Clinical Assessment Specialists: A New Faculty Role to Improve Clerkship Assessment.

INTRODUCTION: Ambulatory clerkships, including longitudinal integrated clerkships (LICs), face challenges to assessment, including time pressure and clinical demands on preceptors. High-quality clinical assessment is critical to implementing competency-based medical education, generating valid grades, and supporting learning. This importance is further heightened with the new pass/fail scoring for US Medical Licensing Exam Step 1, discontinuation of US Medical Licensing Exam Step 2 Clinical Skills, and the growing concern for bias in assessment. METHODS: The Kaiser Permanente Bernard J. Tyson School of Medicine's LIC spans the first 2 years with 50 students per class. In 2021-2022, the authors created a new faculty role, the clinical assessment specialist (CASp). CASps are highly trained clinical teachers who directly observe clerkship students in the ambulatory setting, provide feedback, and complete competency-based assessment forms. RESULTS: CASps completed 186 assessments of first-year (Y1) LIC students and 333 assessments of second-year (Y2) LIC students. Y2 students achieved average higher milestones and were rated as requiring less supervision compared to Y1 students. Y1 students rated CASps more favorably than Y2 students. Preceptors rated the contribution of CASps similarly across both years. Clerkship directors described benefits including identification of at-risk students and value of augmenting preceptor assessments. DISCUSSION: The CASp role may offer an innovative way to generate valid assessment of student performance, offset clinical pressures faced by preceptors, identify at-risk students, and mitigate bias, especially in an LIC. Future studies may examine assessment validity, including use in summative assessment. CONCLUSION: CASps are an innovative approach to clinical clerkship assessment.

Developing an Entrustment Process: Insights from the AAMC CoreEPA Pilot.

One of the main goals of the CoreEPA pilot has been to determine the feasibility of developing a process to make summative entrustment decisions regarding entrustable professional activities (EPAs). Five years into the pilot, we report results of a research study we conducted to explore approaches to the entrustment process undertaken by our ten participating schools. We sought to identify the choices that participating schools made regarding the entrustment process and why these decisions were made. We are sharing these results, highlighting ongoing challenges that were identified with the intent of helping other medical schools that are moving toward EPA-based assessment. We conducted semi-structured interviews with representatives of all 10 medical schools in the CoreEPA pilot to understand their choices in designing the entrustment process. Additional information was obtained through follow-up communication to ensure completeness and accuracy of the findings. Several common themes are described. Our results indicate that, while approaches to the entrustment process vary considerably, all schools demonstrated consistent adherence to the guiding principles of the pilot. Several common barriers to the entrustment process emerged, and there was a consensus that more experience is needed with the process before consequential entrustment decisions can be made. The CoreEPA pilot schools continue to address challenges identified in implementing entrustment processes and making entrustment decisions for our students graduating in the Class of 2020.

Developing and Implementing Curricular Objectives for Sexual Health in Undergraduate Medical Education: A Practical Approach.

PROBLEM: In 2014, medical students at the Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) first drew attention to perceived gaps in the sexual health curriculum. The authors used Kern and colleagues' model for curriculum development to review and update the existing curriculum. APPROACH: To develop longitudinal sexual health curricular objectives for undergraduate medical education (UME), the authors reviewed existing specialty- and organization-specific objectives. Then, an iterative process guided by clear criteria was used to develop feasible objectives, which were refined through stakeholder feedback. As these objectives were being finalized in 2017, UME sexual health competencies were first published; the authors mapped their objectives to these, as possible. The medical school's course activities and assessments were mapped to the authors' sexual health objectives to identify curricular gaps and unplanned redundancies. OUTCOMES: This process resulted in 12 sexual health curricular objectives that are adaptable by other institutions. In mapping the FIU HWCOM curriculum to these objectives, specific gaps and assessment weaknesses emerged. With stakeholder support obtained through a strong curricular management structure, the work of modifying content to address gaps has begun. NEXT STEPS: New assessments specific to these sexual health objectives are needed, especially within the clinical curriculum. Assessment of these objectives may be strengthened through the development of new sexual-health-related entrustable professional activities (EPAs) nested within the broader Core EPAs for Entering Residency being piloted. When data on learning outcomes are available, the process of targeting curricular improvement will begin.

A Pilot Project Exploring Medical Students' Barriers to Screening for Intimate Partner Violence and Reproductive Coercion.

BACKGROUND: Multiple studies have shown that the majority of health care practitioners do not routinely screen for intimate partner violence (IPV); lack of provider preparedness and education is an often-cited barrier to screening. Our third-year family medicine clerkship includes a pregnancy options counseling objective structured clinical examination (OSCE) that requires students to review a preencounter online educational module that highlights screening guidelines for IPV and reproductive coercion. The goal of this study was to explore students' internal barriers to screening patients for IPV and reproductive coercion, and whether our curricular interventions adequately addressed these barriers. METHODS: We administered an immediate postencounter, anonymous, online survey with open-ended and Likert-type questions to 118 medical students during the 2016 academic year. We used an exploratory, iterative process to analyze qualitative responses and quantify recurrent and commonly identified themes. RESULTS: After the OSCE, students reported they were more likely to screen for IPV (94%) and reproductive coercion (82%) in future encounters. Qualitative analysis revealed two major types of barriers to screening: internal barriers concerning the screening inquiry itself and concerns regarding handling of patients' responses. CONCLUSIONS: The online preparatory module and subsequent OSCE provided a low-stakes environment in which to practice screening. However, student comments about their barriers to screening suggest that a first or early curricular intervention folding IPV and reproductive coercion into an educational module on pregnancy options counseling did not optimally promote this screening behavior.

From the Classroom to Entrustment - The Development of Motivational Interviewing Skills as an Entrustable Professional Activity.

This article was migrated. The article was marked as recommended. Introduction The move towards value-based care and population health has highlighted the prominent role of social and behavioral factors in determining health outcomes. Patient-centered behavioral guidance to improve patient self-management is recognized as an evidence-based intervention for a variety of chronic conditions but has yet to be adopted as a core competency or core entrustable professional activity (EPA). Motivational Interviewing (MI) is an evidence-based behavioral intervention involving an integrated set of competencies, featuring reflective listening, affirmation, evocation, and collaborative planning. An MI encounter is an observable, discrete task that can be framed as an EPA. Successful implementation of EPAs in the workplace requires institutional engagement, a thoughtful curricular approach, faculty development, and feasible, valid workplace-based assessment (WBA). Methods We implemented competency-based MI training and assessed competency outcomes for students and faculty. After joining the Association of American Medical Colleges Core EPA Pilot, we applied an iterative group process to develop an EPA and workplace-based assessment based on established MI competencies. Results Drawing upon nine years of developing MI curriculum, we present competency data for a student training study and a faculty coaching study, describe how we transitioned training from the classroom to the clinical setting employing an EPA framework, and present a one-page schematic and related WBA for an EPA based on MI. Conclusion We propose that MI is a core EPA for future physicians practicing value-based care, and offer a roadmap for curriculum implementation.

Faculty Development Revisited: A Systems-Based View of Stakeholder Development to Meet the Demands of Entrustable Professional Activity Implementation.

In 2015, the Association of American Medical Colleges implemented an interinstitutional pilot of 13 core entrustable professional activities (EPAs) for entering residency, activities that entering residents should be expected to perform with indirect supervision. The pilot included a concept group on faculty development; this group previously offered a shared mental model focused on the development of faculty who devote their efforts to clinical teaching and assessment for learning and entrustment decision making. In this article, the authors draw from the literature of competency-based education to propose what is needed in overall approaches to faculty development to prepare institutions for undergraduate EPA implementation.Taking a systems-based view that defines the necessary tasks of EPA implementation, the authors move beyond the variably used term "faculty" and enumerate a comprehensive list of institutional stakeholders who can meaningfully support and/or engage in the relationships and organizational processes required for EPA learning and assessment. They consider each group's responsibilities and development needs according to five domains delineated by Steinert: teaching improvement, leadership and management, research-building capacity, academic career building, and organizational change.The authors argue that the EPA framework addresses barriers posed with the use of a competency-based framework. By facilitating the communication required for organizational change, enabling valid assessment with comprehensive yet feasible levels of faculty development, and incorporating all relevant data on student professional behavior into summative assessment decisions, EPAs may offer a clearer path toward the goal of competency-based education.

Non-Directive Pregnancy Options Counseling: Online Instructional Module, Objective Structured Clinical Exam, and Rater and Standardized Patient Training Materials.

INTRODUCTION: Many patients receiving news of an unplanned pregnancy need not only a test result, but also the initiation of pregnancy options counseling. Thus, this online instructional module and objective structured clinical examination (OSCE) aim to provide foundational training for medical students in nondirective pregnancy options counseling. METHODS: To further the validity of a previously published OSCE, we reconsidered content, revised the checklist, and produced videos for rater training. We also developed a 30-minute preparatory module outlining a stepwise approach and providing a structured opportunity for values clarification. The 10-minute OSCE scenario involves a 24-year-old woman presenting to an urgent care center with persistent nausea who receives the diagnosis of an early, unplanned pregnancy. She responds to the news with shock and emotional silence, asking for guidance. We conducted the OSCE with 46 third-year medical students on the family medicine clerkship. Immediately after the OSCE, students completed a survey and self-assessment, followed by an individualized feedback session with a faculty member. RESULTS: In the self-assessment phase, students reflected on how successfully they utilized methods in the online module for handling emotional silence and presenting options. Student self-identified areas for improvement highlighted use of terminology and their response to difficult emotional encounters in the future. DISCUSSION: This online module and validated OSCE provide a valued opportunity for learners to practice nondirective pregnancy options counseling skills, including screening for intimate partner violence and reproductive coercion, engagement in self-assessment and receiving feedback, and engaging in personal values clarification.

An educational workshop and student competency in pregnancy options counseling: a randomized controlled trial.

OBJECTIVE: We sought to determine the effect of a pregnancy options counseling workshop focusing on communication skills and ethics on medical student competency. STUDY DESIGN: This educational trial randomized 105 third-year students to performance of an objective structured clinical examination before or after participation in the workshop assessed by a blinded reviewer. The primary outcome variable was student-level global competency in options counseling; secondary outcomes included competency components of general communication. RESULTS: Global competency was achieved by 36% of students in the preworkshop group and 50% in the postworkshop group (P = .16). Students who participated in the workshop demonstrated higher communication skills. Student ratings of objective structured clinical examination quality were 96-100% positive, with 80% reporting an increase in comfort with options counseling and 88% reporting increased comfort with communication skills. CONCLUSION: Participation in a workshop focusing on conscientious refusal positively improved communication skills, but did not significantly impact students' competency in pregnancy options counseling.

Conscientious refusal in reproductive medicine: an educational intervention.

OBJECTIVE: This study evaluates an educational intervention focusing on the ethical reasoning and communication skills necessary in counseling patients about morally objectionable medical interventions. STUDY DESIGN: All students on the core clerkship in obstetrics and gynecology at the University of Miami Miller School of Medicine participated in a structured workshop. Students completed anonymous surveys before and after the workshop. Associations between the participants' change in comfort level in providing nondirective counseling and measured demographic variables were analyzed. RESULTS: Of 140 students, 37% (n = 52) positively changed their comfort level with nondirective options counseling; 10% (n = 14) negatively changed. Change in understanding of the physician's role was reported by 60% (n = 84). The exercise was rated as educationally valuable by 95% (n = 128), with 84% (n = 115) attesting that the workshop would help them "approach things differently." CONCLUSION: Evaluation of multiple parameters demonstrated that this workshop heightened student awareness of the ethical and communications skills challenges posed by this clinical situation.