Assessment of Knowledge and Performance

1. Assessment of Knowledge and Performance John Littlefield, PhD University of Texas Health Science Center at San Antonio

2. Goals: Assessment of Knowledge and Performance 1. Clarify 2 distinct uses for assessments of clinical knowledge and performance 2. Define 2 aspects of validity for all assessment methods 3. Compare and contrast 3 techniques for assessing clinical knowledge and performance 4. Identify poorly written multiple choice test items and write a key features test item 5. Describe 3 options for scoring OSCE performance 6. Describe three elements of a clinical performance assessment system 7. Critique a clinical performance assessment system that you use 8. Recognize legal issues related to evaluating and dismissing students and residents

3. Agenda: Assessment of Knowledge and Performance • Exercise: Warm-up for assessing knowledge and performance • Presentation: Quality assurance when assessing clinical knowledge and performance • Exercise: Take then critique a multiple choice test • Presentation: Key features test items • Exercise: Write a key features test item • Presentation: Widening the lens on SP assessment • Exercise: Strengths & weaknesses of a clinical performance assessment system that you use • Presentation: Improving clinical performance assessment systems • Exercise: Critique your clinical performance assessment system • Discussion: Legal context for evaluations and dismissals

4. Warm-up Exercise • What answer did you circle to questions 1.a (4 cards) and 1.b (4 people)? 2. What concerns do you have about assessing knowledge and performance that you would like addressed?

5. Uses for Assessment: Formative vs. Summative Purpose Feedback for Certification/Grading Learning Breadth of Narrow Focus on Broad Focus on Scope Specific Objectives General Goals Scoring Explicit Feedback Overall Performance Learner Affective Little Anxiety Moderate to High Response Anxiety Target Audience Learner Society

6. Validity of Knowledge and Performance Assessments • Content - Does the assessment method measure a representative cross-section of student/resident competencies? • Internal structure – Do content and scoring focus on a specific clinical competency (e.g., patient care)? • Relation to other assessments - Do scores from this assessment correlate highly with other measures of same student competency? • Consequences - Do various subgroups of students (e.g., different ethnic groups) score equally well on the assessment? • Generalizability • Does the student perform at about the same level across 5 to 7 different patients / case problems? • Does the student receive a similar rating from different faculty? • Cognitive process – the context surrounding the assessment evokes the domain of cognitive processing used by a physician 1. Standards for Educ. & Psych. Testing, AERA, APA, NCME, 1999, p 11-16.

7. Six Aspects of Assessment Validity Viewed as aCube Generalizability Relation to other assessments Internal structure Consequences Content Cognitive process

8. Generalizability of Physician Performance Scores on Multiple Patients

9. Validity of Knowledge and Performance Assessments • Content - Does the assessment method measure a representative cross-section of student/resident competencies? • Internal structure – Do content and scoring focus on a specific clinical competency (e.g., patient care)? • Relation to other assessments - Do scores from this assessment correlate highly with other measures of same student competency? • Consequences - Do various subgroups of students (e.g., different ethnic groups) score equally well on the assessment? • Generalizability • Does the student perform at about the same level across 5 to 7 different patients / case problems? • Does the student receive a similar rating from different faculty? • Cognitive process – the context surrounding the assessment evokes the domain of cognitive processing used by a physician 1. Standards for Educ. & Psych. Testing, AERA, APA, NCME, 1999, p 11-16.

10. Cognitive Process Aspect of Validity: Four Levels of Performance Assessment1 Does (Global Rating) Shows How ( OSCE) Knows How (Examination – Oral) Knows (Examination – Multiple-choice) • Miller, GE. Assessment of clinical skills/competence/performance, Academic Medicine, 65(9), supplement, 1990,S63-7

11. Compare and Contrast Three Assessment Techniques(multiple choice exam, OSCE, global ratings) M.C.E. OSCE Global rtgs. • Content +++ ++ + • Internal structure +++ ++ + • Rel. to other assessments + + + • Consequences + ++ + • Generalizability • 5 to 7 case problems +++ ++ + • agreement among raters +++ ++ + • Cognitive process+ ++ +++ += adequate ++ = good +++ = excellent

12. Interim Summary of Session • Session thus far • Two uses of knowledge and performance assessments: Formative and Summative • Validity of all assessment techniques • Compare and contrast 3 assessment techniques • Coming up • Take and critique a 14 item multiple choice exam • Presentation on Key Features items

13. How are Multiple Choice Items Selected for an Exam?

14. Sample Exam Blueprint based on Clinical Problems Page G, Bordage G, Allen T. Developing key-feature problems and examinations to assess clinical decision-making skills, Acad. Med. 70(3), 1995.

15. Key Features of a Clinical Problem 1 • Definition: Critical steps that must be taken to identify and manage a patient’s problem • focuses on a step in which examinees are likely to make an error • is a difficult aspect in identifying and managing the problem • Example: For a pregnant woman experiencing third-trimester bleeding with no abdominal pain, the physician should: • generate placenta previa as the leading diagnosis • avoid performing a pelvic examination (may cause bleeding) • avoid discharging from clinic or emergency room • order coagulation tests and cross-match 1. Page G, Bordage G, Allen T. Developing key-feature problems and examinations to assess clinical decision-making skills, Acad. Med. 70(3), 1995.

16. Test Items based on a Clinical Problem and its Key Features

17. Scoring the Placenta Previa Clinical Problem • Key Feature 1: To receive one point, must list placenta previa or one of the following synonyms: marginal placenta or low placental insertion • Key Features 2-4: Receive 1/3 point for listing each of the following: 1. Avoid performing a pelvic exam, 2. Avoid discharging from clinic, 3. Order coagulation tests and cross match • Total Score for Problem: Add scores for items 1 and 2 and divide by 2 (range: 0 - 1)

18. Steps to Develop a Clinical-Problem Based Exam • Define the domain of clinical problems to be sampled by the exam • Develop an exam blueprint to guide selection of clinical problems • Develop a key-feature problem for each clinical problem selected • define clinical situation for the problem (e.g. single typical problem, life-threatening situation etc.) • define key features of the problem • select a clinical case to represent the problem and write scenario • write exam items for case; in general one item for each key feature • select suitable format for each item (e.g., write-in or mcq) • develop scoring key for each item • pilot test items for item analysis data to guide refinement

19. Interim Summary of Session • Session thus far • Two uses of knowledge and performance assessments: Formative and Summative • Validity of all assessment techniques • Compare and contrast three assessment techniques • Take and critique a 14 item multiple choice exam • Write a Key Features item • Coming up • Scoring performance on an SP exam

20. Schematic Diagram of a 9 Station OSCE Start 1 2 3 4 5 9 End 8 7 6

21. Scoring OSCE Performance • Traditional scoring of SP assessment focuses on numerical data typically from checklists • Checklist scoring may not accurately assess clinical performance quality of residents and expert clinicians 1 • Dimensions of the SP exam 2 • basic science knowledge (organize the information) • physical exam skills (memory of routines) • establishing a human connection • role of the student (appear knowledgeable) • existential dimension of the human encounter (balance one’s own beliefs with the patient’s) • Clinical competence – mixture of knowledge and feeling, information processing and intuition • Hodges et. al. OSCE checklists do not capture increasing levels of expertise, Acad. Med. 74(10), 1999, 1129-34. 2. Rose & Wilkerson. Widening the lens on SP assessment: What the encounter can reveal about development of clinical competence, Acad. Med. 76(8), 2001, 856-59.

22. Interim Summary of Session • Session thus far • Two uses of knowledge and performance assessments: Formative and Summative • Validity of all assessment techniques • Compare and contrast three assessment techniques • Take and critique a 14 item multiple choice exam • Write a Key Features test item • Use global ratings and narrative comments when scoring OSCE performance • Coming up • Improving clinical performance assessment systems

23. Recall a student/resident whose clinical performance made you uneasy • What action did you take? a. Talk with faculty colleagues about your concerns: Yes No b. Write a candid performance assessment and send it to the course director: Yes No • If you wrote a candid assessment, did an administrative action occur related to the student/resident? Yes No • Do you think the performance assess- ments in your department’s files reflect the facultys’ candid appraisal of clinical performance quality? Yes No Why do you think this is true?

24. Bubble Diagram of a Resident Performance Assessment System

25. Diagnostic Checklist for Clinical Performance Assessment System

26. Three Year Study to Improve the Quality of Resident Performance Assessment Data • What median percentage of each resident’s rotations returned one or more completed forms? 2. How precise were the scores marked on the returned forms? 3. What median percentage of each resident’s rotations returned one or more forms with behaviorally-specific written comments? Littlefield, DaRosa, Paukert et. al. Improving Resident Performance Assessment Data: Numeric Precision & Narrative Specificity, Acad. Med. (in press)

27. Results of the Study

28. Legal Issues Related to Evaluation and Dismissal 1 • Fair and equitable treatment • Due process for academic dismissals • Documentation, libel, and defamation 1. Irby & Milam. The legal context for evaluating and dismissing medical students and residents. Acad Med, 64(11),1989, 639-43

29. Goals: Assessment of Knowledge & Performance 1. Clarify 2 distinct uses for assessments of clinical knowledge and performance 2. Define 2 aspects of validity for all assessment methods 3. Compare and contrast 3 techniques for assessing clinical knowledge and performance 4. Identify poorly written multiple choice test items and write a key features test item 5. Describe 3 options for scoring OSCE performance 6. Describe three elements of a clinical performance assessment system 7. Critique a clinical performance assessment system that you use 8. Recognize legal issues related to evaluating and dismissing students and residents