Assessment in Undergraduate Medical Education: Is It Fit for Our Purpose?

By Senthil Rajasekaran, MD

The past decade has brought dramatic changes to the field of medical education. Technology has infiltrated the educational universe, transforming the playing field with innovation. Problem-based learning, case-based learning, systems-based approaches to learning, and team-based learning are just a few of the curricular models currently in use in medical schools across the United States.

While these revolutionary changes are exciting, it is concerning to see the debate around the health care crisis continue. It seems as if all these models, some of which have been around for more than a decade, have not been able to improve trends and metrics in care delivery. We are still talking about the need for increasing efficiency, reducing costs, and improving safety—the same high-priority challenges we faced before any of these new and exciting curricular models were introduced. The reasons for a slow pace of change can be multifaceted, but I think some of it has to do with the assessment practices in medical schools. Specifically, are the new curricular models being assessed for purpose and assessed using the proper methods?

In my opinion, assessment throughout medical education helps in building students’ understanding. It provides information on student achievements to those outside the student-teacher relationship, including school administrators, licensing bodies, and accreditation bodies. Assessment data can be used to hold individuals (students and faculty) and institutions accountable for the educational outcomes.

Now, let us examine the most common assessment methods used in medical schools and licensing exams. Written multiple-choice items (in a textual format) and objective structured clinical examinations (OSCE) remain the two most commonly used assessment methods. Scores obtained on these assessments, especially USMLE licensing exams, continue to determine the student’s choice of specialty, despite publications reporting poor correlation between these scores and clinical performance of the students.

Assessment outcomes should be strong predictors for future practice, hence proving the quality of the program. Systems approach, practice-based learning, medical financing, shared decision making, practice quality improvement, and medication safety are among the growing list of models added to the four-year curriculum. Personally, I think many of these topics should replace the outdated content and models that still are taught for the sake for teaching.

Because creating new curricular models and content consumes an enormous amount of time and resources (financial and manpower), we should ensure we are developing appropriate assessment methods to ensure adequate educational outcomes. Accurate assessment tools will serve to hold students and faculty accountable for the content and its outcomes in improving health care.

There are many simple, yet meaningful, innovations possible for assessing medical students with “real-world” platforms. Medical schools should consider using more reflective writing, peer evaluations, short answers, and essay questions as a part of their routine assessment methods. Innovations can also be made in the use of multiple-choice question formats, rather than just using textual information and pictures. Technology now has solutions for easier and more efficient grading of these essays, which can be a mammoth, time-consuming task if done manually. Advances in technology also eliminate the element of subjectivity that can occur in human grading.

I want to emphasize the importance of developing what I would call “assessment to fit the purpose.” The teams working on designing and implementing new curricular models should work on developing innovative and effective assessment tools in parallel with the curricular content. Those assessment tools should offer “real-world” assessment settings offering best prediction values. I am sure we, as educators, know the saying, “Assessment drives learning”!

Senthil-New—Senthil Kumar Rajasekaran is Director, Center for Excellence & Associate Professor at Oakland University William Beaumont School of Medicine. He can be reached at rajaseka@oakland.edu.

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