2024: Approaches to Obtaining Valuable, Fair, and Equitable Assessments of Medical Students in Core Clerkships

Descriptive comments from clerkship faculty typically contribute more than half [N.B. 50 to 75 % from surveys] of grades and are typically coalesced into a narrative of each student’s performance. Yet clerkship directors report that they do not have confidence in them and students themselves often consider them unfair, and “subjective” compared to quantified, standardized assessments, such as MCQs and OSCEs. 

The member organizations of the Alliance for Clinical Education (ACE) offer training on how to write bias-free narratives, and strive to enhance this instruction by including recommendations on how to mitigate bias in assessment. We recognize that implementation of these recommendations may be difficult due to limited time, lack of content knowledge, and resources necessary for clerkship directors (CDs) to deliver effective faculty development in this area. CDs are tasked with ensuring fair and equitable grading (LCME Standard 9.8), yet how much training do clerkship directors receive to identify potential sources of bias in the language?  What system elements related to time and resources are needed for faculty to be able to do this fairly and equitably, mitigating any bias? 

This session aimed to review best practices put forth by ACE’s member organizations for mitigating bias in clinical evaluation, explore barriers to their implementation, and make recommendations on how to overcome these barriers. The session objectives were:

1. Detail efforts by clinical clerkship organizations to address fairness and equity in grading
2. Identify system and resource considerations that facilitate or inhibit clerkship directors efforts to mitigate bias in writing narrative comments
3. Provide recommendations for best practices based on experiences of panel members
4. Discuss strategies to overcome barriers in implementation of best practices to mitigate bias in grade assignment
5. Explore approaches to ensure fairness and equity in clerkship grading

2023: Non-physician Health Professionals and Medical Education

The Liaison Committee on Medical Education (LCME) requires medical students have adequate supervision by faculty and be directly observed for achievement of  competencies. Many students report in surveys that they are not directly observed or given helpful feedback so many schools are involving other health professionals in teaching, observation, and assessment. This panel discussion will  analyze the risks and benefits of engaging other health professionals. Panel members will include administration, faculty, and students.  Participants are invited to share best practices. 

The objectives of the session were to:

• Appraise the LCME standards related to supervision and assessment of medical students
• Evaluate the pros and cons of non-physician health professionals for direct observation and assessment  of medical students
• Analyze risks and benefits of non-physician health professionals for feedback and assessment of medical students

2022: Valuing the Contributions of Medical Educators

Teaching is an integral part of the medical profession as apprenticeship is essential prior to independent practice. Although education is an arm of the tripartite mission of academic medical centers, there is often inequity in the value ascribed to and resources allocated for educators. This has become more apparent with shifting priorities in health care systems, including during the COVID-19 pandemic, and greater emphasis on revenue generation. Educators derive meaning from and are passionate about their roles. During the recent pandemic, they have quickly and valiantly converted curriculum to online platforms, adapted to hybrid models of teaching, and maintained flexibility to accommodate ongoing schedule changes.  However, there remains an inequity in compensation, disparity in protected time allocation, and shortfall in recognizing teaching effort. This, in turn, negatively impacts educator wellness, engagement in training our future physicians, and the learning environment. Educational value units (EVUs) have been proposed as a metric to assess effort in teaching and other scholarly productivity, akin to relative value units for clinical work. Much still needs to be done, however, to establish a broad, equitable process of measuring educational effort. Partnering with departmental and institutional leadership, there are also other creative initiatives that can be developed to recognize and value educators. In this session, members of the Alliance for Clinical Education (ACE) will introduce the topic of EVUs, discuss alternative efforts to recognize educators, and share examples of successfully implemented institutional approaches. The objectives of this session were to:

• Discuss an approach to implementing a metric for educational effort.
• Describe two practical ways to value teaching.
• Advocate for recognition of educators.

2019: Testing Drives Curriculum, But Does It Drive Anxiety?

“Assessment drives learning” is a frequently heard comment from medical educators, and indeed is helpful for learning, but how much is too much? With increasing rates of anxiety in college populations and then ultimately medical student populations, does the focus on assessment in medical school ultimately contribute to the high burnout rates seen in residency and in the practicing physician?  These questions and more were explored during this session.  The objectives of the session were to:

• Identify the main sources of anxiety students have regarding assessments;
• List the attributes of millennial and Generation Z students that might further contribute to their anxiety; and
• Identify ways to mitigate this anxiety in the culture of assessment.

2018: Pass-Fail in Medical School and the Residency Application Process and GME Transition

With the continued move to adopt a competency based medical education mindset in undergraduate medical education, coupled with concerns about student burnout, more medical schools are moving toward a Pass-Fail standard for grading.  While such a standard has an appeal for a competency based program (i.e., one either meets a standard or does not), it meets up against the hard reality of the competitive residency application process.  Residency, and fellowship, program directors are often faced with a large number of applications and either relatively limited information, or information such as the Medical Student Performance Evaluation that they may not fully trust.  Faced with a need to rank applicants, program directors are left with emphasizing those elements of performance that are more easily measured—scores on licensing and other examinations, even if they recognize the limitations in such information. The objectives of this session were to:

• Recognize the current trends in grading in UME and the challenges this may present in the residency application process;
• Describe approaches to enhancing the quality of information gathered and reported in UME; and
• Describe at least one method to enhance the residency review and/or selection process for medical students who come from programs that do not use traditional grades.

2018: Direct Observation and EPAs: The Critical Role of the Preceptor

Due to the AAMC Core Entrustable Professional Activities for Entering Residency, institutions are investigating innovative assessment tools for the clinical learning environments. Challenges include insufficient direct observation opportunities, how to “confer” entrustability, how to ensure continued growth after students reach EPAs, and how to ensure clinical preceptors implement the conceptual framework of EPAs. This interactive session of the Alliance for Clinical Education addressed challenges with solutions as well as brainstorm other practical applications. The objectives of the session were to:

• List the EPAs that are amenable to direct observation depending upon the clerkship specialty;
• Describe challenges related to implanting EPAs into the clinical curriculum; and
• Implement solutions related to above challenges at their home institutions including describing helpful precepting strategies that support direct observation.

2018:  Are Red Flags Incompatible with a Successful Match?

ACE prepared a poster presentation for the meeting.  We were able to have discussions with participants at the reception as well as capture survey data as part of the poster. The poster is available to review by clicking here.

2017: Interprofessional Education: The Quest to Meet and Exceed the Accreditation Requirements

Interprofessional education (IPE) is important because healthcare workers must continuously strive to reduce errors that impact patients. IPE may be an opportunity to prevent their occurrence. During this session, we will co-create a SWOT analysis to develop an IPE curriculum, discuss implementation of IPE curriculum, and overcome common obstacles.

2016: What Are the Responsibilities of the Clerkship Director and for Whom Does He/She Work?

Since the Alliance for Clinical Education’s collaborative statement on the expectations of clerkship directors, clerkship formats have evolved. As a result, so must the expectations of the clerkship director.  The objectives of this session were to:

• Identify and prioritize the job responsibilities of the clerkship director
• Outline the essential skills needed to succeed in those responsibilities, and;
• Identify the individual(s) to whom he/she might report

The results of this panel were published in Medical Education Online. 

2016:  Cultural Barriers to Effective Learning

Participants in this session will identify and discuss strategies to address cultural barriers impacting the learning environment. As individuals transition into professional programs, the expectations is that they make the leap to being an adult learners. This is an important theoretical construct that may be unknown to learners from different cultures as well as the millennial generation.  The objectives of this session were to:

• Discuss cultural barriers that may exist in various learning environments;
• Identify how adult learning theory can be applied to cultural differences; and
• Devise methods of enhancing the learning environment to be more culturally inclusive.

2015: Transition to Residency: Who’s Responsible?

The transition from medical school to residency training has come under scrutiny.  There is a push for competency-based medical education, but few medical educators have frameworks that are easily understood by clinical educators as well as trainees.  This session addressed the efforts to develop milestones and competencies that could be applied in medical student education. 

2014:  Medical Student Mistreatment

The mistreatment of medical students by faculty, residents and others is of increasing concern among medical educators. Much of that abuse is reported to occur on clinical clerkships. The members of this panel will discuss the definition of student mistreatment, the extent of the problem, and possible ways to manage and prevent it. Members of the audience will also be asked to describe ways in which they have successfully dealt with the problem. Attendees of the panel session should be able to:

• Identify what constitutes mistreatment of medical students.
• Describe the extent of the problem of medical student abuse.
• Discuss proposed ways of stopping medical student abuse – and the success of such attempts.

2013: Evaluation and Grading in Clerkships: Current State and Future Directions

For its plenary session at the AAMC meeting, the Alliance for Clinical Education explored the possibility of inter-school standards for evaluating students. In principle, common standards of assessment across schools could make it easier for residency directors to select among candidates for their GME programs, and create less reliance on things like USMLE scores. Viewpoints on this question were presented in a “pro” and “con” fashion with ample time for discussion among the attendees at the session.

2012: Defining Milestones for Undergraduate Medical Education

Medical schools are embracing competency-based education and educators are talking about how to define milestones for undergraduate medical education (UGME). The work to define milestones at the UGME level must be accomplished across rather than within specialty disciplines, and across medical schools rather than within each school. This is an ideal time for medical educators to collaborate to define core UGME competencies and to develop milestones for medical student education. The Alliance for Clinical Education sponsors this panel presentation to bring those working in this arena together to discuss their recent efforts and to help set a vision for the important next steps; therefore, the target audience for this presentation is medical education deans, course and clerkship directors and faculty, members of curriculum committees.

2011: Who Cares About the 4th Year of Medical School?

The fourth year of medical school has long been discussed as an area where curricular renewal is needed. Some argue in favor of leaving it as an open time for students to select any courses they want, while others believe that there should be a more structured curriculum. Efforts are also being made by some disciplines to formalize at least parts of the pre-residency training (such as the subinternships) and to recommend specific courses in the senior year for students going into their specialties.

2010: New Directions for “Clerkship” Education: Lessons from Three Schools

Clinical medical student education has traditionally centered on departmentally based experiences in core disciplines. In the past 10 years, alternative models have emerged, with longitudinal integrated experiences for medical students. Is one better than the other? Is there evidence to support one experience as educationally superior than another? What can we learn from new models to enhance traditional models?

2009: Integrating Electronic Health Records into Undergraduate Medical Education: Challenges and Opportunities

Electronic Health Records (EHR) are powerful tools for optimizing patient care delivery, and many academic centers are incorporating EHR into teaching settings. However, there have been relatively few studies reporting the effect of EHR on the education of medical students, and the optimal integration of EHR into undergraduate medical education has not been well described or documented. As a result, a national survey was conducted of clerkship directors in an attempt to better understand the challenges and opportunities of integrating EHR into daily teaching of medical students.

2008: National Survey of Clerkship Director Demographics, Resources, and Professional Life

After publishing Expectations of and for Clerkship Directors: A Collaborative Statement from the Alliance for Clinical Education (Teaching & Learning in Medicine, 2003, 15:217), a national survey was conducted of clerkship directors in an attempt to validate the expectations for clerkship directors. With more additions to medical school curricula coupled with increasing patient care demands, efforts of clerkship directors may be stymied by forces beyond their control. The findings indicate clerkship directors are doing the best they can, but they are still not able to achieve what the expectations have laid out.

2007: Portfolios in Clinical Medical Education –One Method to Foster Inter-clerkship Growth

Student portfolios are becoming increasingly common in undergraduate medical education. The literature reveals that portfolios are used for many different purposes including stimulating reflection and tracking development of competencies. Portfolios range from small endeavors, designed by a single discipline for a very specific purpose to major undertakings, backed by institutional resources. Several institutions are incorporating patient encounter logs into a portfolio. Many portfolios are multi-disciplinary, allowing the opportunity for collaboration among specialties.

2006: Implementing Longitudinal Themes in Clinical Medical Education

The goal of this workshop is to discuss the challenges clerkship directors face regarding the responsibility of meeting the long-term objectives of our individual institutions (i.e., the longitudinal themes) while also meeting the objectives specific to our individual disciplines. The session will begin with a general introduction with respect to concepts like professionalism, communication skills, interprofessional collaboration, life-long learning, etc. during the clinical years. Next, each panel presenter will discuss their national clerkship organization’s recommendations and resources. In addition, each presenter will discuss some strategies currently in use at their own institution. The session will end with questions and comments from the audience.

2005: Evaluation and Feedback During Clerkships: Solutions from the National Clerkship Organizations

The goal of this workshop was to present a spectrum of perspectives on evaluation and feedback of medical students across the third-year core clerkships. The session provided general background information including the LCME standards for evaluation and feedback. Next, each panel presenter discussed their national clerkship organization recommendations and resources. In addition, each presenter discussed some strategies currently in use at their own institution. The session ended with a discussion on legal issues involved in evaluation and feedback, followed by questions and comments from the audience.