Core Clerkship Research Articles

683: Video podcasts and the 3rd year medical students’ experience on maternal fetal medicine

Resident education of medical students during their clinical rotations is integral to student learning. However, residents on a Maternal Fetal Medicine (MFM) service are often busy with high acuity clinical duties, limiting time for teaching. Therefore, we sought to examine the effect of resident-created self-learning videos on third year Obstetrics and Gynecology Core Clerkship students’ knowledge and attitudes about their MFM rotation when compared to usual teaching. We performed a randomized control trial using block randomization in which students received usual teaching or usual teaching plus six 5-10 minute resident-created self-learning videos, each based on a common MFM topic. Pre- and post-rotation previously validated questionnaires were given to assess student MFM content knowledge and rotation satisfaction. Residents were blinded to the intervention to avoid bias in teaching efforts. Questionnaire answers were compared between intervention and usual teaching students and groups using Student’s t-test, McNemar’s test or the paired t-test as appropriate. Power analysis showed the ability to detect a moderate effect size, with Cohen’s d = 0.58. 48 students were randomized. Students randomized to intervention versus usual teaching did not differ significantly in most demographics, including age (mean=25.5 v. 25.8, p=0.75) and previous exposure to women’s health (33.3% v 37.5%, p=1.00). Intervention group students had completed more third year core clerkships prior to their MFM experience compared to usual teaching group (4.1 vs. 2.5, p>0.01)). There was no difference between groups for pre-intervention MFM content knowledge (36% v. 34%, p=0.75). Post-intervention knowledge scores were also not different between groups (50% vs 59%, p=0.07), although there was a trend to significance. The intervention group was less satisfied with their MFM experience compared to the usual teaching group (mean score 4.00 vs. 4.61, p>0.01) and with resident teaching on the rotation (mean score 3.79 vs. 4.56 p=0.02). Resident-created self-learning videos for third year students on an MFM service did not improve student knowledge or satisfaction with the MFM experience.

Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study.

An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

Students’ Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools

Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling. Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018. Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback. Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Editors' note: Difficult conversations in neurology: Lessons learned from medical students

In “Education Research: Difficult conversations in neurology: Lessons learned from medical students,” Lemmon et al. studied medical student exposure to difficult conversations during a neurology core clerkship. They found that difficult conversations are common in neurology, and represent a valuable opportunity to provide communication skills training on the wards. Commenting on the paper, Dr. Lukas wonders whether participation in difficult conversations across a range of specialties cumulatively builds comfort and expertise in the trainee. Dr. Lukas suggests that the environment of the conversation may also play a role and serve as a learning opportunity for other clinical skills. Authors Lemmon et al. agree and add that quality may be as important as quantity based on the fact that, in their study, students indicated that one influential mentored conversation can have the impact of numerous witnessed experiences. In “Education Research: Difficult conversations in neurology: Lessons learned from medical students,” Lemmon et al. studied medical student exposure to difficult conversations during a neurology core clerkship. They found that difficult conversations are common in neurology, and represent a valuable opportunity to provide communication skills training on the wards. Commenting on the paper, Dr. Lukas wonders whether participation in difficult conversations across a range of specialties cumulatively builds comfort and expertise in the trainee. Dr. Lukas suggests that the environment of the conversation may also play a role and serve as a learning opportunity for other clinical skills. Authors Lemmon et al. agree and add that quality may be as important as quantity based on the fact that, in their study, students indicated that one influential mentored conversation can have the impact of numerous witnessed experiences.

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

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. 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. 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. 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.

Gender-based analysis of factors affecting junior medical students\u2019 career selection: addressing the shortage of surgical workforce in Rwanda

BackgroundThere is a strong need for expanding surgical workforce in low- and middle-income countries. However, the number of medical students selecting surgical careers is not sufficient to meet this need. In Rwanda, there is an additional gender gap in speciality selection. Our study aims to understand the early variables involved in junior medical students’ preference of specialisation with a focus on gender disparities.MethodsWe performed a cross-sectional survey of medical students during their clinical rotation years at the University of Rwanda. Demographics, specialisation preference, and factors involved in that preference were obtained using questionnaires and analysed using descriptive statistics and odds ratios.ResultsOne hundred eighty-one respondents participated in the study (49.2% response rate) with a female-to-male ratio of 1 to 2.5. Surgery was the preferred speciality for 46.9% of male participants, and obstetrics/gynaecology for 29.4% of females. The main selection criteria for those who had already decided on surgery as a career included intellectual challenge (60.0%), interaction with residents (52.7%), and core clerkship experience (41.8%) for male participants and interaction with residents (57.1%), intellectual challenge (52.4%), and core clerkship experience (52.4%) for female participants. Females were more likely than males to join surgery based on perceived research opportunities (OR 2.7, p = 0.04). Male participants were more likely than their female participants to drop selection of surgery as a speciality when an adverse interaction with a resident was encountered (OR 0.26, p = 0.03).ConclusionThis study provides insight into factors that guide Rwandan junior medical students’ speciality preference. Medical students are more likely to consider surgical careers when exposed to positive clerkship experiences that provide intellectual challenges, as well as focused mentorship that facilitates effective research opportunities. Ultimately, creating a comprehensive curriculum that supports students’ preferences may help encourage their selection of surgical careers.

Evaluation of the Characteristics of a Workplace Assessment Form to Assess Entrustable Professional Activities (EPAs) in an Undergraduate Surgery Core Clerkship

Entrustable Professional Activities (EPAs) are explicit, directly observable tasks requiring the demonstration of specific knowledge, skills, and behaviors that learners are expected to perform without direct supervision once they have gained sufficient competence. Undergraduate level implementation of EPAs is relatively new. We examined the characteristics of a workplace assessment form (clinic card) as part of a formative programmatic assessment process of EPAs for a core undergraduate surgery rotation. A clinic card was introduced to assess progression towards EPA achievement in the clerkship curriculum phase. Students completing their core eight (8) week clerkship surgery rotation submitted at least 1 clinic card per week. We compiled assessment scores for the 2015 to 2016 academic year, in which EPAs were introduced, and analyzed relationships between scores and time, EPA, training site, and assessor role. We surveyed preceptors and students, and conducted a focus group with clinical discipline coordinators of all core rotations. This study took place at the Faculty of Medicine, Memorial University in St. John's, Newfoundland, Canada. Third year medical students (n = 79) who completed their core eight (8) week surgery clerkship rotation during the 2015 to 2016 academic year, preceptors, and clinical discipline coordinators participated in this study. EPAs reflecting tasks commonly performed by students were more likely to be assessed. EPAs frequently observed during preceptor-student encounters had higher entrustment ratings. Most EPAs showed increased entrustment scores over time and no significant differences in ratings between teaching sites nor preceptors and residents. Survey and focus group feedback suggest clinic cards fostered direct observation by preceptors and promoted constructive feedback on clinical tasks. A binary rating scale (entrustable/pre-entrustable) was not educationally beneficial. The findings support the feasibility, utility, catalytic and educational benefits of clinic cards in assessing EPAs in a core surgery rotation in undergraduate medical education.

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

Medical Student Weight Bias: the Relationship of Attitudinal Constructs Related to Weight Management Counseling

Obesity is a prevalent disease that is often a source of stigmatization. Weight bias has been documented in healthcare settings and associated with less physician time spent with patients, less patient-centered communication, and more patient delay or withdrawal from care. Weight bias is widespread in society and the healthcare field, including among medical students. This study examined the hypothesis that weight bias in medical students is related to negative attitudes toward weight management counseling (WMC), perceived WMC skills, and self-efficacy for WMC. A sample of 762 medical students during their core clerkship rotation (graduating class of 2017) from eight US medical schools completed questions related to weight bias, attitudes toward WMC, perceived WMC skills, and self-efficacy for WMC. Results indicated that medical students with more weight bias held more negative attitudes toward WMC, even after adjustment for age, gender, and intended medical specialty. Weight bias was not significantly related to perceived WMC skills or self-efficacy for WMC. Females had a more positive attitude toward WMC, but lower perceived WMC skills and self-efficacy for WMC than males. Males had significantly more weight bias and were less likely to choose primary care than females. Implications for medical education are discussed.

Education Research: Difficult conversations in neurology: Lessons learned from medical students.

To characterize features of medical student exposure to difficult conversations during a neurology core clerkship. This was a cross-sectional concurrent nested mixed methods study, and all students rotating through a required neurology clerkship between 2014 and 2015 were enrolled. Data collection included an electronic communication tracker, baseline and end-of-clerkship surveys, and 4 facilitated focus groups. Students were asked to log exposure to patient-clinician conversations about (1) new disability, (2) poor prognosis, (3) prognostic uncertainty (4), terminal diagnosis, and (5) end-of-life care. A total of 159 students were enrolled and 276 conversations were tracked. Most (70%) students observed at least 1 difficult conversation, and conversations about poor prognosis, new disability, and prognostic uncertainty were most commonly logged. At clerkship end, most students (87%) desired additional bedside training in communication skills. Exposure to one of the predefined conversation types did not improve student perceived preparedness to lead difficult conversations in the future. In focus groups, students noted that the educational value of observation of a difficult conversation could be optimized with preconversation planning and postconversation debriefing. Difficult conversations are common in neurology, and represent a valuable opportunity to provide communication skills training on the wards. Future curricula should consider ways to leverage these existing opportunities to enhance communication skills training.

Opinion and Special Articles: Neurology education at US osteopathic medical schools.

Osteopathic medical schools have a longstanding tradition of training primary care physicians (PCP). Neurologic symptoms are common in the PCP's office and there is an undersupply of neurologists in the United States. It is therefore crucial for osteopathic medical students to have a strong foundation in clinical neurology. Despite the importance, a mere 6% of osteopathic medical schools have required neurology clerkships. Furthermore, exposure to neurology in medical school through required clerkships has been correlated with matching into neurology residency. As osteopathic medical schools continue to expand, it will become increasingly important to emphasize the American Academy Neurology's published guidelines for a core clerkship curriculum. Practicing neurologists should take an active role in encouraging osteopathic medical schools to adopt these guidelines.

Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships.

The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.

Competency assessment form to improve feedback.

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. 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. The revised form elicitedmore narrative commentsin 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 toa medical student assessmentform to elicit narrativecomments by competencyimproved 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.

The Impact of a Postpartum Rounding Video Module on Medical Student Learning During the Obstetrics and Gynecology Core Clerkship

BACKGROUND: The 4C-ID model has been adapted for medical education to help students manage significant cognitive loads while developing strategies for improvement. To date, no 4C-ID intervention exists for the wards or postpartum rounding. METHODS: Third-year medical students on the OB-GYN core clerkship who agreed to participate were randomized by clerkship block to receive the 20-minute postpartum rounding video module, or standard education. Knowledge and clinical reasoning were assessed during orientation and clerkship conclusion using a clinical scenario (32 points) and the Diagnostic Thinking Inventory (246 points). Satisfaction was assessed using Likert scale questions (0–5, 5=very satisfied/strongly agree). RESULTS: Seventy-eight of 79 eligible students participated. The only significant baseline difference between groups was greater knowledge of physical exam skills in the intervention group (4.8/7, 4.1/7 P=.049). Students in the intervention group demonstrated higher postintervention improvement in knowledge (8.9, 4.5 P=.0011). Both groups increased clinical reasoning, however there was no significant difference between groups pre- or postintervention (160.1, 160.5 P=.92,165.0, 168.8 P=.34). Students in the control group reported a better clerkship experience (3.9, 3.5 P=.04). Students who received the video would recommend the video to their peers (3.7). DISCUSSION: A postpartum video based in the 4C-ID model of education increased student knowledge in the 3rd-year medical student OB-GYN core clerkship. Video learning is acceptable to medical students, and can be easily incorporated into specialty rounds at any institution.

Residents as Teachers: Analysis of Performance on End-of-Clerkship Questionnaire and Correlation With Graduation Questionnaire Outcomes

BACKGROUND: Several reports indicate ObGyn medical education is one of the lowest-rated of 3rd-year the core clerkships. Resident teaching is among the lowest of the areas rated. Following our department's low rating in 2012–2013 we sought to determine how resident performance as teachers (RAT) changed after instituting a series of improvements, and to validate performance changes by correlation with student comments and GQ survey outcomes. METHODS: Medicine and ObGyn End of Clerkship survey responses to the statement, “Residents were interested in teaching, spent time with students and treated students as valuable members of the health-care team” were collapsed into two groups (disagree or neutral, and agree or strongly agree) and compared using the Pearson χ2 Test. Differences between each year’s performance were considered significant if P<.05. Medicine clerkship responses served as a control. RESULTS: Medicine resident teaching performance did not change over 4 years. ObGyn performance was significantly lower than Medicine in the first year of evaluation and dropped further in the second year. Following initiation of a RAT program, ObGyn performance improved significantly and correlated with an improvement in GQ performance. Typical student responses include “I found this a great opportunity to get a lot of hands-on experience and the residents I worked with were exceptional” and “Fantastic learning experience, feel lucky to have had the opportunity and a wonderful resident supervisor.” DISCUSSION: Student rating of resident teaching performance improved significantly after instituting a RAT program, demonstrating that teaching performance can improve.

Editorial Comment

On a yearly basis, urology residency program directors review hundreds of applications and interview dozens of applicants with the goal of selecting those applicants who will develop into excellent residents and urologists. This study identifies applicant features that predicted excellent residency performance at Mayo Clinic, including no negative interview comments, graduating from a lower ranked medical school, and obtaining honors in all core clerkships. Needless to say, each urology residency program may judge residency performance differently. Therefore, as further research is conducted, it will be interesting to see if the applicant features identified by this study can also predict performance at other residency programs. If not, individual residency programs may wish to conduct their own investigations as to which application features predict performance at their specific institutions to help guide their decision-making during the match.

Medical Student Experiences on Consultation-Liaison Psychiatry Rotations: A Nationwide Survey

Consultation-liaison (C-L) psychiatry clerkship rotations may improve medical students' understanding of psychiatric principles relevant to the settings in which they will ultimately practice. This study aimed to characterize students' experiences on C-L rotations. This cross-sectional survey study, sponsored by the Academy of Psychosomatic Medicine Subcommittee on Medical Student Education, was conducted at 5 US medical schools between 2012 and 2016. After the C-L rotation, students completed a voluntary 17-item survey. A total of 235 surveys were collected (mean response rate = 92%). The most frequently endorsed benefit of C-L was learning to manage psychiatric disorders in the context of medical illness (89%). The most frequently endorsed drawback was inconsistent/excessively variable workload (40%). Overall, 82% of respondents recommended C-L to other students; 80% reported that the ideal clerkship would include exposure to both C-L and inpatient psychiatry. Overall, 38% reported that their C-L experience increased their interest in psychiatry as a career. Effect of C-L on interest in psychiatry did not differ by study site, age, sex, clerkship length, or time spent on C-L. Respondents who noted more positive role-modeling on C-L compared to other clerkship rotations were more likely to report increased interest in a psychiatry career (odds ratio = 2.70). Most medical students perceive C-L rotations favorably. Positive role modeling may increase their consideration of psychiatry specialization. The findings that C-L rotation length did not correlate with attitudes and that most students preferred exposure to both inpatient and C-L psychiatry suggest that C-L exposure can beneficially be integrated into core clerkships containing other elements.

A Mixed-Methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship.

To review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students. In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empower ment to address mistreatment. Counts and types of mistreatment were compared from a year before (January-December 2013) and two years after (January 2014-December 2015) implementation. Students' end-of-clerkship ratings and responses to open-ended questions were analyzed. From March 2014-December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January-August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program's first year, and 4 in the second year. The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.

Clinical Performance Evaluations of Third-Year Medical Students and Association With Student and Evaluator Gender.

Clinical performance evaluations are major components of medical school clerkship grades. But are they sufficiently objective? This study aimed to determine whether student and evaluator gender is associated with assessment of overall clinical performance. This was a retrospective analysis of 4,272 core clerkship clinical performance evaluations by 829 evaluators of 155 third-year students, within the Alpert Medical School grading database for the 2013-2014 academic year. Overall clinical performance, assessed on a three-point scale (meets expectations, above expectations, exceptional), was extracted from each evaluation, as well as evaluator gender, age, training level, department, student gender and age, and length of observation time. Hierarchical ordinal regression modeling was conducted to account for clustering of evaluations. Female students were more likely to receive a better grade than males (adjusted odds ratio [AOR] 1.30, 95% confidence interval [CI] 1.13-1.50), and female evaluators awarded lower grades than males (AOR 0.72, 95% CI 0.55-0.93), adjusting for department, observation time, and student and evaluator age. The interaction between student and evaluator gender was significant (P = .03), with female evaluators assigning higher grades to female students, while male evaluators' grading did not differ by student gender. Students who spent a short time with evaluators were also more likely to get a lower grade. A one-year examination of all third-year clerkship clinical performance evaluations at a single institution revealed that male and female evaluators rated male and female students differently, even when accounting for other measured variables.

Tying knots: an activity theory analysis of student learning goals in clinical education.

Learning goal programmes are often created to help students develop self-regulated learning skills; however, these programmes do not necessarily consider the social contexts surrounding learning goals or how they fit into daily educational practice. We investigated a high-frequency learning goal programme in which students generated and shared weekly learning goals with their clinical teams in core Year3 clerkships. Our study explores: (i) how learning goals were incorporated into the clinical work, and (ii) the factors that influenced the use of students' learning goals in work-based learning. We conducted semi-structured interviews with 14 students and 14 supervisors (attending physicians and residents) sampled from all participating core clerkships. Interviews were coded for emerging themes. Using cultural historical activity theory and knotworking as theoretical lenses, we developed a model of the factors that influenced students' learning goal usage in a work-based learning context. Students and supervisors often faced the challenge of reconciling contradictions that arose when the desired outcomes of student skill development, grading and patient care were not aligned. Learning goals could function as tools for developing new ways of acting that overcame those contradictions by facilitating collaborative effort between students and their supervisors. However, for new collaborations to take place, both students and supervisors had to engage with the goals, and the necessary patients needed to be present. When any one part of the system did not converge around the learning goals, the impact of the learning goals programme was limited. Learning goals are potentially powerful tools to mediate interactions between students, supervisors and patients, and to reconcile contradictions in work-based learning environments. Learning goals provide a means to develop not only learners, but also learning systems.