In Pursuit of Honors: A Multi-Institutional Study of Students’ Perceptions of Clerkship Evaluation and Grading

Abstract

Purpose To examine medical students’ perceptions of the fairness and accuracy of core clerkship assessment, the clerkship learning environment, and contributors to students’ achievement. Method Fourth-year medical students at 6 institutions completed a survey in 2018 assessing perceptions of the fairness and accuracy of clerkship evaluation and grading, the learning environment including clerkship goal structures (mastery- or performance-oriented), racial/ethnic stereotype threat, and student performance (honors earned). Factor analysis of 5-point Likert items (1 = strongly disagree, 5 = strongly agree) provided scale scores of perceptions. Using multivariable regression, investigators examined predictors of honors earned. Qualitative content analysis of responses to an open-ended question yielded students’ recommendations to improve clerkship grading. Results Overall response rate was 71.1% (666/937). Students believed that being liked and particular supervisors most influenced final grades. Only 44.4% agreed that grading was fair. Students felt the clerkship learning environment promoted both mastery and performance avoidance behaviors (88.0% and 85.6%, respectively). Students from backgrounds underrepresented in medicine were more likely to experience stereotype threat vulnerability (55.7% vs 10.9%, P < .0005). Honors earned was positively associated with perceived accuracy of grading and interest in competitive specialties while negatively associated with stereotype threat. Students recommended strategies to improve clerkship grading: eliminating honors, training evaluators, and rewarding improvement on clerkships. Conclusions Participants had concerns around the fairness and accuracy of clerkship evaluation and grading and potential bias. Students expressed a need to redefine the culture of assessment on core clerkships to create more favorable learning environments for all students.

Guidelines: The dos, don’ts and don’t knows of remediation in medical education

“…Whether or not an institution openly acknowledges the predictable need for remediation and works to destigmatize and adequately resource remediation in medical education is a reflection of the culture of that institution [37]. Medical education programs have traditionally used deficit-based approaches to education, which can encourage learners to focus on surface performance rather than deeper understanding to avoid negative labels [38]. More recently, programs have increased adoption of competency-based approaches, which de-emphasize time spent in training and emphasize the developmental, possibly time-variable, nature of the acquisition of capacities [39].…”

“…Many stressors, particularly those fostered by the implicit curriculum, can influence the need for future remediation. Students report feeling that they are constantly being evaluated, particularly in the setting of clerkships where the criteria and expectations for grades are subjective and appear arbitrary and whimsical [38, 72, 73]. A strategy shown to have potential to alleviate some of that stress is the facilitated support group with sessions aimed at increasing self-awareness, self-care, and/or mindfulness training [74–76].…”

Association Between Racial and Ethnic Diversity in Medical Specialties and Residency Application Rates

“…The learning environment also has implications for professional development and career choice. Students from URM groups have reported experiencing discrimination at greater rates, 13 , 26 and studies have found racial disparities in clerkship grades 27 , 28 , 29 and medical student evaluations. 30 Stereotype threat (ie, fear of confirming a primarily negative perception about one’s racial, ethnic, or other social group), which is prevalent among Asian and Black students, 31 is more likely to occur in less diverse settings, with consequences for performance, grading, and effective educational alliances.…”

Improving Student Understanding of Clerkship Expectations With an Online, Interactive Frame-of-Reference Training Module

“…Assessment of medical students during clerkships is largely driven by clinical performance ratings, but many students perceive clinical evaluations to be “unfair” and call for more training of evaluators. 1 Limitations in self-assessment may contribute to this perception, 2 and frame-of-reference training may improve students’ ability to recognize different levels of performance. 3 The objective of this study was to determine if an online, frame-of-reference training module can improve students’ understanding of clerkship expectations for clinical performance in the medicine clerkship.…”