Vascular Surgery Curriculum for Medical Students: A National Targeted Needs Assessment.

BACKGROUND: At present, neither the American College of Surgeons (ACS) nor the Society for Vascular Surgery (SVS) provides curriculum recommendations for medical students rotating on a vascular surgery service. We sent a targeted needs assessment to vascular surgeons across the country in order to investigate the need for a structured curriculum for medical students participating in a vascular surgery rotation during their clinical clerkships. METHODS: The survey was developed with input from medical students, vascular surgeons, and medical educators. Respondents were identified from the Fellowship and Residency Electronic Interactive Database (FREIDA). The needs assessment was sent to program directors of vascular residencies and fellowships and to other vascular surgery educators. The survey collected data regarding the existing vascular surgery curriculum at the respondent's institution, the need for a standardized curriculum, desired experiences for medical students, and important vascular topics for medical students to cover while on rotation. RESULTS: Responses were obtained from 50 of the 146 surveyed individuals (response rate = 34.2%). 48 respondents (96%) worked in an academic hospital or academic affiliated hospital. With regard to the existing vascular surgery curriculum, only 28 respondents (61%) indicated that they had a curriculum approved by the surgery clerkship director. 37 respondents (77.1%) said there were at least goals and objectives for students on the vascular surgery service, and 29 respondents (60.4%) indicated that there was dedicated time for didactic sessions. Only 17 respondents (35.4%) indicated students gave a case presentation on the service. 29 respondents (63%) agreed or strongly agreed that there should be a standardized vascular curriculum for medical students. When asked to rank 9 topics from most important to least important for students to learn, respondents ranked peripheral arterial disease, aortic disease, and carotid disease highest. Simulation experience was most frequently indicated as a desired addition to the curriculum, and only 16 respondents (33.3%) reported opportunities for vascular surgery specific simulation experiences. CONCLUSIONS: This study identified the lack of an existing structured curriculum for medical students, the desire for a standardized curriculum, and key topics and experiences that are felt to be important for students to cover.  With this information in hand, vascular educators have the potential to enhance the learning experience of medical students rotating through the service by developing a standardized curriculum.

Clerkship Grading and the U.S. Economy: What Medical Education Can Learn From America's Economic History.

Clerkship grades (like money) are a social construct that function as the currency through which value exchanges in medical education are negotiated between the system's various stakeholders. They provide a widely recognizable and efficient medium through which learner development can be assessed, tracked, compared, and demonstrated and are commonly used to make decisions regarding progression, distinction, and selection for residency. However, substantial literature has demonstrated how grades imprecisely and unreliably reflect the value of learners. In this article, the authors suggest that challenges with clerkship grades are fundamentally tied to their role as currency in the medical education system. Associations are drawn between clerkship grades and the history of the U.S. economy; 2 major concepts are highlighted: regulation and stock prices. The authors describe the history of these economic concepts and how they relate to challenges in clerkship grading. Using lessons learned from the history of the U.S. economy, the authors then propose a 2-step solution to improve upon grading for future generations of medical students: (1) transition from grades to a federally regulated competency-based assessment model and (2) development of a departmental competency letter that incorporates competency-based assessments rather than letter grades and meets the needs of program directors.

Washington University School of Medicine in St. Louis Case Study: A Process for Understanding and Addressing Bias in Clerkship Grading.

In 2018, in response to a news story featuring the Icahn School of Medicine's decision to eliminate its chapter of Alpha Omega Alpha (AOA) due to perceived racial inequities, students at Washington University School of Medicine in St. Louis (WUSM) brought similar concerns to leadership. WUSM leadership evaluated whether students' race, ethnicity, and gender were associated with their receipt of honors in the 6 core clerkships, key determinants of AOA selection. In preliminary analysis of the school's data, statistically significant racial and ethnic disparities were associated with receipt of honors in each clerkship. Leaders shared these findings with the WUSM community along with a clear message that such discrepancies are unacceptable to the school. An effort to further analyze what lay behind the findings as well as to identify steps to resolve the problem was launched. Using a quality improvement framework, data from focus groups and student surveys were analyzed and 2 overarching themes emerged. Students perceived that both assessment and the learning environment impacted racial/ethnic disparities in clerkship grades. In multivariable logistic regression models, shelf exam scores (a part of student assessment) were found to be associated with receipt of honors in each clerkship; in some (but not all) clerkships, shelf exam scores attenuated the effect of race/ethnicity on receipt of honors, so that when the shelf scores were added to the model, the race/ethnicity effect was no longer significant. This case study describes WUSM's process to understand and address bias in clerkship grading and AOA nomination so that other medical schools might benefit from what has been learned.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey.

BACKGROUND: Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE: To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN: National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES: The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS: The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS: Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

Challenging cases during clinical clerkships beyond the domain of the "medical expert": an analysis of students' case vignettes.

Background: During clinical clerkships students experience complex and challenging clinical situations related to problems beyond the domain of the "Medical Expert". Workplace routine may leave little opportunity to reflect on these situations. The University of Zurich introduced a mandatory course directly after the clinical clerkship year (CCY) to work up these situations. Prior to the course each student submitted a vignette on a case he or she had perceived challenging during the CCY and which was not related to the domain of the "Medical Expert" role. In this paper we want to characterize these cases in respect to most prominent themes and related CanMEDS roles. The goal was to inform clinical supervisors about potential teaching demands during the CCY. Methods: All case vignettes submitted by a years' cohort were analysed by three researchers in two ways: for the clinical characteristics and the main theme of the underlying problem and the most prominent CanMEDS roles involved. Themes of the underlying problem were aggregated to overarching topics and subsequently to main categories by pragmatic thematic analysis. Results: 254 case vignettes covered the whole spectrum of clinical disciplines. A wide range of underlying themes could be assigned to five main categories: "communication within team" (23.2%), "communication with patients and relatives" (24.8%), "patient behavior and attitudes" (18.5%), "clinical decision making" (24.0%), and "social and legal issues" (9.4%). Most frequent CanMEDS roles were "Communicator" (26.9%) and "Professional" (23.5%). Conclusions: Cases students perceived as challenging beyond the "Medical Expert" were reported from all clinical disciplines. These were mainly related to communicational and professional issues, mirrored by the CanMEDS roles "Communicator" and "Professional". Therefore, supervisors in clinical clerkships should put an additional teaching focus on communication and professionalism.

Moving Toward Summative Competency Assessment to Individualize the Postclerkship Phase.

In the move toward competency-based medical education, leaders have called for standardization of learning outcomes and individualization of the learning process. Significant progress has been made in establishing defined expectations for the knowledge, skills, attitudes, and behaviors required for successful transition to residency training, but individualization of educational processes to assist learners in reaching these competencies has been predominantly conceptual to date. The traditional time-based structure of medical education has posed a challenge to individualization within the curriculum and has led to more attention on innovations that facilitate transition from medical school to residency. However, a shift of focus to the clerkship-to-postclerkship transition point in the undergraduate curriculum provides an opportunity to determine how longitudinal competency-based assessments can be used to facilitate intentional and individualized structuring of the long-debated fourth year.This Perspective demonstrates how 2 institutions-the University of Virginia School of Medicine and the University of Michigan Medical School-are using competency assessments and applying standardized outcomes in decisions about individualization of the postclerkship learning process. One institution assesses Core Entrustable Professional Activities for Entering Residency, whereas the other has incorporated Accreditation Council for Graduate Medical Education core competencies and student career interests to determine degrees of flexibility in the postclerkship phase. Individualization in addition to continued assessment of performance presents an opportunity for intentional use of curriculum time to develop each student to be competently prepared for the transition to residency.

Social Determinants of Health Curriculum Integrated Into a Core Emergency Medicine Clerkship.

Introduction: Demand that health centers address health inequities has led medical schools to emphasize social determinants of health (SDH). The Emergency Department often serves as first (or sole) point of health care access, making it an ideal environment in which to identify/explore SDH. Yet there are few SDH curricula targeting core emergency medicine (EM) clerkships. We describe implementation and outcomes of a three-part SDH curriculum instituted in a 4-week EM clerkship. Methods: We created a longitudinal curriculum aimed at fourth-year medical students in their EM clerkship. Students interviewed patients to discuss social and other influences on their health care and wrote reflections. After this, they discussed their individual cases in small groups, selected one patient, and found literature and strategies/systems to fit the patient's needs. Finally, groups presented their work to student-peers and faculty for discussion. Students were assessed for each activity and surveyed for impact of the curriculum. Results: We evaluated the curriculum, with preliminary data showing a wide range of topics covered. On a 5-point scale (1 = Hardly at All, 5 = To a Very High Degree), students responded with means of 4.4 to "I am able to recognize barriers to health that patients and families face from diverse socio-economic backgrounds" and 4.6 to "I feel it is important to recognize and address the social determinants of health as part of whole patient care." Discussion: This curriculum introduces SDH, uses metacognitive skills across multiple domains, and is feasible and has been well received in an EM clerkship.

Broadly sampled assessment reduces ethnicity-related differences in clinical grades.

CONTEXT: Ethnicity-related differences in clinical grades exist. Broad sampling in assessment of clinical competencies involves multiple assessments used by multiple assessors across multiple moments. Broad sampling in assessment potentially reduces irrelevant variances and may therefore mitigate ethnic disparities in clinical grades. OBJECTIVES: Research question 1 (RQ1): to assess whether the relationship between students' ethnicity and clinical grades is weaker in a broadly sampled versus a global assessment. Research question 2 (RQ2): to assess whether larger ethnicity-related differences in grades occur when supervisors are given the opportunity to deviate from the broadly sampled assessment score. METHODS: Students' ethnicity was classified as Turkish/Moroccan/African, Surinamese/Antillean, Asian, Western, and native Dutch. RQ1: 1667 students (74.3% native Dutch students) were included, who entered medical school between 2002 and 2004 (global assessment, 818 students) and between 2008 and 2010 (broadly sampled assessment, 849 students). The main outcome measure was whether or not students received ≥3 times a grade of 8 or higher on a scale from 1 to 10 in five clerkships. RQ2: 849 students (72.4% native Dutch students) were included, who were assessed by broad sampling. The main outcome measure was the number of grade points by which supervisors had deviated from broadly sampled scores. Both analyses were adjusted for gender, age, (im)migration status and average bachelor grade. RESULTS: Research question 1: ethnicity-related differences in clinical grades were smaller in broadly sampled than in global assessment, and this was also seen after adjustments. More specifically, native Dutch students had reduced probabilities (0.87-0.65) in broadly sampled as compared with global assessment, whereas Surinamese (0.03-0.51) and Asian students (0.21-0.30) had increased probabilities of having ≥3 times a grade of 8 or higher in five clerkships. Research question 2: when supervisors were allowed to deviate from original grades, ethnicity-related differences in clinical grades were reintroduced. CONCLUSIONS: Broadly sampled assessment reduces ethnicity-related differences in grades.

Generalizability of Competency Assessment Scores Across and Within Clerkships: How Students, Assessors, and Clerkships Matter.

PURPOSE: Many factors influence the reliable assessment of medical students' competencies in the clerkships. The purpose of this study was to determine how many clerkship competency assessment scores were necessary to achieve an acceptable threshold of reliability. METHOD: Clerkship student assessment data were collected during the 2015-2016 academic year as part of the medical school assessment program at the University of Michigan Medical School. Faculty and residents assigned competency assessment scores for third-year core clerkship students. Generalizability (G) and decision (D) studies were conducted using balanced, stratified, and random samples to examine the extent to which overall assessment scores could reliably differentiate between students' competency levels both within and across clerkships. RESULTS: In the across-clerkship model, the residual error accounted for the largest proportion of variance (75%), whereas the variance attributed to the student and student-clerkship effects was much smaller (7% and 10.1%, respectively). D studies indicated that generalizability estimates for eight assessors within a clerkship varied across clerkships (G coefficients range = 0.000-0.795). Within clerkships, the number of assessors needed for optimal reliability varied from 4 to 17. CONCLUSIONS: Minimal reliability was found in competency assessment scores for half of clerkships. The variability in reliability estimates across clerkships may be attributable to differences in scoring processes and assessor training. Other medical schools face similar variation in assessments of clerkship students; therefore, the authors hope this study will serve as a model for other institutions that wish to examine the reliability of their clerkship assessment scores.

The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM).

INTRODUCTION: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. METHODS: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. RESULTS: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. CONCLUSION: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.

Competency assessment form to improve feedback.

BACKGROUND: In-training evaluation reports are a commonly used assessment method for clinical learners that can characterise the development of competence in essential domains of practice. Strategies to increase the usefulness and specificity of written narrative comments about learner performance in these reports are needed to guide their learning. Soliciting narrative comments by competency domain from supervising doctors on in-training evaluation reports could improve the quality of written feedback to students. METHODS: This is a pre-post study examining narrative comments derived from assessments of core clerkship students by faculty members and resident supervisors in seven clerkships using two assessment forms in academic years 2013/14 (pre; two comments fields - summative, constructive) and 2014/15 (post; seven comments fields - six competency domains, constructive comments). Using a purposive sample of 60 students based on overall clerkship performance, we conducted content analysis of written comments to compare comment quality based on word count, competencies addressed and reinforcing or constructive content. Differences between the two forms across these three components of quality were compared using Student's t-tests. RESULTS: The revised form elicited more narrative comments in all seven clerkships, with more competencies addressed. The revised form led to a decrease in the proportion of constructive comments about the students' performances. In-training evaluation reports are a commonly used assessment method for clinical learners DISCUSSION: Structural changes to a medical student assessment form to elicit narrative comments by competency improved some measures of the quality of narrative comments provided by faculty members and residents. Additional study is needed to determine how learners use this information to improve their clinical practice.

Benefits and Challenges of Supervising Physical Therapy Students in the State of Kuwait: A National Study.

One common component of allied health education is clinical fieldwork. It is the bridge between the didactic curriculum and clinical practice. Clinical supervisors perceive that being a clinical supervisor has both benefits and challenges. A modified questionnaire was distributed to 75 physical therapists who had previously or were currently engaged in supervising physical therapy students in 12 public hospitals in the State of Kuwait. In addition to demographic data, the questionnaire asked about the benefits and challenges associated with supervising students. The results indicated that the clinical fieldwork supervisors regarded their student supervision process as highly beneficial and reported that it improved their professionalism, problem-solving skills, and clinical reasoning. Challenges to supervision included students' lack of theoretical knowledge, poor hands-on skills, and poor writing/documentation skills. Suggestions are put forth to promote additional benefits and overcome existing challenges to develop a more successful physical therapy clinical education process for the supervisors and the students.

The Future of Clinical Education: Opportunities and Challenges from Allied Health Deans' Perspective.

ISSUE: There is limited information and consensus on the future of clinical education and the key factors impacting allied health (AH) clinical training. AH deans identified both opportunities and challenges impacting clinical education based on a proposed educational model. METHODS: From July 2013 to March 2014, 61 deans whose institutions were 2013 members of the Association of Schools of Allied Health Professions (ASAHP) participated in a three-round Delphi survey. Agreement on the relative importance of and the ability to impact the key factors was analyzed. Impact was evaluated for three groups: individual, collective, and both individual and collective deans. AH deans' responses were summarized and refined; individual items were accepted or rerated until agreement was achieved or study conclusion. RESULTS: Based on the deans' ratings of importance and impact, 159 key factors within 13 clinical education categories emerged as important for the future of clinical education. Agreement was achieved on 107 opportunities and 52 challenges. CONCLUSIONS: The Delphi technique generated new information where little existed specific to AH deans' perspectives on AH clinical education. This research supports the Key Factors Impacting Allied Health Clinical Education conceptual model proposed earlier and provides a foundation for AH deans to evaluate opportunities and challenges impacting AH clinical education and to design action plans based on this research.

A Nationwide Medical Student Assessment of Oncology Education.

Cancer is the second leading cause of death in the USA, but there is minimal data on how oncology is taught to medical students. The purpose of this study is to characterize oncology education at US medical schools. An electronic survey was sent between December 2014 and February 2015 to a convenience sample of medical students who either attended the American Society for Radiation Oncology annual meeting or serve as delegates to the American Association of Medical Colleges. Information on various aspects of oncology instruction at participants' medical schools was collected. Seventy-six responses from students in 28 states were received. Among the six most common causes of death in the USA, cancer reportedly received the fourth most curricular time. During the first, second, and third years of medical school, participants most commonly reported 6-10, 16-20, and 6-10 h of oncology teaching, respectively. Participants were less confident in their understanding of cancer treatment than workup/diagnosis or basic science/natural history of cancer (p < 0.01). During the preclinical years, pathologists, scientists/Ph.D.'s, and medical oncologists reportedly performed the majority of teaching, whereas during the clinical clerkships, medical and surgical oncologists reportedly performed the majority of teaching. Radiation oncologists were significantly less involved during both periods (p < 0.01). Most schools did not require any oncology-oriented clerkship. During each mandatory rotation, <20 % of patients had a primary diagnosis of cancer. Oncology education is often underemphasized and fragmented with wide variability in content and structure between medical schools, suggesting a need for reform.

Development and assessment of a pediatric emergency medicine simulation and skills rotation: meeting the demands of a large pediatric clerkship.

OBJECTIVE: To implement a curriculum using simulation and skills training to augment a Pediatric Emergency Medicine (PEM) rotation within a pediatric clerkship. BACKGROUND: PEM faculty are often challenged with a high learner to teacher ratio in a chaotic clinical setting. This challenge was heightened when our pediatric clerkship's traditional 1-week PEM rotation (consisting of 4 students completing four 8-hour ED shifts/week) expanded to 8 students every 2 weeks. We sought to meet this challenge by integrating simulation-based education into the rotation. METHODS: Clerkship students from March to June 2012 completed our traditional rotation. Students between July and October 2012 completed the new PEM-SIM curriculum with 19 hours ED shifts/week and 16 hours/week of simulation/skills training. Pre/post-tests evaluated 1) medical management/procedural comfort (five-point Likert scale); and 2) PEM knowledge (15 multiple-choice questions). RESULTS: One hundred and nine students completed the study (48 traditional, 61 PEM-SIM). Improvement in comfort was significantly higher for the PEM-SIM group than the traditional group for 6 of 8 (75%) medical management items (p<0.05) and 3 of 7 (43%) procedures, including fracture splinting, lumbar puncture, and abscess incision/drainage (p<0.05). PEM-SIM students had significantly more improvement in mean knowledge compared to the traditional group (p<0.001). CONCLUSIONS: We have successfully integrated 16 hours/week of faculty-facilitated simulation-based education into a PEM rotation within our clerkship. This curriculum is beneficial in clinical settings with high learner to teacher ratios and when patient care experiences alone are insufficient for all students to meet rotation objectives.

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis.

BACKGROUND: Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care. OBJECTIVE: To examine medical students' perceptions of healthcare delivery as it relates to cost consciousness DESIGN: Retrospective qualitative analysis of medical student narratives PARTICIPANTS: Third-year medical students during their inpatient internal medicine clerkship MAIN MEASURES: Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students' awareness and perceptions regarding the practice of cost-conscious care within our medical center. KEY RESULTS: Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.) CONCLUSIONS: Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.

The Short-Answer Vignette Examination (SAVE): an assessment tool for the core psychiatry clerkship.

OBJECTIVE: This study aims to develop a vignette-based assessment tool for medical students on the psychiatry clerkship, with the goal of capturing knowledge and clinical reasoning. METHODS: The Short-Answer Vignette Exam (SAVE), four case vignettes with open-ended questions regarding assessment, differential diagnosis, management, and treatment, was developed for and administered to medical students rotating through psychiatry at a university medical school over one academic year (n = 169). The correlation of SAVE scores to resident/faculty evaluations (clinical rating) and Shelf exam scores were analyzed. RESULTS: SAVE scores were significantly correlated with scores on both the Shelf and Clinical Rating. By contrast, Shelf scores were not significantly related to Clinical Rating. CONCLUSION: The SAVE may measure aspects of clinical decision making not measured by the Shelf, without being redundant in what is assessed by the Clinical Rating. The SAVE provides an additional potentially useful assessment tool to evaluate medical students on the psychiatry clerkship.

Assessment of neurological clinical management reasoning in medical students.

In neurology education there is evidence that trainees may have greater ability in general localization and diagnosis than they do in treatment decisions, particularly with considering longer term care and supportive care. We hypothesized that medical students completing a neurology clerkship would exhibit greater skill at considering the acute diagnostic and therapeutic management than at considering supportive management measures. Data from 720 standardized patient encounters by 360 medical students completing a neurology clerkship being evaluated via an objective structured clinical examination were analyzed for skill in three components of clinical decision making: diagnostic evaluation, therapeutic intervention, and supportive intervention. Scores for all standardized patient encounters over the 2008-2012 interval revealed a significantly higher percentage of correct responses in both the diagnostic (mean [M]=62.6%, standard deviation [SD]=20.3%) and therapeutic (M=63.0%, SD=28.8%) categories in comparison to the supportive (M=31.8%, SD=45.2%) category. However, only scores in therapeutic and supportive treatment plans were found to be significant predictors of the USA National Board of Medical Examiners (NBME) clinical neurology subject examination scores; on average, a percent increase in therapeutic and support scores led to 5 and 2 point increases in NBME scores, respectively. We demonstrate empirical evidence of deficits in a specific component of clinical reasoning in medical students at the completion of a neurology clerkship.