SCHOOL OF MEDICINE STUDENT HANDBOOK

EVALUATION OF STUDENT PERFORMANCE
CLASS OF 2010 AND SUBSEQUENT YEARS

Examination Policy

Foundations of Medicine and Health Curriculum

Summative Portfolios

Core Clinical Rotations

Advanced Core Rotations

Research and Scholarship

Flexible Program

Promotion Guidelines

Remediation

Students must satisfactorily complete all components of the educational program to be eligible for promotion and graduation. In keeping with the goal of a balanced and coherent educational program, the Case Western Reserve University School of Medicine seeks to identify potential academic problems early, and to provide non-prejudicial intervention as necessary to assist all students in meeting academic standards.

Foundations of Medicine and Health SSEQs are administered in proctored classrooms and answers are expected to represent each student’s own work.  All National Board of Medical Examiners (NBME) Tests are administered following NBME guidelines.  Students are required to sign an Examinee Acknowledgement Form before the first examination is administered.  This form is reproduced in Appendix II.

All students must take the examinations in the assigned facility on the scheduled examination date and time.   Students who are not able to take a Foundations of Medicine and Health Curriculum examination at the scheduled date and time because of illness or emergency must contact their Society Dean before the examination.  When an acute illness or other emergency arises less than 24 hours before an examination, students should contact their Society Dean to report the situation.  When deemed appropriate, the student will be granted official approval to defer the examination and personnel will be notified.  

Disabilities and Accommodations
The School makes accommodations available to those students who, because of a documented disability, require accommodations.  Students with disabilities who request accommodations must provide written documentation to his/her Society Dean who will submit the request to the Accommodations Committee.  The specific procedure and forms that must be completed are described in Appendix I and Appendix II.

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Student assessment in the WR2 Curriculum is designed to accomplish three goals:  1) drive the types of learning and inquiry that are goals for the WR2 Curriculum; 2)  ascertain whether students attain the level of mastery set as a goal for graduates of Case Western Reserve University School of Medicine; and 3)  prepare students for medical licensure.  These three goals are accomplished through multiple assessment methods.
Student performance is assessed by a variety of methods with special emphasis on scientific reasoning, comprehension, and problem solving, (e.g., synthesis essay questions, multiple-choice, laboratory practical).  Performance is designated as “meets” or “does not meet criteria.”  Students who do not meet criteria are identified to the Society Deans and the Block Leader (see the Remediation of Foundations of Medicine and Health Curriculum section).  Information concerning examination performance and class rankings is not part of the student’s permanent record.  However, examination scores are recorded for students participating in the Medical Scientist Training Program. The following assessments are used in the Foundations of Medicine and Health:

1.  Assessment of students’ participation in weekly Case Inquiry (IQ) groups by faculty facilitators, based upon observable behavior and focused on contributions to the group content, contributions to the group process, and professional behaviors.

2.  Synthesis Essay Questions (SEQs).  Weekly, formative, open book concept reasoning exercises in which students are  given a brief written clinical scenario and asked to explain a clinical phenomenon and its basic science underpinnings.  Throughout a teaching block, students complete SEQs at the end of each week.  They then compare their answers to an ideal answer as well as get feedback on their reasoning ability from their IQ group faculty.

3.  Summative Synthesis Essay Questions (SSEQs), are designed to measure what students know at specific points in their education, are closed book assessments with approximately 5 scenarios that take 3-4 hours to complete.  SSEQs are based on the synthesis essays students completed in an open book fashion throughout the block.  In the final week of the block, SSEQs present concepts from previous exercises in new contexts and require a more sophisticated level of concept integration. These summative assessments are scheduled at the end of each large teaching module (every 3-4 months) and are graded by faculty who are content specialists.

4.  Structure Practical Exercises.  These assessments occur in the final week of blocks 2-6 and integrate anatomy, histo-pathology and radiology through clinical scenarios and questions that ask for anatomic localization and histo-pathologic identification.

5.  Self-Assessment Multiple Choice Questions (MCQs).   At the beginning of each 12- week teaching block, students have access to 200 MCQs and answers drawn from the School of Medicine’s existing extensive bank of questions which will be mapped to learning objectives for the block. These questions are intended to help students prepare for the United States Medical Licensing Examination (USMLE) Step 1. Students may use these MCQs throughout the block as study aids  and self-assessment.

6.  Cumulative Achievement Tests (CAT). At the end of each block, students complete a secure formative MCQ achievement test, based on content covered in the current teaching block as well as on content from each previous block.  These exams are designed using test question resources available through the National Board of Medical Examiners NBME.  Tests become progressively longer throughout the Foundations of Medicine and Health.  The final CAT reflects material across all curriculum blocks.     These formative tests enable students to gain perspective on their overall progress and preparedness for the USMLE Step 1.

7.  Student progress in Foundations of Clinical Medicine is measured by small group facilitator assessment in the Seminars of Clinical Practice, direct observation of skills, preceptor evaluation of patient-based activities, and OSCE examinations.

8.  Professional Learning Plan.  The Professional Learning Plan is created by students to teach them how to use the continuous quality improvement model to improve their academic performance.  In the first 20 months of the medical school curriculum, students meet in medium sized groups composed of their society members to work on their PLP.  The first meeting is held at mid-block and students complete an on-line structured plan.  They must first identify an area that they want to work on, usually drawn from some feedback they have received.  They must identify the issue and come up with a plan for remediation, then  come to the mid-block meeting to share this plan with their colleagues.  This vetting process allows them to hone their plan.  The students then have the remainder of the block to work on their plan.  The week following the end of the block, the students come together in a group to share their evidence for completion of their PLP.  These meetings allow students to share best practices with one another on how best to master the material of medical school.

Required Assessment Tools to Measure Achievement of Learning Goals in WR2
                                                                       

Foundations of Clinical Medicine (Foundations) is the first course in the clinical curriculum and continues throughout Medical School.  In years 1 and 2, the guiding principle is that early exposure to patients, with direct observation by experiences faculty physicians, is optimal for both professional development of students as doctors and assessment of their clinical skills.  Foundations has three interrelated components:  clinical skills training, patient care experiences, and Foundations of Clinical Medicine Seminars.
 
Students will be evaluated formatively throughout the year on each aspect of the Foundations course.  Summative evaluations will be employed as well, and will include preceptor evaluations, peer reviews, and objective structured clinical examinations.  At the end of each block of the Foundations of Medicine and Health Curriculum, students will receive a designation of “meets expectations,” “provisionally meets expectations,” or “does not meet expectations.”  These designations will be approached in a manner consistent with assessment in Foundations of Medicine and Health.

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Summative ePortfolios

Overview & Definitions
The WR2 curriculum is a competency-based curriculum with 9 Core Competencies that students are expected to achieve prior to graduation from the School of Medicine.

Competencies – The knowledge, skills and behaviors a student must demonstrate to meet the performance standards for an MD degree from Case. The following nine Core Competencies are required for graduation. 

• Medical Knowledge
• Patient Care
• Interpersonal & Communication Skills
• Professionalism
• Life-long Learning & Personal Development
• Research & Scholarship
• Civic Professionalism, Health Advocacy and Leadership
• Practice-based Learning & Improvement
• Systems-based Practice

Achievement of some competencies can be demonstrated by test performance, achievement of others by a Reflective Essay accompanied by supporting Evidence, collected in a Portfolio.

Evidence - Something that provides proof.  Performance check lists, reflection essays, reports, patient write-ups, project presentations, examples of feedback/evaluations received or given to others, personal learning plans (PLPs), etc.  All these pieces of evidence need to be saved and stored.

Portfolio (medical education) – A collection of thoughtful essays, each accompanied by selective supporting evidence, that demonstrates what a student has accomplished and areas for improvement.

ePortfolio
“Storage” ePortfolio = Electronic repository of all of student’s work (evidence) for purposes of storage; is private and non-selective. Combination of SOM ePortfolio and files stored on a student’s hard drive.

Summative ePortfolio = Reflective essays and selective evidence, created by students to share with faculty reviewers for purposes of assessment.  These collections of reflective essays are accompanied by supporting evidence at three time points to provide assessment of how a student is progressing with respect to meeting the 9 Competencies of the WR2 curriculum. At each time point, students submit one essay for each required competency (see table below).

Reflection: A thoughtful, critical self-appraisal of one’s performance, discussing
strengths and areas for improvement; a crucial professional skill for medical doctor.

Process
ePortfolios are submitted electronically through the eCurriculum, and consist of essays documenting the student’s learning progress with regard to specific benchmarks, or Achievement Levels, for each Competency. Students will submit one essay for each required competency, as indicated in the table below. In the essays, students reflect on their progress toward mastering each Achievement Level, identify strengths and areas for improvement, and provide Evidence to support their discussion. (See Appendix VII for complete list of Achievement Levels for each set of portfolios.)

Summative ePortfolios are submitted at three points in time, and consist of essays on each of the required competencies:

*Subject to change

The essays are reviewed anonymously by faculty reviewers to determine if the portfolio meets expectations. The faculty reviewers use the following criteria to assess the students’ ePortfolios:

• Is the narrative consistent with the evidence?
• Is the narrative balanced, i.e., includes areas of strength and areas for improvement?
• Is this a thoughtful, insightful essay?
• Is the essay organized and information communicated clearly and convincingly?
• Have all achievement levels for the competency been addressed?

Faculty reviewers will provide feedback/comments and one of three possible ratings for each essay: Meets Expectations, Meets Expectations with Targeted Areas for Improvement, or Does Not Meet Expectations. A rating of “Does Not Meet Expectations” for any one competency essay will result in an overall rating of “Does Not Meet Expectations”. Students will be provided an opportunity to revise any essays that do not meet expectations, working with their Society Dean, faculty and administrative support staff, as appropriate. Successful completion of each of the 3 portfolios, i.e. achieving the designation of “Meets Expectations”, is a requirement for the MD degree for the School of Medicine.

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Assessment in Core Clinical Rotations is multidimensional and competency based. Elements of performance that are assessed are cognitive skills, interpersonal skills, qualities of character, integrity, and work habits.  The procedures used to assign grades is  derived for each discipline (internal medicine, family medicine, surgery, ob/gyn, pediatrics, neurology, psychiatry) from performance on Core Clinical Rotations as outlined below.  The grading strategy combines direct assessment by clinical preceptors (Attendings and Residents), results of the NBME Progress Test, and performance in the Friday afternoon (IQ+) curriculum.

Grades are determined according to the following process:

1. Discipline Leaders determine a clinical grade based on:
1. Summative feedback information provided by preceptors (Attendings and Residents) in the Clinical Assessment System (CAS)
2. Additional information gathered from faculty, residents, and other means agreed on by that discipline across all sites.
3. Assessment by facilitators in the IQ+ curriculum (contributions to group, clinical skills, and reflection)

2. NBME Progress Test gateway:
1. Students will take the NBME Progress Test at the end of each 16-week block and at the end of the year (July 2009) with scores determined for each discipline on each test.
2. The discipline-specific score will be used in two ways:

• To maintain a clinical grade (if the threshold to maintain is not reached, the student will drop to the next lowest category)
• To move up one clinical grade (if the score exceeds a higher threshold)

3. The thresholds will be as follows:

• >70: To maintain a clinical grade of honors or commendable in that discipline (if not achieved, the grade moves down one grade category)
• >54: To pass the specific discipline
• >84: to move up one grade category in a specific discipline (from commendable to honors or from satisfactory to commendable)

4. Students have the opportunity to improve their score in a particular discipline if desired on a subsequent test administration.  Only the highest score in any particular discipline will count.
5. Scores are standardized to a mean=70, std dev = 8, on the basis of test results for the two preceding medical student classes after the March test administration.

3. In order to receive a Satisfactory grade, students must satisfy all the following: 1) a Satisfactory clinical grade in that discipline, 2)an NBME score of > 54 in that discipline, and 3) a “meets expectations” in the IQ+ curriculum.

Final grades of Honors, Commendable, Satisfactory, Unsatisfactory, or Incomplete will be assigned for each core discipline based on this combination of information.  An Incomplete designation must be replaced by an Honors, Commendable, Satisfactory, or Unsatisfactory evaluation; arrangements must be made with the Clerkship Director and the appropriate Society Dean.  Students who receive an unsatisfactory evaluation or whose behavior has been deemed unprofessional will appear before the Committee on Students for review of their total performance throughout all programs of the curriculum.  Satisfactory completion of all required core clerkships is a requirement for graduation.

In addition to the grading process described above, University students will join College students in a parallel end of block assessment process focusing on expectations in relation to core competencies.  At the end of each block, a report for each Discipline will be developed for each student. The report will include a summative assessment for each competency: “Meets all competency standards,” “Meets most competency standards, no remediation required,” “Meets some competency standards, remediation required” or “Not observed/not applicable”.  For “Meets some competency standards, remediation required” a remediation plan will be created. This remediation plan must address all elements that did not meet standards for competency.  This report will be available to the student’s Society Dean.  Students are encouraged to discuss this report with their Society Dean in order to address areas of weakness when planning clinical electives and other learning activities.

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Advanced Core Rotations

For the Class of 2010*, the Advanced Core Rotations consist of 4 separate, required 4-week rotations that are completed in any order. The 4 domains for these experiences are: Chronic Illness, Aging in Men and Women, Peri-Operative Care and Pain Management, and Undifferentiated Care. During the Advanced Core, students are able to build on their clinical activity scores and add to those already achieved in the respective disciplines in the Basic Core. Only Advanced Cores that feature 4 weeks of clinical activity in one discipline area will be counted toward a Basic Core Discipline grade. This includes:

• "Aging" for Internal Medicine
• "Chronic Disease" for Internal Medicine or Pediatrics (but not both)
• "Undifferentiated/Emergent Care" for Internal Medicine or Pediatrics (but not both)

The Advanced Core grades will contribute as follows to the FINAL point total (out of 500 possible points) for the Basic Core grades:

• Advanced Core grade of Honors--add 10 points
• Advanced Core grade of Commendable--add 5 points
• Advanced Core grade of Satisfactory--add 0 points

* Starting with the Class of 2011, the Advanced Cores will consist of 2 separate, required 4-week rotations that can be completed in any order at any of our affiliated hospitals.  The domains for these experiences are 1) Aging and Society and 2) Undifferentiated Care. 

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Research and scholarship is a critical component of the curriculum.  The objective is to help students acquire tools and experience in asking questions, critically assess literature, and develop other aspects of the life-long pursuit of learning that is an integral aspect of the career of all physicians and physician-scientists.    The goal for each student is to formulate a question in an area of interest, to develop an approach to answering it, to carry out this project, and to arrive at an interpretation of the observations.  Research proposals must be approved by the Vice Dean for Research or a reviewer appointed by the Vice Dean. Besides the required research block, the summer following the first year is available for students to engage in elective 8-week, full-time, mentored research experiences with a faculty member here or at another university.   It is also possible to opt for a year off devoted to research and leading to a five-year curriculum.  Requirements for the mandatory research block include two progress reports, the first due 4 weeks after the start date and the other 8 weeks after the start date, and a summary. All three requirements are due online at the student's ePortfolio MyResearch site by the deadline given at this site. The summary is in the format of a manuscript in the leading journal of the field that the student is pursuing. It is due on the last day of the 4-month block. It can form the basis of the M.D. thesis, following any required updating and revision.  The M.D. thesis is required by January 15 of year 4.  A complete description of the requirements is found at the website for the Office of Medical Student Research.

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The Flexible Program provides opportunities for students to pursue electives in areas of personal interest.  A description of the elective offerings and expectations for student performance is available in the Flexible Program Catalogs provided by the Registrar.  In order to drop an elective, a student must secure his/her Society Dean’s permission.

Type A Electives (not required)
Student performance in Type A offerings is evaluated as credit or no credit.  Instructors are encouraged to provide narrative comments on student performance.
Type B Electives  (required)
Student performance in Type B offerings is evaluated as honors, commendable, satisfactory, unsatisfactory, and incomplete. An incomplete designation must be rectified. Instructors are encouraged to provide narrative comments on student performance. Nine type B electives are required; at least 6 of which must be clinical electives.


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Academic Expectations for the Foundations of Medicine and Health
Students must achieve passing marks in all components of the Foundations of Medicine and Health curriculum.  If a student does not meet expectations in any block, remediation is required.
Students are required to remediate all basic science subject committees in order to emphasize:

• Mastery of basic science concepts
• Early identification of failure to master basic science material
• Personal responsibility in the remediation process
• Standardized remediation strategy for all basic science subject material

WR2 Remediation in Foundations of Medicine and Health (FMH)   
The Following components make up the end of block ratings:
            1. SSEQs
            2. Structure Practical Exercise
            3. Cumulative Achievement Test
            4. Final Case Inquiry Faculty Assessment
            5. Medium Group Faculty Assessment
            6. Foundations of Clinical Medicine
            7. Clinical Immersion Exercise
            8. Professional Learning Plan
            9. Society Dean Advising meeting (mid & final)

Definition and consequences of end of block ratings:
Meets criteria; overall satisfactory achievement of criteria:the student has met all expectations for all components of the block.
Does not meet Criteria:  3 possibilities

1) Targeted remediation required-- Students will receive this rating if they do not meet criteria for any of the following:       
           Structure Practical Exercise
           Cumulative Achievement Test
           Final Case Inquiry Faculty Assessment
           Medium Group Faculty Assessment
           Foundations of Clinical Medicine
           Clinical Immersion Exercise
           Professional Learning Plan
           Society Dean Advising meeting (mid & final)

The student is required to meet with his/her Society Dean and develop a plan to address specific areas noted and show evidence of successful remediation in his/her portfolio.

Deadlines:  Targeted remediation for blocks 1-4 must be completed prior to submission of the end of block 4 portfolio.  Targeted remediation for blocks 5 and 6 must be completed prior to submission of the end of block 6 portfolio.  Note that the Structure Practical Exercise is a component of each of blocks 1-6.  Exceptions to this timing must be approved by the student's society dean.

2) SSEQ remediation required--  Students who do not meet criteria for the SSEQ examination are required to remediate.  All students will be required to pass a parallel form of the assessment designed by block faculty.  Evidence of successful remediation must be provided in the portfolio.

Deadlines:  Block 1 SSEQ remediation must be completed by the end of winter break of the same academic year.  SSEQ remediation for blocks 2-4 must be completed prior to the start of block 5.  SSEQ remediation for blocks 5 and 6 must be completed before the student can continue with any curricular activities beyond the Foundations of Medicine and Health at the end of block 6.

3) Incomplete-- Student is unable to achieve the objectives of the block due to illness or emergency.  The student will work with his/her society dean and corresponding block faculty to develop a suitable schedule for fulfilling block requirements.

Referral to Committee on Students (COS):

A student will be referred to the COS if either of the following two criteria are met:

           1.  A student fails one SSEQ exam in blocks 1-6 and fails that block's remediation.
           2.  A student fails two SSEQ exams in blocks 1-6.

A student may be referred to the COS for failure to remediate successfully in any of the 9 components that make up the end of block ratings.
        

For complete COS policies see the Committee on Students section in the Student Handbook.

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