Assessment System: Direct Observation

Rationale

Direct observation of medical learners during clinical encounters with patients are conducted for the purpose of providing feedback and assessment of learner achievement. This includes learner acquisition of the knowledge, behaviors, and skills specified in the BSOM Institutional Learning Objectives. Direct observation of clinical skills is essential to ensure medical learner development and improvement in performing appropriate histories, physical examinations, and communication skills.

Scope

This Standard Operating Procedure applies to BSOM faculty members who teach, facilitate, or precept medical learners in the core clerkships.

Definitions

Direct Observation: An assessment based on the direct observation of a medical learner’s clinical skills that is designed to provide feedback on skills essential to the delivery of high-quality clinical care.

Procedures for Implementation and Review

Completion of clerkship requirements will be affirmed through a written document, either in paper or electronic form, containing the signatures of faculty members responsible for determining those clinical objectives have been met by each learner.

Clerkship Leadership

• Written documentation of direct observation completion is reviewed by clerkship leadership (e.g., clerkship directors, site director, associate clerkship director) to determine whether each learner has been directly observed.
• At the mid-clerkship feedback session, the clerkship director discusses the status and/or results of the direct observation with the learner.
• If direct observation has not occurred by the last week of the rotation, the learner’s clerkship preceptor or other supervisor will be identified and contacted directly by a designated midpoint evaluator. Clerkship Directors then work with the faculty to ensure an evaluation is scheduled prior to the end of the clerkship.
• At the end of the clerkship, clerkship leadership is responsible for completing initial review of each written document to verify whether participating faculty members have completed Direct Observation Forms. Completed forms are collected by clerkship leadership and maintained in the learner’s file.
• If clerkship leadership determines that full compliance with this policy has not been achieved by participating faculty, a list of preceptors and/or other supervising faculty members who failed to provide director observation is provided to the department chair for further action.

Office of Medical Education:

At the end of the clerkship, the Office of Medical Education surveys learners on whether they have been directly observed performing relevant portions of history taking and physical exams. A yearly summary is reviewed by the ECC and its subcommittees and shared with department chairs and clerkship leadership.

Responsibilities

This procedure requires collective supervision by all current department chairs and clerkship directors in the Brody School of Medicine.

Clerkship Directors

• Ensures that direct observation is taking place.
• Informs the department chair of any issues that may impede full compliance with this procedure.

Department Chair

Works collaboratively with the clerkship director and is ultimately responsible for ensuring departmental compliance with the procedure.

Faculty/Residents

• Directly observes medical learners during designated clinical encounters with patients for the purpose of performing learner assessments and providing feedback.
• Directly observes part or all of a patient’s history and mental status/physical exam during clinical encounters.
• Documents the direct observation utilizing a Direct Observation Form as designated by the clerkship.
• Submits completed Direct Observation Forms to the Clerkship/Course Director.

Curriculum Management Administrator

• Creates and administers surveys that collect data on direct observation.
• Prepares annual reports for OME Deans, ECC, and its subcommittees.

Assistant Dean for Assessments and Outcomes

Presents annual summary at retreats and curriculum meetings.

Schedule for Review

This policy is reviewed and may be revised by the Executive Curriculum Committee as necessary, but at least every three years.

Related Policies

None

Applicable Laws, Regulations & Standards

LCME 9.0 Teaching, Supervision, Assessment, and Student and Patient Safety
LCME 9.5 Narrative Assessment
LCME 9.7 Formative Assessment and Feedback