Many hospitalists regularly work with medical trainees—medical students, interns, and upper-level residents—and teaching, overseeing, and evaluating these trainees is an important aspect of the job. But many evaluators haven’t received explicit instruction on how best to make trainee evaluations fair and helpful to both learners and education program directors. Time limitations and other constraints can sometimes make this challenging.
Dr. Hunt
Daniel Payson Hunt, MD, MHM, a hospitalist, director of the division of hospital medicine, and a professor of medicine at Emory in Atlanta, pointed out that these clinical evaluations supply key information about learners that can’t be obtained through other means. “Doctoring is taking care of patients, and it doesn’t take place in conference rooms or during an exam,” he said. “Exams tell us a fair amount about [the trainee’s] knowledge, but not their applied knowledge.”
Dr. Woller
John Woller, MD, a hospitalist, associate program director for clinical reasoning for the Osler medical residency training program, and assistant professor of medicine at Johns Hopkins Medical School in Baltimore, added, “Our feedback should be timely, specific, and personally tailored to the individual.”
Dr. Bullis
Eliza Bullis, MD, a hospitalist, internal medicine/pediatric specialist, and director of undergraduate medical education in the department of medicine at Maine Medical Center in Portland, Maine, emphasized, “A brief, high-quality observation is better than a long evaluation with lots of general statements.”
The Hospitalist talked with these and other hospitalists experienced in evaluating medical trainees and in reviewing such evaluations in the context of medical-student or resident education. They focused on key advice to other hospitalists who evaluate learners, sharing their insights on giving high-quality feedback that promotes trainee growth.
Trainee evaluations: Context, benefits, impact, and challenges
Dr. Woller noted that the foremost purpose of evaluations is providing formative feedback, so trainees can become better at practicing medicine. The evaluation process may be particularly important to flag a struggling trainee, identifying those who aren’t progressing adequately in their milestones and who might need extra support and guidance.
However, Dr. Woller noted that evaluations also possess other functions, like providing clues about whether a medical student might be a good fit for a residency program, or a resident for employment after residency.
At schools that have not gone to pass/fail grading, clinician evaluations are factored into medical students’ rotation grades, but the evaluations can also significantly impact students’ careers at pass/fail institutions. Dr. Woller explained that in addition to the move to pass/fail rotations at many medical schools, the change making the United States Medical Licensing Examination pass-fail has meant that physician evaluations may hold even greater weight than they did in the past. Regardless of the grading system, students’ letters from the dean—so critical for residency applications—may rely highly on specific quotes taken from their rotation evaluations.
Programs vary in the specifics of the format and frequency of required trainee evaluations. However, these evaluations are designed to be in alignment with nationwide recommendations on areas of competence and milestones for medical students and residents. Typically, both in-person and written evaluation components are required at the end of rotations with a clinician. Evaluations vary by institution but typically include both scales to rank trainees’ competency numerically, and also more open-ended questions, where physicians can share more specific comments about trainee achievements or areas for future growth.
Dr. Bullis noted a semantic distinction between trainee assessment and trainee evaluation. Assessment is often conceptualized as ongoing and formative, one critical component of continued learning. Clinicians might perform this kind of ongoing assessment and feedback throughout a rotation, as specific learning points arise. Some characterize evaluation, in contrast, as more definitive and retrospective, assigning some sort of value to a person’s work.
Dr. Bullis said, “But I think in medicine, we’re really doing assessing and evaluating all the time. No matter where they are as trainees, you are always trying to help them get better.”
However, several physicians noted challenges to providing truly informative evaluations. Dr. Woller noted that it can be difficult to find time to provide solid feedback on a service with many patient responsibilities and many trainees, but it’s still critical to do so. Dr. Bullis also noted that due to limited time on service, clinicians might not witness enough encounters to evaluate trainees in all the various domains assessed in evaluations.
Dr. Hunt remarked that one relatively recent challenge in evaluating medical students and interns is the cut-and-paste function in writing patient notes in electronic health records. He said, “We used to be able to look at documentation and glean a lot about the writer’s thought process, but now you can’t do that as much.”
Another concern is implicit bias, which can affect even the most well-intentioned evaluators. Dr. Woller pointed to studies that have demonstrated that factors like race, sex, or ethnicity may impact evaluations.1-3
Tips for helpful and informative evaluations
Dr. Chinn
Several of the doctors recommended setting expectations and goals with trainees at the beginning of their rotation. Alex J. Chinn, MD, FHM, is a hospitalist, internal medicine physician, and associate program director for the internal medicine residency program at the University of Tennessee Health Science Center in Memphis, Tenn. He asks his trainees to give him a specific goal that they want to accomplish during their rotation. He added, “Often, they know the places they need to improve, and it might be something that’s not specifically on the evaluation form.”
Dr. Bullis also embraces this approach, adding, “It also helps you as the evaluator, because you can laser focus on those moments rather than trying to absorb and give feedback on everything they do throughout the day.”
Some programs explicitly require mid-rotation check-ins with students. Even if these are not mandatory, several of the hospitalists recommended doing them to give trainees time to improve based on their initial feedback.
It’s also often helpful to become familiar with the evaluation forms required by one’s institution before the rotation begins. Dr. Chinn and others pointed out that doing so helps inform the evaluator’s perspective from the beginning, prompting better awareness of the domains that will need attention. In evaluating these different areas, Dr. Bullis also noted that a good evaluation usually has some variation in it, as it’s very uncommon for learners to be at exactly the same level in every domain.
Unlike some hospitalists, Dr. Hunt still chooses to do bedside rounding with his whole team, interspersing teaching points and questions between seeing each patient. He finds this method a particularly helpful way to observe his trainees, take notes on their performance, and offer specific feedback in the moment.
This notetaking approach was heartily endorsed by others as well, e.g., during student presentations, both to provide better evaluations and also to make the evaluation writing process itself less difficult and tedious. Whatever mode is most personally convenient is best, whether an electronic device that is always handy or an old-fashioned small notebook dedicated to this purpose.
Dr. Chinn remarked on the importance of being mindful of time and place when giving an in-person evaluation. Although some kinds of specific feedback might be appropriate during rounding with the whole team, more difficult or serious discussions should be held in private. “You shouldn’t write down anything in a written evaluation that you wouldn’t be willing to say face-to-face,” Dr. Waller added.
Setting the right tone for the team can also make a big difference in how well the feedback is received. It’s important to build a relationship with the trainee and build a sense of shared purpose and community. “You want to let people know early on that you want them to be the best that they can be,” Dr. Bullis explained.
As part of that, good evaluators give feedback on specific areas for potential improvement, whether with respect to their direct clinical skills or in other areas. However, Dr. Hunt remarked on the importance of also reinforcing and underscoring areas where trainees are already excelling, encouraging them to keep building on their strengths.
Dr. Chinn elaborated, “Giving anecdotes really does help illustrate what you are talking about. More generic comments like, ‘did a good job’ are generally not very helpful for those of us trying to assess readiness for promotion, and they aren’t helpful for the resident or student who is trying to become a better doctor.” Dr. Bullis agreed that it was better, for example, to explain what a student did to demonstrate their professionalism, rather than simply stating that they were professional.
To be able to provide this level of specific feedback requires dedicated attention. Dr. Woller noted that with so much activity, it’s easy to get distracted on the wards. “I want to make sure I’m really dedicating some mental space to the medical student or resident,” he added.
Dr. Bullis concurred, “Being intentional about spending five minutes or ten minutes specifically observing someone gives you a lot of information. Then, you can debrief with them about what they did, which is huge.”
Dr. Woller also recommended being thoughtful about one’s own possible implicit bias and trying to be as objective and as concrete as possible. “It’s much easier than we think to form opinions based on first impressions. We should all try to be thoughtful about evaluating trainees based on their abilities and competence and not simply whether we enjoyed spending time with them,” he said.
It’s best to write evaluations promptly, just after a given rotation is complete, when one’s memories of the trainee are clearest. If that’s not possible, Dr. Chinn encourages physicians at least to take some notes then, so they’ll have some points to share when they do fill out the official forms.
Dr. Chinn also added an overall point to help trainees take their comments to heart: “When you’re having difficult conversations, be honest, but also be kind. It doesn’t help your learner for you to withhold your thoughts if you have concerns about the performance, but they’re not going to take much away from it if it’s a very unpleasant conversation.”
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine in Indianapolis. She is a freelance medical writer living in Bloomington, Ind.
References
- Ross DA, et al. Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations. PLoS One. 2017;12(8):e0181659. doi: 10.1371/journal.pone.0181659.
- Rojek AE, et al. Differences in narrative language in evaluations of medical students by gender and under-represented minority status. J Gen Intern Med. 2019;34(5):684-691. doi: 10.1007/s11606-019-04889-9.
- Bhanvadia S, et al. Evaluation of bias and gender/racial concordance based on sentiment analysis of narrative evaluations of clinical clerkships using natural language processing. BMC Med Educ. 2024;24(1):295. doi: 10.1186/s12909-024-05271-y.