception of one, described success as being comprised of elements (capital) at both ends of the service-research spectrum (i.e., Albert's PP-PU structure). Our analysis highlights the forms of "habitus" (i.e., behaviors, attitudes, demeanors) directors use to negotiate, strategize and position the unit within their local context. These findings may assist institutions in developing a new--or reorganizing an existing--MERI unit. We posit that a better understanding of these complex social structures can help units become savvy participants in the MERI "field". With such insight, units can improve their academic output and their status in the MERI context-locally, nationally, and internationally.

Oral examinations have become more standardized over recent years. Traditionally a small number of raters were used for this type of examination. Past studies suggested that more raters should improve reliability. We compared the results of a multi-station structured oral examination using two different rater models, those based in a station, (station-specific raters), and those who follow a candidate throughout the entire examination, (candidate-specific raters).Two station-specific and two candidate-specific raters simultaneously evaluated internal medicine residents' performance at each station. No significant differences were found in examination scores. Reliability was higher for the candidate-specific raters. Inter-rater reliability, internal consistency and a study of station inter-correlations suggested that a halo effect may be present for candidates examined by candidate-specific raters. This study suggests that although the model of candidate-specific raters was more reliable than the model of station-specific raters for the overall examination, the presence of a halo effect may influence individual examination outcomes.

When setting standards, administrators of small-scale OSCEs often face several challenges, including a lack of resources, a lack of available expertise in statistics, and difficulty in recruiting judges. The Modified Borderline-Group Method is a standard setting procedure that compensates for these challenges by using physician examiners and is easy to use making it a good choice for small scale OSCEs. Unfortunately, the use of this approach may introduce a new challenge. Because a small scale OSCE has a small number of examinees, there may be few examinees in the borderline range, which could introduce an unintentional bias. A standard setting method called The Borderline Regression Method will be described. This standard setting method is similar to the Modified Borderline-Group Method but incorporates a linear regression approach allowing the cut score to be set using the scores from all examinees and not from a subset. The current study uses confidence intervals to analyze the precision of cut scores derived from both approaches when applied to a small scale OSCE.