Letters to the Editor
To the Editor:
We read with great interest the recent article by Warm and colleagues1 on their assessment system based on entrustment of observable practice activities. As fellow academic internists, we recognize the tremendous feat they have accomplished in creating a robust evaluation system at the University of Cincinnati College of Medicine’s internal medicine residency program that utilizes faculty incentives and training to generate what appears to be thousands of direct observation-based summative assessments. Furthermore, they appear to have trained their clinical competency committee (CCC) to be able to analyze narratives generated from those direct assessments to identify hidden problems, suggesting that their CCC members are comfortable and facile with qualitative analysis methodology.
Although the authors have demonstrated all the components of a mature assessment system, they note that residents scored the assessment system low on satisfaction with their feedback, and the assessors felt that the summative components dominated their assessment work. Considering these findings, the authors set out to clarify the aims and goals of the system to the assessors and residents.
We suggest that the next step may not be reeducation on assessment aims, reorganization of the rating instrument, or rebalancing of the equations that interpret it but, rather, doing away with the scale portion of the rating altogether—truly “embracing the subjective.”2 The work of Dr. Shute3 demonstrates that learner change in response to formative feedback can be completely blunted by providing simultaneous summative feedback, and medical educators have called for assessors to replace scales with narrative ratings.4 We believe the authors’ mature assessment system may be a uniquely ideal place to embrace subjectivity, and we welcome their thoughts on this.
Anthony Donato, MD, MHPE
Associate program director, Tower Health, Reading, Pennsylvania, and professor of medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Anthony.email@example.com; ORCID: http://orcid.org/0000-0002-8294-6769.
Susmita Paladugu, MD
Academic hospitalist, Tower Health, Reading, Pennsylvania; ORCID: http://orcid.org/0000-0001-7981-7862.
1. Warm EJ, Kinnear B, Kelleher M, Sall D, Holmboe E. Transforming resident assessment: An analysis using Deming’s system of profound knowledge. Acad Med. 2019;94:195–201.
2. Ten Cate O, Regehr G. The power of subjectivity in the assessment of medical trainees. Acad Med. 2019;94:333–337.
3. Shute VJ. Focus on formative feedback. Rev Educ Res. 2008;78:153–189.
4. Hanson JL, Rosenberg AA, Lane JL. Narrative descriptions should replace grades and numerical ratings for clinical performance in medical education in the United States. Front Psychol. 2013;4:668.