A Guide to Grading
A Guide to Grading 1. Identify student’s current status and prior clinical experience. 2. Review course goals and objectives with student. 3. Establish your expectations early. 4. Provide feedback frequently so there will be no end of rotation surprises 5. Expect improvement. The evaluation is based on the last day of the rotation, not the first. 6. Our expectations of a student in the first 3-4 rotations will be different than more advanced expectations in the last 3-4 months. 7. Attitude counts. A knowledge of prior clinical experience will help you set expectations. Examples: A student who had completed OB- GYN should have a good working knowledge and skill level for that topic but may have to spend more time developing a knowledge base for chronic disease. Do not, however, assume a strong skill set just because of the prior experience without observation. The table below is a “user’s guide” for the grade sheet. The yellow column would represent higher level of competency in the beginning clerk. The grading form Item analysis Basic Medical Knowledge: Relative to level of training [Medical knowledge] The early student who has had minimal clinical experience should, at a minimum, display a basic knowledge of common problems by the end of the rotation. Better students will range in the high pass level. Honors is the exceptional student who displays clinical skills that exceed (not just level of training) expectation. Fail Low Pass Pass High pass Honors Comments Poor fund of Limited fund Fund of Solid fund Outstanding Please use knowledge: of knowledge of fund comment limited knowledge; consistent knowledge; of section to ability to can apply with level applies knowledge; provide apply clinically: has of training. readily to superior, support for clinically. potential for clinical advanced fail, low improvement. problems. skills pass or applying to honors. complex problem Elicits focused histories: Relative to level of training [Patient care] The average student will need some organization help, especially in the beginning. It is not uncommon to be over inclusive of data in a “casting the net and hoping to catch a fish” style. This should show improvement over the course of the rotation. Better students will be able to focus on the specific problem, organize and prioritize information during a basic, uncomplicated encounter. Exceptional students will be able to sort through a patient with multiple problems and prioritize data. Fail Low Pass Pass High pass Honors Direct observation Disorganized, Organized; Organized, Excellent Excellent Yes incomplete, obtains usually skills; skills; lacks focus. basic complete thorough thorough yet No history but including focused succinct and points pertinent (+) history. focused Did you often & (-) ROS; history. Able observe the missed but often to prioritize patient including with data obtaining a pertinent extraneous appropriately. history? (+) & (-) information. ROS. Performs focused physical exam relative to level of training [Patient care] The student will be fulfilling basic expectations with an exam that is focused and competent for the common problem, more broad for the complex or overall health evaluation visit. Respect of patient’s privacy and sensitivity is expected at all levels. Better students will be thorough in a manner that is adequate to the evaluation of the problem/s that need attention and display good technique. The honors student will have good, organized exam skills, display excellent technique in a sensitive fashion and be able to identified focused exam needs for focused problems as well as disease specific exams in chronic problems. Fail Low Pass Pass High pass Honors Direct observation Omits Generally Complete; Thorough Thorough Yes critical complete usually and and parts of but often recognizes accurate; accurate; No the exam misses abnormal focused on focused on and/or significant findings the problem the problem, Did you observe the deficient abnormal well exam? exam skills findings. organized, includes pertinent negatives Diagnostic tests and procedural skills relative to Family Medicine [Patient care] Students love to observed and be involved in procedures. Procedures in this case, however, include the selection and use of laboratory tests, imaging studies and referred procedures. The average student will suggest tests and be able to discuss indications. The better student will recommend procedures or studies that represent established guidelines when available. Actual office procedure skills should be commented on as to performance documentation and observed skill level in the comments section. The honors student selects tests and procedures with an understanding of efficacy and cost. Fail Low Pass Pass High pass Honors Direct Observation Doesn’t Knows Understands Uses tests Uses Yes understand indications of indications skillfully and tests/procedures indications some for recommends skillfully, No for most procedures tests and procedures aware of cost procedures and tests procedures appropriately effectiveness, or lab tests and test efficacy Oral presentations [Patient care] [Communication] The beginning student may ramble and be either excessive in detail or may be too restricted, report only verbatim history. As the month and student experience progresses the student should begin to focus and organize data in a more succinct fashion. This may require some coaching at first…remember, set expectations. You can let the student know what you expect to hear on a case by case basis. Compare the SOAP based presentation to the presentation on daily rounds for those who have only inpatient experience. Exceptional students will “get it” and be organized and succinct. If you feel that your job is easier at the end of the student’s presentation, you have an exceptional students. Fail Low Pass Pass High pass Honors Disorganized/ Generally Presentations Presentations Consistently Did not incomplete; complete; organized and organized, organized, observe by end, may lack logical with logical; logical, listeners organization/ assistance. highlights complete; uncertain of fail to Highlights abnormal highlights primary highlight pertinent findings; pertinent Presentation clinical abnormal positives and succinct information; skills problem or findings; negatives. preparation adversely recent events. needs much does not impacted by assistance require anxiety. assistance. Succinct Written notes: Problem oriented SOAP format [Patient care] [Communication] The student should use the SOAP format for documentation of notes. The average student may mix components and use the inappropriate A/P technique. Point out that “A” is what you think and “P” is what you plan to do. The exceptional student will review charts beforehand, update the medication list, review chronic disease parameters, update prevention data and have an organized note or notes. Fail Low Pass Pass High pass Honors Direct observation Incomplete or Includes basic Accurate, Pass plus Accurate, erroneous information; thorough, ongoing thorough, Yes rarely and succinct. assessments and succinct. No analyzes new Focuses on of primary Updates data/ impact presenting problems. chronic You do not on patient complaint. problems, have to management. prevention include the and student’s note medications. in your chart, but, please review their notes. Differential diagnosis, application of clinical skills [Patient care] ][Medical knowledge] Prioritizing problems and establishing a working differential is an advanced skill and may not be evident initially. We expect growth in this area as the rotation progresses. The student should become adept at this skill in the more common, simple problems. The student should display a knowledge of the evaluation and management of common chronic diseases as well by the end of the rotation. Most will be overwhelmed by the complex, multi-problem patient. Exceptional students will begin to prioritize their approach and ask guidance when indicated. Fail Low Pass Pass High pass Honors Direct observation Usually Usually Formulates Consistently High pass unable to handles major assessment able to plus provides Yes formulate an problem; may of major formulate rationale for No assessment of not integrate problem; may assessment of decision basic medical all aspects have trouble basic making. problems. (H&P, labs, identifying/ problems; Evidence of rx); suggests prioritizing also can clinical elemental multiple prioritize guidelines understanding problems. multiple when . problems. available. Management plans and follow-up [Patient care] [Medical knowledge] [System based practice] Don’t be surprised if early learners miss the boat on management plans. As the student grows so should this skill. Plans should include: diagnostic evaluations, medications with dosage, patient education and follow up. The exceptional student will also review chronic problems and prevention and document plans for updating in the appropriate section of the record and the note. This student will be aware of evidence based treatment goals and surveillance intervals. This information is readily available to all the students. Selection of medications may require your guidance. Fail Low Pass Pass High pass Honors Direct observation Treatment Plan often Plans are Plans High pass plans neglects appropriate, excellent plus: Includes Yes inadequate. important complete and including updates for No Fails to components, timely education, disease recognize including follow-up, surveillance when urgent education and and and self- treatment follow-up prevention mgmt plan. indicated Incorporates health promotion and disease prevention [Medical knowledge] [System based practice] Prevention is a major focus of the Family Medicine experience. Students have been instructed to review this element for all their patients by chart review. The USPSTF is the guide for this task and they have a Palm based program to assist. The exceptional student will not have to be asked but will review the record (preferably in preparation for the clinic day) and identify prevention needs accurately. This student will consider the patient’s characteristics and risk factors in decision making. Average students will consider this only when it is a “health maintenance” visit. You can decide how much counseling…beyond the basics…you want to have the student do. You can evaluate their skills by direct observation or by asking the patient what they understand from the interaction. Fail Low pass Pass High pass Honors Comments Ignores all Rarely includes Appropriately Often includes Always opportunities preventive includes age prevention; includes for prevention services; specific identifies prevention; underestimates preventive patient’s identifies risks effect patient’s services high risk and readiness behaviors on behaviors and to change and risk offers skillful in counseling counseling Dependability, motivation, responsibility, initiative [Professionalism] [Communication, Personal interaction] This is not training level dependent. The student’s ability to display professional behaviors and attitudes should start on Day 1. Fail Low Pass Pass High pass Honors Comments Unreliable, Sometimes Punctual, Pass plus Dependable; often absent late, not dependable, Dependable; highly or late; reliably able accepts highly committed to commitment to complete responsibility committed to clinical care; uncertain. assignments and enjoys seeks or tasks clinical care. opportunities to help clinic team Rapport and relationships with patients [Professionalism] [Communication, Personal interaction] This is not training level dependent. The student’s ability to display professional behaviors and attitudes should start on Day 1. Fail Low Pass Pass High pass Honors Insensitive to Uncomfortable Interacts well Extremely Compassionate, Did not observe needs, in patient with compassionate respectful, feelings, interactions patients and and respectful receives values of families. with patients spontaneous patients. and families positive feedback Broaches boundaries Lack of compassion Rapport with colleagues, staff and attending [Professionalism] [Communication, Personal interaction] This is not training level dependent. The student’s ability to display professional behaviors and attitudes should start on Day 1. Fail Low Pass Pass High Pass Honors Disrespectful, Often fails to Communicates Very strong Strong communication rude and act well; communication skills, professional insensitive in collegially; respectful, skills and demeanor, looks for office or communication cooperative professional opportunities to help hospital unclear, and demeanor the clinical team. incomplete, or collegial disorganized Intellectual curiosity: Review of medical literature and other resources to advance medical knowledge base This is not training level dependent. The student’s ability to display professional behaviors and attitudes should start on Day 1. Fail Low Pass Pass High pass Honors Fails or refuses Misses Looks up Reads more Reads extensively, to read, study important clinical data broadly than communicates or investigate clinical or appropriately; patients’ findings, shares reference reads up on problems; knowledge information; patients’ actively seeks and actively reads only problems daily ancillary teaches, enjoys when asked clinical data learning and uses inappropriate sources Accepts constructive criticism and feedback [Professionalism] This is not training level dependent. The student’s ability to display professional behaviors and attitudes should start on Day 1. Fail Low Pass Pass Honors High pass Actively "Chip on Open to Actively Actively Did not observe rebuffs or shoulder" feedback and seeks seeks avoids slow to constructive feedback; feedback; change. change. criticism. grows with grows with Doesn't Defensive Willing and each each recognize able to encounter; encounter; own change learns form learns form limitations. each each mistake; mistake. provides feedback as well Knowledge of psychosocial and family issues [Patient care] [Interpersonal and communication skills] This knowledge and skill set should grow during the rotation. Students will need to be aware of the psychosocial issues that impact disease management. This component should not overshadow other aspects of care, but should compliment the patient centered approach. Early students may get stuck in the dramas of our patients’ lives and may need help with balance. As the student advances their tendency to “take care” inspite of all odds will be tempered with reality. The exceptional student will recognize the need to look for an evaluate medical and psychosocial resources in care plan. Fail Low Pass Pass High Pass Honors Ignores Underestimat Considers Considers Always fully Did not psychosocial es social, psychosocial integrates observe issues in impact of psychological issues and psychosocial patient psychosocial , and their impact issues care and family issues on disease into all family issues mgmt. aspects of patient care Chronic Disease Management (CDM): Using evidence based clinical guidelines (EBG) The management of chronic health problems and common chronic diseases brings into focus the Family Medicine concept of continuous, comprehensive care. The chronic disease management model provides an opportunity for students to learn about the long term management of such problems as diabetes, hypertension, asthma, COPD, etc. Students will have access to learning modules about the process as well as receiving a didactic presentation during orientation. The average student will complete the required disease registries and report what they thought about management. The exceptional student will be proactive in looking at the chart in advance and reviewing the target problems. That student will grow in the knowledge of population management as well as individual care focused on assisting patient with the identification and attainment of skills to achieve treatment goals. She or he will help with the update of the documentation of care as well. Fail Low Pass Pass High Pass Honors Ignores Addressed Correctly Incorporated Did chronic health BG addressed review of prospective Instructed issues or has parameters EBG EBG at every review of student to no working when parameters encounter EBG and address only knowledge of prompted do for chronic (with updated items the presenting EBG so with disease exception of correctly for complaint assistance or focused visits. urgent each unless visit incompletely priority) encounter. specific to Displayed chronic awareness of disease mgmt. patient characteristics that might impact goals and intervention. CDM: Patient Self-mgmt skills Most students will attempt to “educate” patients about their illness or problem in the traditional didactic fashion. Look for the exceptional approach including motivational interviewing, identification of patient directed and identified goals that are realistic and manageable in the short term. The outstanding student will consider barriers, access to care, support resources, education and the role of the health care team in working toward treatment goals. Fail Low Pass Pass High pass Honors Comments Ignored the Provided Provided Pass criteria High pass patient’s role patient patient plus identified criteria plus in disease education but education and and addressed demonstrates management did not assessed self-mgmt. ability to and include self patient’s needs motivate prevention management willingness to patients skills change toward self behavior management. when needed. Provides culturally aware intervention and sensitivity to the psychosocial factors that impact care.