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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
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development
• A desire to produce a learner optimally prepared to enter the
next phase of training and ultimately enable all graduates to
deliver high-quality and safe care
The good news is that there have been meaningful advances in
assessment practices and educators’ assessment toolbox is more
robust than ever. There have been substantial strides since the launch
of multiple nationally based initiatives, such as the Graduate Medical
Education (GME) Outcome project and the Undergraduate Medical
Education (UME) Medical School Objectives Projects (MSOP) in the
United States, the Canadian Medical Education Directives for
Specialists (CanMEDS) initiative in Canada, and Good Medical
Practice in the United Kingdom (and similar efforts in other
countries) over the past 25 years (see Chapter 1). However, UME and
GME training programs still face challenging barriers undermining
the implementation of assessment programs that effectively integrate
all assessments into a synthetic, holistic judgment about
preparedness for the next stage of a professional’s career.
3–6
For example, too many UME and GME programs still rely heavily
on processes designed and implemented based on a hypothesized
equivalence between satisfactory completion of educational
activity(ies) and competence. In this framing, faculty and programs
mostly use assessments to determine whether satisfactory
completion of the activity or program has occurred, and often rely on
proxies, such as oral (case-based) patient presentations and multiplechoice in-training examination performance as evidence that a
learner possesses sufficient knowledge, skills, and attitudes across
core competencies. High-stakes testing, such as licensing and
certification examinations, are another proxy assessment used to
provide assurance that the learner has satisfactorily completed a
stage of training. Abundant evidence now exists that overreliance on
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these assessment proxies produces variable educational outcomes
and fails to adequately assess critical workplace-based abilities such
as systems-based practice, professionalism, interprofessional
teamwork, and practice-based learning and improvement
competencies in the United States, and key competencies in other
countries’ frameworks (see Chapter 1 for the crosswalk among
competency frameworks). Fundamentally, one major tension faced
by health professions educational systems is between educational
activities that may lead to better short-term performance on isolated,
single assessments (as assessed within a traditional assessment
program that relies heavily on examinations and other assessments of
learning) and programmatic assessment designed to support
professional developmental learning trajectories (with a predominant
focus on assessment for learning).
7
Training programs must embrace three core principles to realize
the full potential of programmatic assessment to enable the
achievement of desired medical education outcomes. This chapter
will provide guidance on effective practices in creating
programmatic assessment, along with tools the reader can use to
judge their own programs of assessment. I will use a systems lens to
help the reader build, review, and reflect on their programs of
assessment.
Three Overarching Principles to Improve
Programmatic Assessment
Programmatic Assessment Must Support Professional
Development
Past and current assessment practices have and are overly focused on
learners’ demonstrations of knowledge or skills at limited, specific
points in time. For example, the US medical education system
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especially places a heavy reliance on assessment proxies to determine
clinical competence, such as single-point-in-time, high-stakes
examinations or end-of-rotation summative assessments completed
by faculty. This overreliance on point-in-time, summative
assessments fails to support a developmental or growth mindset
among learners, faculty, and training programs.
8
,9
It is well established that learners have different learning
trajectories that vary by specific competencies within the
individual.10 The current design of most of our educational
programs, from curriculum to assessment, disregards this reality and
treats each individual learner as a monolithic product moving along
a disjointed curricular and assessment assembly line. For example,
most assessments fail to incorporate theories and empiric evidence
for deliberate practice in attaining expertise, stage models of learner
development, and mastery-based learning.
3,11,12
Using a
developmental lens, assessment for learning is much more important
than assessment of learning. Yet learners rarely have access to timely
assessments, which prevents them from using assessment results to
set goals and action plans. Learners must have full and ongoing
access to their assessment information, ideally in the form of a
learning portfolio, but also have ongoing support to meaningfully
aggregate and synthesize their assessment information into learning
plans and future activities (see Chapter 15). Programmatic
assessment without some form of coaching/mentoring rarely works
(see Chapter 14). Additionally, assessments in CBME must be
developmentally designed where what the learner cannot do is as
important to identify as what they can do.
A developmental approach that encourages a growth mindset
should be the foundation for significantly redesigning instructional
methods, learning experiences, and assessment practices.
8–12
Training programs should focus on promoting learner growth and
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development in the desired competencies through frequent
assessment that is rich in feedback associated with individualized
coaching.13 In 2019, Elaine Van Melle and colleagues outlined five
core components for CBME (see Chapter 1):
1. Competencies required for practice are clearly articulated.
2. Competencies and their developmental markers are arranged
and sequenced progressively.
3. Learning experiences are tailored to facilitate the progressive
development of competencies.
4. Teaching practices promote the progressive development of
competencies.
5. Assessment practices support and document the progressive
development of competencies.
Importantly, the core components framework is grounded in a
growth mindset fully cognizant of the individualized trajectories
each learner will experience.13 Traditional assessment programs, and
especially those that are still operating from the perspective of
objectively measuring competence, start from a deficiency mindset
model. In this model, outcomes of assessment are defined in terms of
deficiency; for example, a student with a score of 75% on an
examination or OSCE is more deficient than someone with a score of
85%. Everything that doesn’t “load” onto a single scaled score is
essentially ignored. Furthermore, while the score provides a
judgment and ranking, the score alone is almost completely useless
in providing the guidance needed to support future training
activities and professional development.
In programmatic assessment, by combining multiple “bits” of
information over time from various and multiple assessment sources,
a personal narrative is produced that allows for a more diverse and
holistic view of the developing learner. Programmatic assessment
embraces a diversity model and therefore recognizes the
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individualized trajectories of each learner. Training programs should
focus on frequent formative assessments that are rich in feedback
and individualized coaching. Educators and programs must
therefore design and use assessment tools that support the
developmental trajectories of learners and integrate them into a
program of assessment, or programmatic assessment, that supports
the learner’s professional development.13 This is not meant to
undermine the importance of a summative assessment around
progression decisions such as whether a learner is ready to advance
to the next level of training or ultimately graduate to unsupervised
practice. In the end, if the training program treats the results (e.g.,
ratings, narrative comments, etc.) of each individual learner
assessment event as formative (“here is where you are”) and
incorporates feedback and learning goals with subsequent results on
the follow-up activities and assessments as the key inputs into
summative judgments, you would still have an assessment for
learning program.
Addressing Bias and Fairness in Programmatic
Assessment
There is an urgent need to confront and address the persistent and
pernicious effects of bias in medical education and assessment. Bias
can occur at multiple levels. Structural bias involves institutional
(e.g., medical schools, hospitals) patterns and practices that provide
advantage to some groups and disadvantage to other groups based
on personal and demographic characteristics and identity. At the
individual level, explicit bias refers to conscious beliefs and attitudes
one possesses about another person or groups. Implicit bias refers to
an individual’s “prejudicial attitudes towards and stereotypical
beliefs about a particular social group or members therein.”14 These
individual attitudes are often subconscious. A growing body of
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literature describes the factors contributing to, and the harmful
effects of, implicit bias and educational inequity on learners who are
underrepresented in medicine (URiM) or otherwise at risk for
marginalization in assessment practices. It is also important to note
that the makeup of URiM groups can vary by country.
Bias affects learners broadly—from the interpersonal dynamics of
teaching dyads or teams to structural phenomena, such as
standardized exams with grade cutoffs. Hagiwara et al. note that
implicit bias has both affective and cognitive components and
educators must recognize the distinction between prejudice and
stereotyping when considering interventions to reduce implicit bias
in assessment.14 Prejudice relates to the negative attitudes
individuals form toward other persons or groups often in advance or
without any actual experience with the affected individuals.
Stereotyping refers to rigid, fixed, and overgeneralized beliefs about
a specific group of people. Prejudicial attitudes and stereotypical
beliefs are often activated spontaneously and can produce changes in
an individual’s teaching and assessment behaviors. Likewise,
structures and policies can recapitulate these ingrained behaviors to
create a biased and inequitable learning environment.
Assessment occurs within the inextricably linked learning and
working environments
15,16
where faculty responsibilities reside in
the overlapping domains of patient care and education. Structural
factors at the community and institutional levels can negatively affect
the training of all learners in the combined learning-working
environment. For example, inequities in community access to
healthcare due to racism, xenophobia, and other biases produce
suboptimal care for marginalized groups that may inculcate
suboptimal clinical care behaviors in learners. Explicitly learning and
understanding community-level factors affecting healthcare, a core
tenet of systems-based practice in the United States, is crucial for
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learners. Institutions should routinely examine their own clinical care
measures for evidence of bias and inequitable care and share that
information with programs and learners to help drive improvement
in both education and clinical practice.
When learners experience structural bias, it results in suboptimal
learning environments, which compromise learners’ well-being and
ability to function at the top of their skills. Multiple studies have
found that learners from groups historically URiM receive lower
assessment ratings from faculty.
12,13
There are racial disparities in
exam score grading and fewer admissions to honor’s societies even
when corrected for grades and other factors.
17–19
These effects are
cumulative. Small differences in assessment translate to disparities in
future opportunities, including training and employment, a
phenomenon described as the amplification cascade.
20
At the program level, conflicting priorities, time constraints, and
burnout can lower the threshold for faculty to unconsciously apply
their activated biases to their assessments of students. Bias affects
learners and faculty through multiple phenomena that play
themselves out intra- and interpersonally. Learners from URiM
groups experience social isolation and heightened visibility that can
lead to and reinforce stereotype threat and impostor syndrome.
21
Learners can also experience hostility and prejudice from patients
and families, which may lead to sidelining or exclusion from patient
care if teams are not equipped to handle difficult interpersonal
dynamics with patients. Learners also experience different
expectations in the preclerkship and clerkship settings.
22–25
Fairness is another essential principle needed to reduce the harmful
effects of bias. Valentine and colleagues have published several
studies, including a systematic review, that have led to a conceptual
model codifying what constitutes a fair program of assessment.
26–28
The model contains three interdependent domains: judgment
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decisions, individual assessor characteristics, and system factors (Fig.
3.1). Judgment decisions must be transparent, defensible, credible,
and fit for purpose. Important individual characteristics include the
need of narrative for the learner that supports defensibility,
creditability, and transparency; evidence to support the assessment
judgment, such as the link of a competency performance to better
patient care; boundaries that specifically address what is not
pertinent to an assessment decision such as race and ethnicity as
discussed earlier; expertise in both clinical care and assessment; and
finally, agility to manage and acknowledge ambiguity, uncertainty,
and context in assessment events.
FIG. 3.1 Valentine framework for fairness in health professions
education assessment. (From Valentine N, Durning S, Shanahan EM,
Schuwirth L. Fairness in human judgement in assessment: a hermeneutic
literature review and conceptual framework. Adv Health Sci Educ Theory
Pract . 2021 May;26(2):713–738. doi: 10.1007/s10459-020-10002-1 .)
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As noted at the outset of the chapter, systems thinking is essential
for programmatic assessment. Systems fairness factors identified by
Valentine and colleagues include procedural, such as due process in
remediation decisions (see Chapter 17); documentation that is clear,
robust and accessible to the learner; multiple opportunities for
assessment; multiple assessors involved in providing assessment
information; and ongoing and persistent pursuit of the validity
evidence to support assessment judgments and assessment
approaches used as part of programmatic assessment. To Valentine’s
model, I would add the need to use the core principles of
translational (bench to bedside) science and quality improvement to
mitigate individual and structural bias.
2,29
Programmatic Assessment Must Use a SystemsThinking Approach
Supporting professional development while reducing bias and
enhancing fairness requires robust, thoughtfully designed
programmatic assessment. Assessment programs are best viewed as
a subsystem within a training program. A system can be simply
defined as “two or more interdependent parts that work together to
accomplish a shared aim.”30 Assessment programs possess a number
of components or parts (called structures within a system), including
people (learners, peers, faculty, interprofessional team members, and
increasingly, groups of experts, commonly called clinical competency
committees [CCCs], that judge learner progress), tools (e.g., exams,
case presentations, faculty assessment forms, mini-clinical evaluation
exercise [mini-CEX], etc.), and technology (e.g., learning
management systems, smartphone apps). People are the most
important components of a system. Fig. 3.2 provides an overview of
some of the critical parts, or structures, of an assessment system and
highlights the multiple connections, or interdependencies, among the
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components. The figure notes the centrality of the information “hub”
that is typically housed within an electronic learning management
system or portfolio. All the important agents in the system, such as
the learner, faculty, clinical competency committees, and advisors,
interact with the assessment information to support professional
development.
FIG. 3.2 Assessment structures: key components and actors.
Using systems thinking, an assessment program should function as
a group of people, including the learners, who regularly work
together to perform, review, and reflect on assessments, and provide
feedback, coaching, and career guidance throughout training. The
group must possess shared mental models of desired educational
goals and outcomes and integrate individual assessments into
holistic views of professional development.
31,32
This requires
unbiased feedback and the feed-forward of learner performance to
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