Grading Practices and Distributions Across Internal Medicine Clerkships

Residency program directors use clerkship grades for high-stakes selection decisions despite substantial variability in grading systems and distributions. The authors apply clustering techniques from data science to identify groups of schools for which grading distributions were statistically similar in the internal medicine clerkship. Grading systems (e.g., honors/pass/fail) and distributions (i.e., percent of students in each grade tier) were tabulated for the internal medicine clerkship at U.S. MD-granting medical schools by manually reviewing Medical Student Performance Evaluations (MSPEs) in the 2019 and 2020 residency application cycles. Grading distributions were analyzed using k-means cluster analysis, with the optimal number of clusters selected using model fit indices. Among the 145 medical schools with available MSPE data, 64 distinct grading systems were reported. Among the 135 schools reporting a grading distribution, the median percent of students receiving the highest and lowest tier grade was 32% (range: 2%-66%) and 2% (range: 0%-91%), respectively. Four clusters was the most optimal solution (η 2 = 0.8): cluster 1 (45% [highest grade tier]-45% [middle tier]-10% [lowest tier], n = 64 [47%] schools), cluster 2 (25%-30%-45%, n = 40 [30%] schools), cluster 3 (20%-75%-5%, n = 25 [19%] schools), and cluster 4 (15%-25%-25%-25%-10%, n = 6 [4%] schools). The findings suggest internal medicine clerkship grading systems may be more comparable across institutions than previously thought. The authors will prospectively review reported clerkship grading approaches across additional specialties and are conducting a mixed-methods analysis, incorporating a sequential explanatory model, to interview stakeholder groups on the use of the patterns identified.

Background: Despite published literature demonstrating deficiencies in chest radiograph (CXR)/basic radiology interpretation skills of 4th-year medical students, studies and subsequent curricula regarding the training needed to obtain these skills are lacking. Terms such as clinical exposure and radiology teaching have been used to describe the experience for these basic interpretive skills, but best practice methods of delivery, let alone common methods, have yet to be defined. Purpose: The objective is to describe the current methods of teaching and assessing CXR/basic radiology interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship. Methods: In 2005, the Clerkship Directors in Internal Medicine (CDIM), an international organization representing U.S. and Canadian medical schools, surveyed its institutional members. Twelve questions on the survey dealt with X-ray interpretation. Results: Eighty-eight of 109 members (81%) responded to the survey. Overall, 81% of respondents felt that CXR interpretation is an important clinical skill for medical students. Seventy-six percent indicated that instruction in these skills occurs on the IM clerkship. The most cited methods of instruction were lectures (56%) and teaching rounds (48%). Most schools spent on average of 2 to 4 hr during the IM clerkship on formal radiology instruction. Only 33% indicated that radiology interpretation skills are assessed during the clerkship. The most common assessment methods were written examination (19%) and OSCE (19%). Conclusion: Substantive data regarding attainment and assessment of CXR/basic radiology interpretation skills in the undergraduate curriculum are lacking. Our study provides preliminary descriptive data regarding CXR instruction and assessment on the 3rd-year IM clerkship.

The clinical skills needed to practice high-value care (HVC) are core to all medical disciplines. Medical students form practice habits early, and HVC instruction is essential to this formation. The purpose of this study was to describe the state of HVC instruction and assessment in internal medicine clerkships and identify needs for additional curricula. In 2014, the Clerkship Directors in Internal Medicine conducted its annual survey of 121 U.S. and Canadian medical schools. The authors evaluated a subset of questions from that survey asking clerkship directors about the perceived importance of HVC instruction, type and amount of formal instruction and assessment, achievement of student competence, prioritization of topics, and barriers to curriculum implementation. Descriptive statistics were used to summarize responses, and chi-square tests were used to examine associations between response categories. The overall response rate was 77.7% (94/121). The majority (85; 91.4%) agreed that medical schools have a responsibility to teach about HVC across all phases of the curriculum. Of respondents, 31 (32.9%) reported their curricula as having some formal instruction on HVC, and 66 (70.2%) felt the amount was inadequate. Highest-priority topics for inclusion included overuse of diagnostic tests and treatments, defining value and its application to clinical reasoning, and balancing benefit and harm. Only 11 (17.8%) assessed students' competence in HVC. Internal medicine clerkship directors reported that HVC is insufficiently taught and assessed in medical school, despite relevance to practice. Developing generalizable curricular materials, faculty development, and dedicated curricular time may enhance HVC education.

Valuing the Education Mission: Implementing an Educational Value Units System

The Council of Emergency Medicine Residency Directors (CORD) introduced the standardized letter of recommendation (SLOR) in 1997, and it has become a critical tool for assessing candidates for emergency medicine (EM) training. It has not itself been evaluated since the initial studies associated with its introduction. This study characterizes current SLOR use to evaluate whether it serves its intended purpose of being standardized, concise, and discriminating. This retrospective, multi-institutional study evaluated letters of recommendation from U.S. allopathic applicants to three EM training programs during the 2011-2012 Electronic Residency Application Service (ERAS) application cycle. Distributions of responses to each question on the SLOR were calculated, and the free-text responses were analyzed. Two pilots, performed on five applicants each, assisted in developing a strategy for limiting interrater reliability. Each of the three geographically diverse programs provided a complete list of U.S. allopathic applicants to their program. Upon randomization, each program received a list of coded applicants unique to their program randomly selected for data collection. The number of applicants was selected to reach a goal of approximately 200 SLORs per site (n = 602). Among this group, comprising 278 of 1,498 applicants (18.6%) from U.S. allopathic schools, a total of 1,037 letters of recommendation were written, with 724 (69.8%) written by emergency physicians. SLORs represented 57.9% (602/1037) of all LORs (by any kind of author) and 83.1% (602/724) of letters written by emergency physicians. Three hundred ninety-two of 602 SLORs had a single author (65.1%). For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%; question not answered by some), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine." For 405 of 602 of all SLORs (67.2%), one or more questions were left unanswered, while 76 of all SLORs (12.6%) were "customized" or changed from the standard template. Finally, in 291 of 599 of SLORs (48.6%), the word count was greater than the recommended maximum of 200 words. Grade inflation is marked throughout the SLOR, limiting its ability to be discriminating. Furthermore, template customization and skipped questions work against the intention to standardize the SLOR. Finally, it is not uncommon for comments to be longer than guideline recommendations. As an assessment tool, the SLOR could be more discerning, concise, and standardized to serve its intended purpose.

Background and Purpose: Reflective writing programs have been implemented at many medical schools, but it is unclear to what extent and how they are structured. Methods: We surveyed the 107 Clerkship Directors of Internal Medicine member institutions on use of reflective writing assignments during the internal medicine clerkship. Results: Eighty-six of 107 (80%) institutional members completed the survey. Thirty-five percent reported having a reflective writing assignment, 48% did not, and 6% did not but were considering starting one within the next 2 years. Of the 30 assignments, most were partially structured (60%), involved small-group discussion (57%), and provided individual student feedback (73%). A minority (30%) contributed to the students’ grade. Respondents believed assignments contributed to students’ learning in multiple domains, most often Professionalism (97%) and Communication (77%). Conclusions: Although reflective writing programs were common, variability existed in their structure. Further research is needed to determine how best to implement them.

As electronic health records (EHRs) became broadly available in medical practice, effective use of EHRs by medical students emerged as an essential aspect of medical education. While new federal clinical documentation guidelines have the potential to encourage greater medical student EHR use and enhance student learning experiences with respect to EHRs, little is known nationally about how students have engaged with EHRs in the past. This study examines medical student accounts of EHR use during their internal medicine (IM) clerkships and sub-internships during a 5-year time period prior to the new clinical documentation guidelines. An online survey about EHR use was administered to medical students immediately after they completed USMLE Step 2 CK. The sample included 16,602 medical students planning to graduate from US medical schools from 2012 to 2016. Descriptive statistics were computed to determine the average percentage of students engaged in various health record activities during their IM educational experiences by graduation year. The vast majority (99%) of medical students used EHRs during IM clerkships or sub-internships. Most students reported that they entered information into EHRs during the inpatient component of the IM clerkship (84%), outpatient component of the IM clerkship (70%), and the IM sub-internship (92%). Yet, 43% of the students who graduated in 2016 never entered admission orders and 35% of them never entered post-admission orders. Medical school graduates ought to be able to effectively document clinical encounters and enter orders into EHR systems. Although most students used and entered information into EHRs during their IM clinical training, many students appear to have received inadequate opportunities to enter notes or orders, in particular. Implications for graduate medical education preparedness are considered. Future research should address similar questions using comparable national data collected after the recent guideline changes.

Reliable assessments of clinical skills are important for undergraduate medical education, trustworthy handoffs to graduate medical programs, and safe, effective patient care. Entrustable professional activities (EPAs) for entering residency have been developed; research is needed to assess reliability of such assessments in authentic clinical workspaces. A student-driven mobile assessment platform was developed and used for clinical supervisors to record ad hoc entrustment decisions using the modified Ottawa scale on 5 core EPAs in an 8-week internal medicine (IM) clerkship. After a 12-month period, generalizability (G) theory analysis was performed to estimate the reliability of entrustment scores and determine the proportion of variance attributable to the student and the other facets, including particular EPA, evaluator type (attending versus resident), or case complexity. Decision (D) theory analysis determined the expected reliability based on the number of hypothetical observations. A g-coefficient of 0.7 was used as a generally agreed upon minimum reliability threshold. A total of 1368 ratings over the 5 EPAs were completed on 94 students. Variance attributed to person (true variance) was high for all EPAs; EPA-5 had the lowest person variance (9.8% across cases and four blocks). Across cases, reliability ranged from 0.02 to 0.60. Applying this to the Decision study, the estimated number of observations needed to reach a reliability index of 0.7 ranged between 9 and 11 for all EPAs except EPA5 which was sensitive to case complexity. Work place-based clinical skills in IM clerkship students were assessed and logged using a convenient mobile platform. Our analysis suggests that 9-11 observations are needed for these EPA workplace-based assessments (WBAs) to achieve a reliability index of 0.7. Note writing was very sensitive to case complexity. Further reliability analyses of core EPAs are needed before US medical schools consider wider adoption into summative entrustment processes and GME handoffs.

Curriculum Management and Governance Structure ♦ The Curriculum Oversight Committee is the standing committee responsible for the overall curriculum. ♦ Four other curriculum committees (First Year, Second Year, Required Clerkship, Elective Clerkship), composed of course directors, clerkship directors, administrators, and students, provide year-specific discussion and advice on the curriculum (Figure 1).FIGURE 1:: Management of the Curriculum Office of Education ♦ The Curriculum Office within Academic Affairs has primary responsibility for overseeing and managing the curriculum. ♦ The Division of Medical Education and Evaluation within the Department of Medical Education and Biomedical Informatics (MEBI) supports the medical education program in a number of ways. MEBI was founded in 1967 as a division to help medical school faculty improve the teaching and learning process. The division achieved departmental status in 1989. ♦ The department's Division of Medical Education and Evaluation employs nine full-time faculty members and two part-time faculty; many clinician–educators have affiliate appointments in the department. MEBI faculty hold many leadership roles in the School of Medicine. These include representatives on every curriculum committee, Year 1 Curriculum Committee chair, School of Medicine Director of Evaluation, Teaching Scholars Program codirectors, OSCE program codirector, Medical Information for Decision Making course chair, and Institute for Simulation and Interprofessional Studies codirector. ♦ The department's mandate has broadened to provide instruction to faculty and students, conduct faculty development workshops, assist with and implement performance-based teaching and evaluation, and train medical education researchers and educators through the Teaching Scholars Program conduct research into teaching and learning in a variety of settings provide professional services for health sciences faculty, including course evaluation and test design and scoring develop innovations in biomedical and health informatics Financial Management of Educational Programs ♦ The diversity in the revenue base of the School of Medicine has helped the School respond to the current global financial crisis. ♦ The School's sources of revenue remain stable. However, the relative proportion of total revenue derived from each source is changing over time: Although state revenues and spending will continue to be constrained and the School of Medicine's state funds were cut in Fiscal Year 2010, the state revenue in support of a recent medical school class expansion will continue to be phased in until fully funded in 2013. The University and the School of Medicine completed a seven-year capital campaign in FY 2008. UW Medicine exceeded its capital campaign goal of $1 billion; the pledges of endowment and gifts supporting faculty, students, and programs will be realized over the next few years. The School is in a good position to continue to realize above-average growth in research programs that are integral to its educational programs. The hiring of faculty who are leaders in biomedical sciences and clinical practice and who are active in biomedical research is an important source of the School's success and high quality. The clinical programs recorded continued growth and positive financial performance in Fiscal Year 2009. Rapid systemwide process improvements to reduce costs, eliminate redundant services, and improve overall efficiency in conjunction with effective strategic planning increased key patient volumes and revenues. Revenues are transferred from the practice plans and hospitals to support the teaching, research, and patient care activities of the School of Medicine. ♦ Both the University and the School of Medicine provided bridge funding to support the academic programs. ♦ UW Medicine, the health system in which the School of Medicine is one of seven entities, is executing a comprehensive strategic plan to improve performance, implement new programs, consolidate programs to reduce costs and increase efficiency, and develop business plans around the larger strategic initiatives. The implementation of the strategic plan will achieve desired growth in the system and inform future decisions around resource allocation in the face of ongoing financial turmoil. Valuing Teaching ♦ The Colleges program, although technically not a teaching academy, has created an effective learning community of medical school teachers: Started in 2001, the Colleges' program consists of 37 faculty educators who function as a cohesive learning community, administrative unit, and cadre of teachers and mentors within the School of Medicine. The Colleges oversee a four-year integrated curriculum of clinical skills and professionalism; teach the Introduction of Clinical Medicine II course throughout the second year through weekly bedside teaching sessions with consistent, small student groups; and provide a consistent faculty mentor for all students throughout their medical school career. Faculty from diverse specialties are selected through a competitive process and devote a minimum of 0.25 FTE to the Colleges; selection criteria include clinical, teaching, and mentoring excellence. Faculty conduct and receive considerable faculty development in addition to direct involvement in curriculum development, teaching, and mentoring activities. ♦ The Teaching Scholars, a nine-month faculty development program, has developed a cadre of faculty educators who continue to work together on educational projects, workshops, and curriculum development after they have completed the formal program. To date, 168 faculty from more than 20 clinical specialties, including nursing, physician assistants, pharmacy, and dentistry, have participated in the program. Many have been promoted and/or gone on to leadership positions at UW and elsewhere. ♦ The UW Medicine Faculty Appointments and Promotions Guide, which augments departmental criteria and the University Faculty Code, states that “to foster innovation and creativity, flexibility is encouraged in how contributions to scholarship, teaching, and service are evaluated and weighted.” The guide describes the scholarship of teaching as an important type of scholarship; teaching contributions listed as scholarship include curriculum development, materials for in-house use, educational software or video, educational information on the Internet, and new methods to evaluate the success of educational programs and the progress of trainees. ♦ Virtually all promotion packets now include a teaching portfolio that documents and highlights the faculty member's educational contributions. ♦ Evaluation of the scholarship of teaching is elicited through solicited evaluations from outside reviews at the time of promotion, including users of the information (faculty, trainees, students, and so on) and/or publication in peer-reviewed journals and presentation at scientific meetings. Curriculum Renewal Process ♦ The UW School of Medicine launched a comprehensive review of the medical school curriculum in 1998. The review was completed in 2001 and implementation of the resulting plan began in 2001-02. ♦ The guiding principles of the charge by the Dean specified that the review should include a balanced, thorough examination of course content examine teaching methods employed, emphasizing the introduction and use of contemporary information technology assure continuity and internal integrity within the curriculum, with strong themes introduced in first year and followed throughout the four years develop clear lines of responsibility and authority for the administration and management of the curriculum and its component parts develop a new approach to teach core clinical skills and professionalism ♦ The curriculum review process was organized into three phases: Phase I assessed the current curriculum, identifying strengths, weaknesses, and opportunities for enhancement; Phase II developed recommended changes to address areas of concern in Phase I; and Phase III developed specific implementation plans for the recommendations. Changes to the first and second years as a result of the curriculum review included addition of an evidence-based medicine and critical thinking first-year course that has evolved into Medical Information for Decision Making greater emphasis on small-group versus lecture-based teaching addition of the Colleges program, in which a cohort of dedicated clinical faculty teach bedside clinical skills to small groups of assigned students throughout the second year and continue to mentor those students throughout their medical school education Major additions to the third and fourth clinical years included: a required 4-week Neurology Clerkship, a required four-week surgical selective, and expansion of the Chronic Care/Rehabilitation Medicine Clerkship from two to four weeks, with focus on chronic care, rehabilitation medicine, geriatrics, pain management, and palliative care. The medical student research requirement was restructured into an Independent Investigative Inquiry, with expanded options for completing the requirement, including data gathering/hypothesis-driven inquiry; critical review of literature; experience-driven inquiry; and a special simulation-based experience. The curriculum management system was restructured to implement year-specific curriculum committees and a curriculum oversight committee. Learning Outcomes/Competencies ♦ The University of Washington School of Medicine learning objectives are available at: http://uwmedicine.washington.edu/Education/MD-Program/Current-Students/Curriculum/Pages/default.aspx. New Topics in the Curriculum Since 2000 ♦ Patient safety is included in the following courses: Medical Information for Decision-Making (first year), Capstone I-Transition to Clerkships (second year), Medicine Health and Society (second year), courses in the Institute for Simulation and Interprofessional Studies (ISIS) (courses available in all years) ♦ Quality improvement is included in the following courses: Medical Information for Decision Making (first year), Medicine, Health and Society (second year), Introduction to Clinical Medicine II (second year), ISIS (all years) ♦ Team-based learning is included in the following courses: Capstone I-Transition to Clerkships (second year), Problem-based Learning (second year), Chronic Care Clerkship (fourth year), Emergency Medicine Clerkship (fourth year), ISIS (all years) ♦ Simulations/training in new surgical techniques are included in the following: Capstone I-Transition to Clerkships (second year), Capstone II-Transition to Residency (fourth year). Started in 2005, ISIS was founded to improve the cost, patient safety, and quality of medicine by improving the education system for health professionals. ISIS trains students, residents, and fellows in psychomotor skills, interprofessional and communication, crisis management, and team building. Currently, ISIS is one of the few simulation centers nationally with a focus on collaborative research and is the nation's only simulation center that has begun to quantify utilization. Future plans focus on integrating education and research to deliver patient safety and quality outcomes and further integrating simulation into education. ISIS currently has 16 courses in which medical students can participate, including basics of airway management, emergency medicine procedures and resuscitation, thoracentesis, suturing and wound management for medical students, fundamentals of laparoscopic surgery, and others. Areas of Increased Emphasis Since 2002 ♦ Cultural competency (incorporated into many courses and programs, including Introduction to Clinical Medicine I and II, Healthcare for the Underserved, and through longitudinal pathway programs that students may undertake: Hispanic Health Pathway, Indian Health Pathway, Global Health Pathway, and Underserved Pathway). ♦ Evidence-based medicine (including the required first-year course Medical Information for Decision-Making). ♦ Bedside clinical-skills teaching, especially through the Colleges program in Introduction to Clinical Medicine II. ♦ Professionalism and ethics (incorporated into multiple courses, including Introduction to Clinical Medicine I and II; Cases in Clinical Ethics; and others). ♦ Medical humanities (incorporated into a number of courses, including Mind, Body and Pen: Writing and the Art of Becoming a Physician; Thinking Visually: How to Observe in Depth). ♦ Global health (incorporated into courses offered through the Department of Global Health, including Introduction to Global Health, Multidisciplinary Perspectives in Global Health, Global Health Challenges, and others). ♦ Successful transitions between training stages (incorporated into Capstone I-Transition to Clerkships and Capstone II-Transition to Residency). ♦ Chronic care, including increased attention to end-of-life care (incorporated into the expanded Chronic Care Clerkship that offers rehabilitation medicine, palliative care, pain management, and geriatrics core options; Respectful Death: Exploring Interdisciplinary End-of-Life Care; and other courses). Changes in Pedagogy ♦ Increased emphasis on small-group learning; success is measured through student course evaluations and faculty course evaluations. ♦ New emphasis on alternative learning technologies—Podcasts, Mediasite, common learning resources across regional sites; success is measured through student and faculty course evaluations. ♦ Increased emphasis on bedside teaching of basic skills; success is measured through annual surveys, exit interviews, student performance, attitude surveys, and other methods. ♦ Provision of transitional instruction between classroom and clerkships and medical school and residency; success is measured by surveys at the completion of transition experiences/courses. ♦ Increased emphasis on vertical integration of medical skills; success is measured by regular discussions between College Faculty with clerkship directors. ♦ Increased emphasis on professionalism; success is measured by end-of-year student surveys, student course evaluations, and exit interviews. ♦ Increased emphasis on mentoring and incorporating mentoring into the educational process through the Colleges; success is measured by student surveys and exit interviews. ♦ Increased emphasis on student and faculty learning communities through the Colleges program; success is measured by student surveys, exit interviews, and faculty surveys. ♦ Increased focus on interprofessional collaboration and teamwork; success is measured through multiple ISIS evaluation mechanisms. Changes in Assessment ♦ Clarification of and emphasis on evaluation of professionalism/professional behavior in education and practice. ♦ Limited utilization of web-based testing in basic science and clinical courses. ♦ Use of NBME subject examinations in clerkships. ♦ Increased centralization and standardization of student evaluation of courses and clerkships across all teaching sites. Clinical Experiences ♦ As the regional allopathic medical school for more than one quarter of the land mass of the United States, the UW School of Medicine relies on approximately 200 clinical training sites throughout the five-state WWAMI region (Washington, Wyoming, Alaska, Montana, and Idaho) for ensuring that the students have exposure to an appropriate mix of clinical teaching settings. ♦ The main teaching hospitals and clinics in Seattle are the University of Washington Medical Center, Harborview Medical Center, UW Physicians Neighborhood Clinics, Seattle Children's Hospital, and the VA Puget Sound Health Care System; Northwest Hospital and Regional Medical Center joined UW Medicine in 2010. ♦ These sites are supplemented in the WWAMI region with major, well-established hospital teaching sites in Boise, Idaho, Anchorage, Alaska, Billings and Missoula, Montana, and Spokane, Washington, and smaller hospitals and clinics in towns and cities across the WWAMI region. ♦ The clinical instruction is rated very highly by medical students and is regarded as the greatest strength of the curriculum; the individual clerkships receive exceptional overall ratings, in particular for teaching and patient care interactions. ♦ Because students complete their clerkships across five states with multiple clinical instructors, collecting and providing grades and feedback on clinical performance can take long periods of time; new electronic resources are strongly mitigating this time lag. ♦ The logistics of travel to and housing and services at clinical sites throughout the five-state region can be challenging, especially for students with families; the school and individual clerkships attempt to reduce this challenge as much as possible by providing housing at distant sites. ♦ Residents do not teach students in all regional clinical sites; this introduces both challenges and opportunities. Residents are a good source of constant teaching for students and introduce different levels and types of instruction; where residents are not available for teaching, students have a unique opportunity to work directly and closely with attending physicians, particularly in small rural sites. Regional Campuses ♦ The University of Washington School of Medicine's WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) program utilizes six regional campuses, in addition to the main campus in Seattle, for the first year of medical school: Montana State University—Bozeman, Montana University of Alaska at Anchorage—Anchorage, Alaska University of Idaho—Moscow, Idaho University of Wyoming—Laramie, Wyoming Washington State University—Pullman, Washington Washington State University Riverpoint Campus—Spokane, Washington (started in 2008, adding 20 medical students per class to the School of Medicine) Highlights of the Program/School The Colleges program provides students with a combination of strong, standardized bedside clinical-skills training in the second year in small-group settings, sustained mentoring from a College faculty member throughout students' education, and community and connectedness in the context of a large medical school. As the medical school for the five WWAMI states, the UW School of Medicine's regional program is truly unique; the strong partnership that has developed among universities across these states, including legislatures, academic and community physicians, and health care professionals, is a model of collaboration, resource sharing, and cost efficiency. The School of Medicine focuses on and has relative success in addressing the need for primary care and health care for underserved regions while maintaining a strong research program. In its efforts to increase and enhance primary care and health care for the underserved, the School has developed unique programs, such as the Targeted Rural Underserved Track (TRUST), the WWAMI Rural Integrated Training Experience (WRITE), and the Rural/Underserved Opportunities Program (R/UOP) programs, in which students spend from weeks and months to entire years in rural and underserved communities learning medicine. The Department of Global Health, founded in 2007 as a joint department within the schools of Medicine and Public Health, builds and expands on long-standing strengths in infectious diseases. Students have multiple options for courses and international experiences. Additional educational opportunities are provided through the Institute for Health Metrics and Evaluation, established in 2007. It is a research center that measures the world's pressing health issues and provides scientific evaluations of health system and program performance for guiding health policy and accelerating global health progress.

Background: For years, quantifiable examinations have been a core component of assessing medical student competence during the internal medicine clerkship. Purpose: To determine how internal medicine clerkship directors use and view examinations and how uses of examinations have changed. Methods: In 1999, the Clerkship Directors in Internal Medicine conducted a confidential survey of its 123 institutional members. Results: Survey response rate was 89% (109/123). The National Board of Medical Examiners subject examination was used by 83%, alone (49%) or in combination with a faculty developed examination or a standardized patient examination (34%). Minimum passing scores were required for the subject exam by 80%, for faculty-developed examinations by 65%, and for the standardized patient exam by 63%. Examinations contribute approximately 25% toward a student's final grade. Students with acceptable clerkship performances but who fail an exam typically retest after self-study. Students who fail a retest receive unsatisfactory grades and require additional medicine experience. Of the clerkship directors who reported using the National Board of Medical Examiners subject examination, 45 (50%) provided comments on ways to improve the examination. Comments focused on examination content, reporting results, basing the exam on a published core curriculum, and general administrative issues. Over the past decade, use of the National Board of Medical Examiners subject examination has increased (66% to 83%), use of faculty-developed examinations has declined (46% to 27%), and the use of a clerkship standardized patient examination increased sharply (2% to 27%). Conclusions: Internal medicine clerkship directors commonly require students to pass standardized or locally developed exams and use test results to make academic decisions. The use of standardized patient examinations has increased significantly and likely reflects a broadening of competency assessment. Our results can serve as a basis for individual programmatic evaluation, for internal medicine and other clerkship directors.

New York University School of Medicine

Background: Patient encounter logs help assess a student's educational experience. The use of a grading incentive linked to the mandatory documentation of prespecified clinical encounters has been insufficiently studied. Purposes: Given this, our objectives were to determine (a) if mandating student exposure to patients with 18 key training problems leads to the successful documentation of these encounters, (b) the degree of difficulty students and clerkship directors experienced in meeting these mandates, (c) the accuracy of mandated log entries, and (d) how often the log entries were questioned or rejected by preceptors. Methods: Ninety-two 3rd-year internal medicine students and 6 internal medicine clerkship directors at 9 geographically dispersed hospitals and 30 ambulatory sites participated in the study. Over a single academic year, we directly measured the completion rate of mandated logs, the degree of their accuracy as judged against faculty-generated logs of two required videotaped standardized patient encounters, and the percentage of logs that were not validated. We surveyed students and directors on the perceived degree of difficulty in meeting mandated requirements. Results: Ninety-eight percent of students met our mandated requirements and 93.8% of students found it “easy” or “very easy” to meet this requirement. The amount of estimated time spent by clerkship directors helping students meet mandated requirements for the entire year was 4.5 hr. The accuracy of submitted logs was 77%; however, almost all inaccurate log entries were “validated” by preceptors. Conclusions: Mandating encounters is effective in assuring that students document encounters with patients who present with specific clinical problems. The accuracy of our students' mandated logs is similar to previously published data. However, even inaccurate logs were rarely questioned or rejected by preceptors.

The purpose of assigning grades at the conclusion of a course is to convey the level of achievement of learners. However, with the presence of grade inflation in nursing education, it poses a great threat to the evaluation process. The purpose of this article is to highlight the factors that influence grade inflation and to explore possible solutions to minimize the incidence of grade inflation in nursing education. A review of the literature revealed that a variety of factors influenced grade inflation and educators were indeed lenient with their grading practices, which hence attenuates the purpose of grading and evaluation. While it may be an arduous task for nursing faculty to evaluate nursing students, nursing faculty have the obligation to preserve academic integrity and must devise appropriate solutions to address the incidence of grade inflation in nursing education.

Grade inflation and school competition: an empirical analysis based on the Swedish upper secondary schools

Despite the high-stakes nature of the residency application process, data are lacking on the training, resources, and guidance provided by specialty-specific advisors. To establish best practices and improve the quality of specialty-specific advising in internal medicine (IM), the authors surveyed IM clerkship directors (CDs) about their roles and responsibilities as advisors. From September to December 2023, 140 IM CDs at U.S. medical schools with full or provisional Liaison Committee on Medical Education accreditation were surveyed. The survey was based on 22 questions regarding CDs' roles and experiences as advisors and an annual 8-question section on CD and medical school characteristics. Of the 140 CDs sent the survey, 116 (83.0%) responded. Two participants did not finish the entire survey but completed the section on which this study is based, leaving a total sample size of 118. The IM CDs advised a median of 12 students (interquartile range, 5-25; range, 0-50) per application cycle and performed a mean (SD) of 9.0 (4.0; range, 1-17) different advising responsibilities. Only 14 of the 118 participants (11.9%) received dedicated full-time equivalent time for advising. The CDs reported using a range of faculty development resources, but training provided by schools was limited; only 52 of 117 (44.4%) received education on best practices for advising. Of the 118 respondents, 75 (63.6%) reported not knowing whether their school provided resources for students underrepresented in medicine applying to residency. Finally, CDs noted a change in their advising, with 54 of 116 (46.6%) recommending that the average (i.e., middle-third) IM applicant apply to more programs compared with previous years. The IM CDs provided essential insight into specialty-specific advisors' roles, resources, and advising practices. This study revealed opportunities to promote equitable advising, reduce application inflation, and optimize the training and support of specialty-specific advisors.