To our knowledge, this is the first study describing multidisciplinary preceptors' use of the RIME framework in formal evaluation sessions in a longitudinal setting. In addition, we describe the strategies used by preceptors to guide students' clinical development over the principal clinical year. This ‘in vivo’ view of LIC students' development illustrates how preceptors addressed various obstacles to progress in data gathering and the acquisition and application of knowledge.
Based on the qualitative analysis, our preceptors' longitudinal relationships with their students seemed to facilitate insights into students' progressive development, and, perhaps more importantly, the preceptors had sustained opportunities for observation, implementation of learning strategies, and monitoring of progress. This continuity allowed preceptors to select student tasks that were appropriately challenging to advance their learning and useful for the preceptor to determine whether learning goals were achieved (19
). The manner in which our preceptors identified strategies for accomplishing next steps in students' learning and observed progress toward those goals over time is consistent with recommended conceptualization of feedback as part of an ongoing dialogue to support learners' advancement (22
). We also heard from preceptors how they attempted to balance providing challenge for students with providing support in the fast-paced ambulatory setting. These preceptor efforts align with a social-constructivist model of learning, in which teachers respond to learners' needs in addition to challenging them to higher levels of performance (23
Consistent with early learners' performance according to the Dreyfus scheme for development of expertise, our students' progress occurred at the interface of novice and advanced beginner (24
). In that perspective, preceptors appropriately recognized the importance of students learning to make connections between knowledge and illness presentations, or between different but similar presentations (25
). Some articulated the teacher's role in providing exposure to general case examples and highlighting key features and underlying principles (26
). Instructional strategies used by preceptors were often consistent with those recommended in the literature on clinical reasoning, such as adjusting expectations based on students' performance, imparting reading strategies, and identifying opportunities for comparing presentations across settings (27
Most students manifested some difficulties in data gathering or clinical knowledge and reasoning at some point in the year. The high prevalence of stalled progress suggests these occurrences may be normal aspects of development, at least for LIC students, that all preceptors should be able to identify and address. For instance, some students who had learned the organization of a history lacked flexibility in their questioning, a hallmark of the novice learner (24
). Our preceptors recognized that they needed to help students progress from simply performing data-gathering maneuvers to connecting their findings to a differential diagnosis (21
). preceptors' focus on effective data-gathering technique has similarly been reported in prior studies of clinical teaching (28
). Our preceptors also used modeling to emphasize basic clinical skills, a strategy that has been recommended for excellent teaching (19
). Future research to clarify mechanisms of distinguishing normal development versus more worrisome deficits would be helpful. The highest-performing students manifested strategies typical of self-regulated learners that seemed to facilitate their advancement with minimal corrective intervention by preceptors; facilitating adoption of these strategies by other students might help those facing obstacles (30
The longitudinal clerkship structure enhanced accountability for preceptors to ensure their students' learning. Because preceptors worked individually with their students over a year, they could identify deficits, prepare feedback with action plans, and monitor subsequent performance (31
). This situation contrasts with most block clerkships, in which shorter periods of interaction may lead faculty to report deficits only on final evaluations or not at all, depriving students of the opportunity to improve with those preceptors (3
). In fact, concern about ‘forward feeding’ information regarding struggling students' performance to subsequent instructors is obviated in the LIC model (32
). The serial evaluation sessions created an environment that allowed faculty to communicate honest opinions and concerns, anticipate developmental progress, and generate collaborative learning plans, in contrast to clerkships that rely solely on written evaluations completed in isolation. Thus use of the RIME framework along with evaluation sessions in this LIC model provides an example of using an assessment strategy in part for the purpose of advancing learning (33
). In fact, the progression of the student group from the level of reporter toward interpreter and manager over the year suggests evidence for the construct validity of the RIME terminology for assessment of students' performance (the construct being ‘growing independence’ that is not dependent on the clerkship discipline). Admittedly, this evidence of validity is difficult to discern given that we asked the faculty to use RIME; comparison of these descriptive data with performance data from other objective assessments of performance could strengthen the evidence of validity.
Our findings may have implications for the design of clinical experiences for students. Our results show how educators attempt to tailor core clinical experiences to LIC students' learning needs within the context of faculty practices (34
). Our preceptors defined and assigned students level-appropriate patients (i.e., basic versus complex presentations) or tasks (i.e., assessment before plan). Observing students' performance level over time and being able to consult with other preceptors seemed to enhance preceptors' ability to customize experiences using readily available clinical resources. Our use of RIME and serial evaluation sessions provided some faculty development on the RIME framework, although there is room to capitalize on the model even more with additional training on how to use evaluation sessions strategically to monitor students' progress in specific domains and intervene accordingly. For instance, faculty development on observation of trainees' clinical skills could augment their ability to characterize students' strengths and deficits (35
). Group faculty development on collaborative interventions could also engage preceptors to address common obstacles for individual students across settings. Further research could explore whether these efforts could facilitate a feedback cycle of information sharing, skills improvement, and subsequent observation of performance (36
This study has limitations. The data derive from a single medical school in one academic year with a limited number of students who chose to enroll in the LIC, although there were no baseline differences between these students and their peers in other clerkship tracks. Other students in other clerkship models might progress differently; however, the RIME framework also applies for students in traditional clerkship settings (8
). We cannot determine how preceptor comments might have been reported differently had the evaluation sessions not used the RIME vocabulary. We did not observe students' clinical performance to verify preceptors' reports of performance, or their changes in performance after preceptors planned, and ideally implemented, strategies to help them; nor did we calculate inter-rater reliability of preceptor RIME adjectives, because students might perform in different ways in different settings. However, involvement of a large number of preceptors from multiple specialties at four timepoints captures longitudinal aspects of students' performance. Participation bias is possible, as not all preceptors attended the evaluation sessions, although our participation rate was high among busy clinical faculty. Faculty were recruited to precept, in part, based on their teaching skill. However, we believe their ability to discern student progress and identify next steps was not unique, but was facilitated by the format of collective sharing and problem solving at the evaluation sessions. We chose to use RIME as a commonly employed and easily understood framework for faculty to describe medical students' development; other frameworks might have produced different faculty discussions, but, reassuringly, our faculty addressed core skills necessary for all clinical students.
This study illustrates how preceptors intervene with the goal of promoting LIC students' clinical development over the core clerkship year. In the context of a developmental perspective, preceptors used templates and modeling to promote data-gathering and reporting skills, and aimed to impart understanding of reading strategies and application of knowledge. Our findings show how preceptors plan to intervene to guide students' development with specific performance feedback and instruction in a setting that facilitates follow-up of students' progress.