Reporter-Interpreter-Manager-Educator: An Observational Framework, Not a Grading Framework

Application of the RIME framework in genetic counseling fieldwork training to assess practice-based competencies

Using educational frameworks for learner assessment in genetic counseling (GC) training may help students and supervisors articulate developmentally appropriate clinical skills-based objectives and tasks that align with various stages of training as students work toward achieving entry-level competency. This professional issues case study describes how two GC programs adapted and implemented the RIME (Reporter-Interpreter-Manager-Educator) learner assessment framework, originally designed for medical education, to support and assess students' acquisition of practice-based competencies (PBCs) during clinical fieldwork placements. Each RIME level describes a different set of expectations regarding the skills students should be able to demonstrate based on the level of training they have achieved up to that point in time. In early training, students work mainly on gathering and reporting clinical information (Reporter level). In early to mid-training, students have learned what information to collect from clients and begin to apply the information to generate differential diagnoses (Interpreter level). When students reach the Manager level (typically by mid- to late-training), they can independently develop and implement case management plans tailored to individual cases. The Educator level, which may not be fully attained until after graduation, involves critically evaluating evidence and educating others about new evidence. The following paper describes our experiences incorporating the RIME framework into two GC graduate programs and explains the development of corresponding RIME-based assessment forms that align with the Accreditation Council of Genetic Counseling's 2023 PBCs. Overall, we find that using the RIME framework fosters a growth mindset by enabling students and supervisors to create developmentally appropriate goals and expectations, thereby facilitating assessment and guidance of trainee progress. Despite these perceived benefits, we acknowledge the need for research to evaluate the efficacy of the RIME framework or other learner assessment models in supporting student progression in achieving the GC PBCs.

R.I.M.E. and reason: multi-station OSCE enhancement to neutralize grade inflation

To offset grade inflation, many clerkships combine faculty evaluations with objective assessments including the Medical Examiners Subject Examination (NBME-SE) or Objective Structured Clinical Examination (OSCE), however, standardized methods are not established. Following a curriculum transition removing faculty clinical evaluations from summative grading, final clerkship designations of fail (F), pass (P), and pass-with-distinction (PD) were determined by combined NBME-SE and OSCE performance, with overall PD for the clerkship requiring meeting this threshold in both. At the time, 90% of students achieved PD on the Internal Medicine (IM) OSCE resulting in overall clerkship grades primarily determined by the NBME-SE. The clerkship sought to enhance the OSCE to provide a more thorough objective clinical skills assessment, offset grade inflation, and reduce the NBME-SE primary determination of the final clerkship grade. The single-station 43-point OSCE was enhanced to a three-station 75-point OSCE using the Reporter-Interpreter-Manager-Educator (RIME) framework to align patient encounters with targeted assessments of progressive skills and competencies related to the clerkship rotation. Student performances were evaluated pre- and post-OSCE enhancement. Student surveys provided feedback about the clinical realism of the OSCE and the difficulty. Pre-intervention OSCE scores were more tightly clustered (SD = 5.65%) around a high average performance with scores being highly negatively skewed. Post-intervention OSCE scores were more dispersed (SD = 6.88%) around a lower average with scores being far less skewed resulting in an approximately normal distribution. This lowered the total number of students achieving PD on the OSCE and PD in the clerkship, thus reducing the relative weight of the NMBE-SE in the overall clerkship grade. Student response was positive, indicating the examination was fair and reflective of their clinical experiences. Through structured development, OSCE assessment can provide a realistic and objective measurement of clinical performance as part of the summative evaluation of students.