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26 September 2007. Student Assessment: New Ideas and Old Basics. Louis Pangaro, MD Professor and Vice-chair for Educational Programs Department of Internal Medicine Uniformed Service University of the Health Sciences. “ clinical assessment”. By teachers (house staff and faculty)

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Student assessment new ideas and old basics l.jpg

26 September 2007

Student Assessment:New Ideas and Old Basics

Louis Pangaro, MD

Professor and Vice-chair

for Educational Programs

Department of Internal Medicine

Uniformed Service University of the Health Sciences

Clinical assessment l.jpg
clinical assessment”

  • By teachers (house staff and faculty)

  • On clinical rotations

  • Based on words = descriptors

  • Using words = descriptive

  • In vivo (vs. in vitro end of course/year)

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What’s old?

  • Suspicion of grades by teachers

  • Teachers reluctance to be direct (honest?)

  • Belief that grading by teachers is subjective

  • Lawsuits about low grades

    • Jamieson, Guidebook for Clerkship Directors, 2005.

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What’s basic?

  • We have an obligation

  • Fairness

  • Mentoring

    • The Hippocratic Oath

  • Professionalism

    • Duty and expertise (Pellegrino)

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How it looked in 1987

  • lack of meaningful comments by evaluators

  • insufficient definition of evaluation criteria

  • too much inter-observer variability

  • late submission of evaluations

  • delay in feedback to students

    Tonesk X, Buchanan RG. J Med Ed. 1987

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How it looked in 2001

  • “Areas of weakness in current [clinical] evaluation models include psychometric properties associated with the tools, namely their questionable reliability and validity.”

  • Turnbull, International Handbook of Research in Medical Education, 2002.

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How it looks in 2007

  • “Constructive criticism is hard to come by..”

  • “…Candor is at least as painful to the provider as to the recipient…”

  • “…faculty members feel uncomfortable inflicting pain even in a good cause like student improvement.”

  • HMS Student Handbook, 2006-2007

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  • The emotional issues for teachers and learners in the grading process.

  • Dealing with barriers to candor.

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What’s new performance.

  • A believe that quality methods can apply to teaching.

  • Search for more rigor.

  • “Best Evididence Med Ed” (BEBM)

  • “Med Ed Research Certificate”

  • MPH, MHPE programs

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New focus on evaluation clincial setting:

  • Attention to professional traits (Papadakis)

  • Lawsuits by patients

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Context of new methods performance.

  • Objective Structured Clinical Exams

  • 3600 assessments

  • Portfolios

  • Descriptive vocabularies

    • To get more inter-rater agreement

    • To calibrate differences between levels of performance

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  • [Norm]

  • Exam is generally appropriate in scope and technique. Identifies major abnormalities and pertinent normal findings, only occasionally missing elements. Exam linked to history. Appropriate for level of training.

  • HMS Clerkship Grading Form

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  • [Poor]

  • Consistently misses important findings and often does not make appropriate connection between history and physical. Often uses faulty or inappropriate technique. Not organized or thorough.

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  • [Excellent]

  • Exam is consistently superior. Uncovers subtle and important findings, incorporating advanced techniques where appropriate. Exceptionally organized and thorough, even on difficult cases.

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American Board of Internal Med performance.

1 2 3 4 5 6 7 8 9

Average and 2 SDs

Minimal acceptable

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ACGME Outcomes Project performance.

  • New emphasis on outcomes (vs curriculum)

  • “long-term effort designed to emphasize educational outcome assessment in residency programs and in the accreditation process.”

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ACGME: Outcomes: a cultural shift performance.

  • Designing Curriculum is no longer enough

  • Results must be demonstrated.

  • A shift from process to product.

  • Content expertise not enough; need pedagogic expertise

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ACGME “Competencies”(1999) performance.

  • Medical Knowledge

  • Interpersonal & communication skills

  • Professionalism

  • Patient Care

  • System-based Practice

  • Practice-based learning & Improvement

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Medical Expert performance.





Health Advocate


CanMEDS (2005)

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“R.I.M.E. Scheme” performance.

  • Reporter

  • Interpreter

  • Manager/Educator

Pangaro, Academic Med, 1999

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Acceptance (1) Ob-Gyn performance.

“The RIME method is a valid, logistically feasible and acceptable way of assessing medical student clinical performance…

…..minimizes disadvantages of descriptive evaluation, and maximizes the opportunity for accurate observations and helpful feedback.”

APGO UME Taskforce:

Espey et al, Am J Ob Gyn, 2007

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Fairness performance.



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Principle 1 : Fairness performance.

  • to society :

    • valid (not arbitrary) and

    • sensitive to detect marginal performers

  • to students :

    • know what’s expected,

    • timely feedback

  • to teachers :

    • know what observations to make

    • protected (legally, emotionally)

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Principle 2 : Consistency performance.

  • Reliability

    • Within teacher

    • Between teachers

      • In same rotation or across blocks

      • Between sites in same clerkship

      • Between disciplines

    • suitable for high-stakes decisions

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strategy performance.

  • Simplicity leads to acceptance and use

  • Acceptance to consistency

  • Consistency to fairness

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Fairness & Consistency performance.

Reliability &Validity =

Stability of measurement and strength of inferences from observations

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“ Old” beliefs in our culture performance.

  • Grading by teachers is subjective, Examinations are objective

  • Measurement > description, Numbers are > words

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Framing the question more simply: performance.

  • What do we expect of students?

  • Can we get all teachers to have the same expectations, and apply them consistently?

  • [A question of words and of conceptual frameworks]

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Educational Goals performance.



Feedback / Grading


Depends on


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The goal: progressive independence of the learner performance.



Content – Goals


after SFDP

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Frames of reference performance.for expressing goals

  • Analytic

  • Developmental

  • Synthetic

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goals for education (generic): performance.

  • attitudes/behavior

  • skills

  • knowledge


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Bloom’s Taxonomies performance.

Cognitive Domain

Psychomotor Domain

Affective Domain

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1. performance.Analytic expression of Goals

  • “ana-lytic”: takes the learner “apart”

  • into domains, categories

  • “attitude”, “skills”, “knowledge”

  • considered separately

  • generic terms

  • useful for discrete assessments

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Curricular Goals performance.: KNOWLEDGE

The School of Medicine will ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following:

  • The capacity to recognize the limitations in one’s knowledge and clinical skills and to make a commitment to engage in lifelong learning

  • Knowledge of the normal structure and function of each of the major organ systems of the body and the current basic scientific mechanisms operative at the systemic, cellular, and molecular levels

  • Knowledge of the various causes (genetic, developmental, metabolic, toxic, microbiologic, immune, psychosocial, neoplastic, traumatic, and degenerative) of illnesses and diseases

  • Knowledge of the altered structure and function of the body and its major organ systems that are seen in various illnesses and diseases

  • Knowledge of the scientific method in establishing the causation of disease and efficacy of traditional and non-traditional therapies

  • Knowledge of health care policy and the economic, psychological, social, and cultural factors that affect health and health care delivery

  • Knowledge of the most frequent clinical, laboratory, radiographic, and pathologic manifestations of common as well as life threatening diseases

  • Knowledge about relieving pain and ameliorating the suffering of patients

  • Knowledge of the epidemiology of diseases and the systematic approaches useful in promoting health

  • Knowledge of techniques of patient education and counseling in basic lifestyle changes/prevention

  • Knowledge of and approaches to reduce the psychological and physical risks and stresses of the practice of medicine

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Curricular Goals performance.: SKILLS

  • The School of Medicine will ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following:

  • The ability to obtain an accurate medical history and the ability to perform both a complete and an organ specific examination, including a mental status examination (See appendix A)

  • The ability to perform routine technical procedures (See appendix B)

  • The ability to interpret the results and be aware of the indications, complications, and limitations of commonly used diagnostic procedures (See appendix C)

  • The ability to demonstrate knowledge of theories and principles that govern ethical decision making

  • The ability to reason deductively and inductively in solving clinical problems

  • The ability to construct appropriate differential diagnoses and treatment plans for patients with common conditions, both acute and chronic, including medical, psychiatric, and surgical conditions, and those requiring short- and long-term rehabilitation

  • The ability to recognize patients with immediate life threatening conditions regardless of etiology, and to institute appropriate initial therapy

  • The ability to recognize and outline an initial course of management for patients with serious conditions requiring critical care

  • The ability to communicate effectively, both orally and in writing, with patients, patients’ families, colleagues, and others with whom physicians must exchange information in carrying out their responsibilities

  • The ability to select appropriate tests for detecting patients at risk for specific diseases and to determine strategies for responding appropriately

  • The ability to retrieve, critically review, and effectively utilize biomedical information from electronic databases and other resources for solving problems and making decisions that are relevant to the care of individuals and populations

  • The ability to evaluate the economic, psychosocial, and cultural factors that impact the health of patients and families and to incorporate these into assessment and treatment plan

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Curricular Goals performance.: ATTITUDES

  • The School of Medicine will ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following:

  • A commitment to advocate the interests of one’s patients

  • Compassionate treatment of patients, and respect for their privacy and dignity

  • Honesty and integrity and dutifulness in all interactions with patients, their families, colleagues, and others with whom physicians interact

  • An understanding of, and respect for, the roles of other health care professionals, and the need to collaborate with others in caring for patients and promoting health

  • A commitment to provide care to patients who are unable to pay and to advocate for access to health care for members of underserved populations

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“Advanced learner”


2. Developmental Terms:

can identify absence of pulse

can distinguish specific arrythmias

can manage ventricular fibrillation

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Dreyfus and Dreyfus performance.

  • Novice

  • Advanced beginner

  • Competent performance

  • Proficient performance

  • Intuitive expert

  • Master




Mind Over Machine(1986)

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Developmental vs. Analytic performance.

  • time-line, progression included levels of function

  • essential for multi-year training

  • although the terms (“novice”, “master”…) remain generic

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Goals: ACGME “Competencies” performance.

  • Medical Knowledge

  • Interpersonal & communication skills

  • Professionalism

  • Patient Care

  • Practice-based learning

  • System-based Practice

What about

the last three??



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A cube to encompass competence performance.



Medical Knowledge

Patient Care

Interpersonal skills








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Resistance is futile performance.

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Educational Goals performance.



Feedback / Grading


Depends on


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3. the “Synthetic”framework performance.

  • “syn-thetic” -putting the learner back together

  • “K S A” are all required, integrated

  • terms are a bit less generic, more behavioral

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“R.I.M.E. Scheme” performance.

  • Reporter

  • Interpreter

  • Manager/Educator

Pangaro, Academic Med, 1999

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a framework to classify level of function performance.

  • rudimentary reporting: “My patient has a fever, cough and a bad rash - it’s vesicular or pustular ….”

  • rudimentary interpreting: “I think it might be due to chicken pox or herpes.”

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  • rudimentary manager/educator performance.: “I’d consider a smear of the fluid and a chest x-ray . …We might observe or treat with acyclovir, …but I’m not sure. I’ll have to look this up.”

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Alternative model R.I.M.E. performance.

  • Framework that is

    • developmental

    • behavioral

      • student can visualize, framework for observer

    • “synthetic”

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“RIME” performance.

  • Reporter: takes ownership of getting the facts on every patient (“what”?)

  • Interpreter: takes ownership of thinking and explaining (“why”?)…

  • Manager: takes ownership of planning with patient (“how?)…

  • Educator: takes ownership of developing and sharing expertise…

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Matrix: transition to higher expectations performance.








I = introduced R = repetition P = proficiency

M = mastery in practice

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Duty and Expertise (Pellegrino) performance.

  • Each RIME “level” is a way of asking, does the student fulfill that promise

  • Making a diagnosis, not “giving” it.

  • “Objective”

  • Does it affect teacher ratings?

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Example: Construct Validity performance.Grade Distributions Univ. of Utah

Low Pass Pass HP Honors

Battistone Acad. Med. , 2001

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Grade Distributions Univ. of Utah performance.after RIME methods


Battistone Acad. Med. , 2001

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Case using RIME: performance.

W.O., student, “presents” Mrs. Jones:

  • 45yo woman with acute lower back pain

  • gives detailed description clinical picture suggestive of acute lumbar strain

  •  through physical examination,

    • blood pressure 130/80, heart rate 80

    • left-sided para-spinal tenderness L2 – L5

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Case using RIME (continued) performance.

  • while student is writing up findings in the patient’s record, you interview and examine patient.

  • Mrs. Jones asks: “Doctor, can you take my blood pressure since no one has?”

  • at what “RIME” level is this student?

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Analytic performance.(domains)




Synthetic (“steps”)




Manager/ Educator

Complimentary Approaches

ACGME “Professionalism”

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The RIME rhythm is familiar: performance.

…….S.0….. ….A…………….P………….






Manager/ Educator

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Reliability versus validity performance.








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reliability performance.

  • Computed estimate of whether an assessment tool is testing a single construct.

  • A reliability of 0.8 is considered needed for high stakes decisions (80% signal).

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Typical Reliabilities performance.

exam type alpha

  • “shelf”-100 MCQ 0.75 - .8

  • Step 1 USMLE 0.9 - .95

  • OSCE (6 stations) 0.5 - 0.6

  • OSCE (12 stations) 0.7 - 0.9

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(Observer) Low Pass performance.

Reporter Pass

Interpreter High Pass

Manager/ Honors Educator

D 1.0

C 2.0

B 3.0

A 4.0

Third-year performance Level = Grade

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USU Medicine clerkship performance.

(students) Reliability

n = 467 0.83

Roop, Amer J Med, 2001

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validity performance.

What can you infer from your evaluation?

Are you measuring what is important?




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EDP Evaluation System performance.

  • RIME Vocabulary

  • Formal Evaluation Sessions

    • Sit down with teachers every few weeks

    • Noel, J Med Ed, 1987 (detecting marginal students)

    • “Frame of reference training”

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Content Validity: Detecting Deficiencies in Professionalism performance.% of professionalism domains rated less than acceptable

Hemmer, Academic Medicine, 2000.

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Predictive Validity: Sensitivity in predicting Internship Problems(PGY1 supervisor surveys)

USU classes

of 86 - 93


Low Ratings Bad Comment

Lavin, Academic Medicine 1998

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Acceptance (2): Medicine Problems

  • 93% teachers’ evaluations

  • 81% NBME subject examination

  • 42 % RIME vocabulary

  • 32% OSCE

  • 22% direct observation (mini-CEX)

Hemmer, Teach Learn Med, 2007

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Limitations of our system Problems

  • RIME is sometimes taken as developmental scheme.

  • The analytic model is very strong, and RIME is used for cognitive growth only.

  • Wanting to skip the Evaluation Sessions - they take time!

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Clinicians are good diagnosticians Problems

We are mentors for our students

We promise society duty and expertise

Descriptors provide patterns and exemplars

Descriptive frameworks allow behavioral feedback

Synthetic frameworks make this simpler

Basics Innovations

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strategy Problems

  • Simplicity leads to acceptance and use

  • Acceptance to consistency

  • Consistency to fairness

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Thanks for coming! Problems