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Fund of knowledge in medical student evaluations

Currently, there are two ways to evaluate medical student fund of knowledge on a clerkship. One is by a subjective evaluation on their clinical performance by residents and attendings (faculty) they work with, and the second, by an examination at the end of the clerkship.

At UCSF medical school, the third and fourth year medical students are evaluated on their fund of knowledge based on certain criteria:

– Understanding of disease mechanisms
– Ability to apply this understanding in clinical situations
– Develop and defend differential diagnoses

Each student receives a score of 1, 2, 3, or 4, depending on how successful they are at demonstrating their fund of knowledge.  In some rotations, like the Surgery clerkship, Honors on the clerkship can only be obtained with a high score on the more objective NBME exam.

Below is a description of what each score implies.

Score of 1: Fund of knowledge and/or understanding of disease mechanisms may or may not be adequate but demonstrates very poor ability to clinically apply knowledge base.

Score of 2: Has limited overall knowledge base but shows abilities in clinical application thereby showing significant potential for growth.

Score of 3: Solid fund of knowledge and understanding of disease mechanisms with frequent demonstrable ability to apply this understanding in clinical situations.

Score of 4: Outstanding fund of knowledge and understanding of disease mechanisms with excellent ability to 1) apply it to clinical situations 2) develop and defend differential diagnosis

This scoring system for fund of knowledge is used in all of the clerkships students rotate in, including OBGYN, Neurology, Psychiatry, Internal Medicine, Family Medicine, Pediatrics,and  General Surgery.

The problem with the way students are evaluated now in most medical schools, is that their fund of knowledge score is assigned by residents and attendings who often base their score on only a few interactions with the student.  These interactions consist of small number of questions posed to the medical student to guage their fund of knowledge.

If that student is able to answer random questions correctly, on the spot, and with confidence, on the few occasions the student is questioned, then he or she might receive a 3 or a 4 on the “fund of knowledge” scale, but only if the resident or attending also likes said student.

The subjective nature of evaluations has been demonstrated in several studies.  One study (1) looked at 100 medical students in their surgical clerkhip , compared the medical student evaluations from faculty and residents, to the students’ attitudes, and more objectives measures of perfomance , i.e. scores on the National Board of Medical Examiners Part II Special Surgical Examination given at the end of the surgical clerkship, MCAT score, USMLE Step 1 scores.

Their results are as follows: “The correlation between clinical assessment of knowledge and the Surgical Examination was 0.23, with a range on individual services from -0.42 to 0.45. There was a higher correlation for the total group of 0.56 between fund of knowledge and attitudes, with a range on individual services of -0.04 to 0.72. The correlations between clinical assessment of knowledge and Part I National Boards, college grade point average, and chemistry MCAT score were 0.23, 0.09, and 0.15, respectively. ”

They concluded that “these results indicate that the clinical assessment of fund of knowledge is not a good predictor of performance on the surgical section of the National Boards. Clinical assessment of fund of knowledge appears to be linked more closely to faculty and resident assessment of student attitudes.”

They speculated that “there are a couple possible explanations for these results: “Clinicians are measuring different aspects of knowledge than are National Boards or clinicians do not accurately assess knowledge and confuse attitudes such as interest and enthusiasm with fund of knowledge.”

A better way of gauging student fund of knowledge, I believe, is to examine students at the beginning, middle, and/or end of the rotation via a written or oral exam, where they are tested on the topics they are supposed to have mastered in that particular specialty.

By doing this, the grade a student receives does not mount to a subjective, global assessment of the student, but rather an objective assessment that, in my opinion, is more fair.

References
1. Surgery. 1985 Jun;97(6):745-9. Assessment of medical student fund of knowledge in surgery. Lawrence PF, Nelson EW, Cockayne TW. http://www.ncbi.nlm.nih.gov/pubmed/4002122

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