Shortcomings in the evaluation of students' clinical skills and behaviors in medical school

The authors review the methods by which U.S. medical schools have evaluated student achievement during the twentieth century, especially for the asses sment of noncognitive abilities, including clinical skills and behaviors. W ith particular reference to the current decade, information collected by th e Liaison Committee on Medical Education (LCME) is used to examine the cong ruence of assessment methods with the rising tide of understanding- and acc reditation requirements-that knowledge, competence, and behavioral objectiv es require different methods of assessment to measure the extent of student s' learning in each domain. Amongst 97 medical schools having accreditation surveys between July 1993 a nd June 1998, only 186 of 751 basic science courses tested students' noncog nitive achievements in things such as the preparation for and participation in small-group conferences, the quality of case-based discussion, library research and literature reviews, and research projects, despite staking out scholarship, habits of life-long learning, and reasoned thinking as educat ional objectives. In the clerkships of these schools, structured and observ ed assessments of clinical skills-with standardized patients and/or OSCEs-c ontributed 7.4-23.1% to a student's grade (depending on the clerkship disci pline), while the predominant contribution (50-70% across the clerkships) w as made by resident and faculty ratings that were based largely on recollec tions of case presentations and discussions having little relationship to i nterpersonal skills, rapport with patients, and logical and sequenced histo ry taking and physical examination. On a more optimistic note, the results show that the number of schools using standardized patients in one or more clerkships increased between 1993 and 1998 from 34.1% to 50.4% of the 125 s chools in the United States, and the number of schools using standardized p atients in comprehensive fourth-year examinations increased from 19.1% to 4 8% of the total. Despite such progress, this study shows that too many medical schools still fail to employ evaluation methods that specifically assess students' achie vement of the skills and behaviors they need to learn to practice medicine. The findings of this article explain why accreditors are paying closer att ention to how well schools provide measured assurances that students learn what the faculties set out to teach.