Answer to "How do I assess learners in a LIC?"

The process to evaluate (assess) a student’s learning status in a longitudinal integrated clerkship (LIC) must allow for the unpredictability and integrated nature of the curriculum, provide regular feedback on learning and test competencies that will be achieved over time.   

Most medical school have moved to competency-based medical education, determining the competencies and the performance standards that learners should achieve at different levels of undergraduate medical education. A programme of assessment is implemented to measure whether learners have attained core competences. All medical students, regardless of the clinical clerkship they undertake, should achieve the same competencies after completion of the clerkship year.

When and how to assess LIC learner gains compared to those of students in traditional block clerkships (TBCs) can prove difficult if only a portion of the medical school is undertaking a LIC. Imposing the TBC based timing of end-of-block discipline-based assessments onto LIC students can undermine achievement of the value of longitudinal and integrated learning.  A whole-class LIC or stand-alone programme does not present this challenge, and can comprise a series of formative assessments over time, before final summative assessments of student competencies.  No two students ever have identical educational experiences throughout their clinical clerkship, whether in a TBC or LIC model. Regulators require equivalency of educational experiences, and evidence that all students have achieved equivalent competencies by the end of the clerkship year. 

Work-place based assessments (WBAs) have gained favour to assess what a student can actually do in the workplace of patient care.  WBAs, such as the mini-CEX, are valuable for formative and summative assessment in both TBC and LIC programmes, however the formative feedback they provide is especially valuable to guide LIC student development over a longitudinal programme.

Assessment using entrustable professional activities (EPAs), a relatively new WBA, has been proposed as a perfect match for evaluating student learning in a LIC.  EPAs are units of professional work made up of a variety of competencies in different domains.  While these were initially developed for postgraduate medicine, the AAMC has described 13 core EPAs that all US medical graduates should be able to carry out with indirect supervision (without a supervisor physically present in the room) when they enter residency. The decision to ‘trust’ or decide if a medical learner can carry out a professional task with indirect supervision is dependent on the behaviour of the student as observed by the supervisor.  A longitudinal supervisor-trainee relationship is needed for a reliable assessment. Preceptors in shorter term discipline-based blocks who often lack sufficient time to establish relationships with learners, may not be able to provide meaningful formative feedback and/or summative decisions. A LIC supervisor, with a longitudinal relationship with a student, is well placed to provide meaningful feedback and decide when a learner has achieved a particular EPA.

In a study comparing perceptions of evaluation in a LIC compared to those in a TBC, preceptors and students favoured evaluation in a LIC on three factors (p ≤ 0.01): validity of the evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback.

References

Englander R, ten Cate O.  LICs and Entrustable Professional Activities: A Perfect Match.  In: Poncelet AN, Hirsh D, editors. Longitudinal Integrated Clerkships: Principles, Outcomes, Practical Tools and Future Directions. North Syracuse, NY: Gegensatz Press; p. 261-270.

Englander R, Aschenbrener CA, Flynn T, Call SA, Carraccio C, Cleary L, et al. 2014

Core Entrustable Professional Activities for Entering Residency: Curriculum

Developers' Guide: Updated. Washington DC: AAMC.

www.mededportal.org/icollaborative/resource/887  Accessed 2018, July 26.

Poncelet A, Hirsh D.  Background, Definitions, History. In: Poncelet AN, Hirsh D, editors. Longitudinal Integrated Clerkships: Principles, Outcomes, Practical Tools and Future Directions. North Syracuse, NY: Gegensatz Press; p.1-8.

Myhre DL, Woloschuk W, Jackson W, McLaughlin K. 2014. Academic performance of

longitudinal integrated clerkship versus rotation-based clerkship students: A

matched-cohort study. Acad Med. 89(2):292-295.

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