Decision-making bias in assessment: the effect of aggregating objective information and anecdote

Four ways to get a grip on making robust decisions from workplace-based assessments

Synthesising the results of workplace-based assessments to inform robust decisions is seen as both important and difficult. Concerns about failing to fail the trainee not ready to proceed has drawn disproportionate attention to assessors. This paper proposes a model for a more systems-based view so that the value of the assessor's judgement is incorporated while preserving the value and robustness of collective decision-making. Our experience has shown it can facilitate robust decisions on some of the more difficult areas, such as professionalism.

Do Resident Archetypes Influence the Functioning of Programs of Assessment?

While most case studies consider how programs of assessment may influence residents’ achievement, we engaged in a qualitative, multiple case study to model how resident engagement and performance can reciprocally influence the program of assessment. We conducted virtual focus groups with program leaders from four residency training programs from different disciplines (internal medicine, emergency medicine, neurology, and rheumatology) and institutions. We facilitated discussion with live screen-sharing to (1) improve upon a previously-derived model of programmatic assessment and (2) explore how different resident archetypes (sample profiles) may influence their program of assessment. Participants agreed that differences in resident engagement and performance can influence their programs of assessment in some (mal)adaptive ways. For residents who are disengaged and weakly performing (of which there are a few), significantly more time is spent to make sense of problematic evidence, arrive at a decision, and generate recommendations. Whereas for residents who are engaged and performing strongly (the vast majority), significantly less effort is thought to be spent on discussion and formalized recommendations. These findings motivate us to fulfill the potential of programmatic assessment by more intentionally and strategically challenging those who are engaged and strongly performing, and by anticipating ways that weakly performing residents may strain existing processes.

A serious game for online-based objective structured clinical examination in nursing: A qualitative study

BACKGROUND

The current pandemic has led to unprecedented scenarios worldwide. In this context, educational institutions had to move abruptly from in-person to online classes, having to be flexible and innovative, one of the main concerns being the semester-end examinations in practical modules.

OBJECTIVE

This study aimed to explore nursing students' perceptions of the use of a serious game-like model in their final online objective structured clinical examination (OSCE).

DESIGN

An exploratory phenomenological study was conducted during the COVID-19 pandemic, in particular during June 2020.

SETTINGS

This study took place at the University of Almeria with nursing students enrolled in a clinical placement module.

PARTICIPANTS

Eighty-nine fourth-year nursing students took part in this study.

METHODS

Following the educational principles of the OSCE, a virtual OSCE was designed, using the Genially platform, an online platform for creating interactive content, to set up an assessment as a story-telling game-like model. A total of 5 focus groups (FGs) were conducted afterwards via the GoogleMeet platform. In addition, 30 semi-structured interviews were performed via the same platform. The data was analysed using a content analysis approach and supported by the ATLAS.ti 8.4 software.

RESULTS

Our finding revealed 2 main themes and 4 sub-themes. The two main themes were (i) generating emotions and feelings in times of virtuality; including emotions and feelings experienced by students during their online assessment process, and (ii) online assessment: a potential alternative to educational barriers; describing the variability of traditional modality, its implications for learning and the acquisition of competences.

CONCLUSIONS

Serious game-like models, such as the story-telling game proposed, as part of their online OSCE assessment appear to be an appropriate alternative assessment method for face-to-face approaches. This paper adds new evidence on the use of innovative and state-of-art resources as part of nursing OSCE assessments in a new reality for most students and teachers. Serious game-like models in online OSCE may empower students and help them to remove perceived barriers in face-to-face assessments.

Social media and its impact on health care

OBJECTIVE

Social media has fundamentally changed how the world shares and receives information. This review offers a perspective for the practicing clinician regarding how patients are being influenced by their online interactions and considerations for proactively discussing medical decision making with patients.

DATA SOURCES

Literature search of PubMed database and online published market research data surrounding social media use.

STUDY SELECTIONS

Peer-reviewed studies, Pew research data, and editorials in the English language were selected and reviewed.

RESULTS

There has been a substantial increase in the breadth and depth of literature surrounding the use of social media by patients and medical professionals. Increased focus on how it contributes to medical decision making and patient-clinician interactions has occurred in recent years. The coronavirus disease 2019 pandemic has highlighted the various sources of misinformation and disinformation and how they impact care on many levels. Best practices have been established to assist medical professionals in developing an online presence to combat misinformation or address individual patients.

CONCLUSION

There is growing understanding and recognition of the myriad of ways in which social media is impacting health care. Health care professionals from all backgrounds need to increase their understanding of these complex interactions to best assist patients with their medical decision making.

Examiners' decision-making processes in observation-based clinical examinations

BACKGROUND

Objective structured clinical examinations (OSCEs) are commonly used to assess the clinical skills of health professional students. Examiner judgement is one acknowledged source of variation in candidate marks. This paper reports an exploration of examiner decision making to better characterise the cognitive processes and workload associated with making judgements of clinical performance in exit-level OSCEs.

METHODS

Fifty-five examiners for exit-level OSCEs at five Australian medical schools completed a NASA Task Load Index (TLX) measure of cognitive load and participated in focus group interviews immediately after the OSCE session. Discussions focused on how decisions were made for borderline and clear pass candidates. Interviews were transcribed, coded and thematically analysed. NASA TLX results were quantitatively analysed.

RESULTS

Examiners self-reported higher cognitive workload levels when assessing a borderline candidate in comparison with a clear pass candidate. Further analysis revealed five major themes considered by examiners when marking candidate performance in an OSCE: (a) use of marking criteria as a source of reassurance; (b) difficulty adhering to the marking sheet under certain conditions; (c) demeanour of candidates; (d) patient safety, and (e) calibration using a mental construct of the 'mythical [prototypical] intern'. Examiners demonstrated particularly higher mental demand when assessing borderline compared to clear pass candidates.

CONCLUSIONS

Examiners demonstrate that judging candidate performance is a complex, cognitively difficult task, particularly when performance is of borderline or lower standard. At programme exit level, examiners intuitively want to rate candidates against a construct of a prototypical graduate when marking criteria appear not to describe both what and how a passing candidate should demonstrate when completing clinical tasks. This construct should be shared, agreed upon and aligned with marking criteria to best guide examiner training and calibration. Achieving this integration may improve the accuracy and consistency of examiner judgements and reduce cognitive workload.

Student progress decision-making in programmatic assessment: can we extrapolate from clinical decision-making and jury decision-making?

BACKGROUND

Despite much effort in the development of robustness of information provided by individual assessment events, there is less literature on the aggregation of this information to make progression decisions on individual students. With the development of programmatic assessment, aggregation of information from multiple sources is required, and needs to be completed in a robust manner. The issues raised by this progression decision-making have parallels with similar issues in clinical decision-making and jury decision-making.

MAIN BODY

Clinical decision-making is used to draw parallels with progression decision-making, in particular the need to aggregate information and the considerations to be made when additional information is needed to make robust decisions. In clinical decision-making, diagnoses can be based on screening tests and diagnostic tests, and the balance of sensitivity and specificity can be applied to progression decision-making. There are risks and consequences associated with clinical decisions, and likewise with progression decisions. Both clinical decision-making and progression decision-making can be tough. Tough and complex clinical decisions can be improved by making decisions as a group. The biases associated with decision-making can be amplified or attenuated by group processes, and have similar biases to those seen in clinical and progression decision-making. Jury decision-making is an example of a group making high-stakes decisions when the correct answer is not known, much like progression decision panels. The leadership of both jury and progression panels is important for robust decision-making. Finally, the parallel between a jury's leniency towards the defendant and the failure to fail phenomenon is considered.

CONCLUSION

It is suggested that decisions should be made by appropriately selected decision-making panels; educational institutions should have policies, procedures, and practice documentation related to progression decision-making; panels and panellists should be provided with sufficient information; panels and panellists should work to optimise their information synthesis and reduce bias; panellists should reach decisions by consensus; and that the standard of proof should be that student competence needs to be demonstrated.

Pass-Fail Decisions for Borderline Performers After a Summative Objective Structured Clinical Examination

Objective. To determine what expert assessors value when making pass-fail decisions regarding pharmacy students based on summative data from objective structured clinical examinations (OSCE), and to determine the reliability of these judgments between multiple assessors. Methods. All assessment data from 10 exit-from-degree OSCE stations for seven borderline pharmacy students (determined by standard setting methods) and one control was given to three of eight assessors for review. Assessors determined an overall pass-fail decision based on their perception of graduate competency. Assessors were interviewed to determine their decision-making rationale. Intraclass correlation coefficients were used to calculate reliability between assessor judgments. Results. Expert consensus was achieved for three of the eight students, however, the assessors' decisions did not align with standard-setting results. The reliability of assessors' decisions was poor. Assessors focused on ability to make correct recommendations rather than on gathering information or providing follow-up advice. Global evaluations (including a student's communication skills) rarely influenced the assessors' decision-making. Conclusion. When faced with making pass-fail decisions for borderline students, the assessors focus on evaluating the same competencies in the students but differed in their expected performance levels of these competencies. Pass-fail decisions are primarily based on task-focused components instead of global components (eg, communication skills), despite that global components are weighted the same for scoring purposes.

Borderline grades in high stakes clinical examinations: resolving examiner uncertainty

BACKGROUND

Objective Structured Clinical Exams are used to increase reliability and validity, yet they only achieve a modest level of reliability. This low reliability is due in part to examiner variance which is greater than the variance of students. This variance often represents indecisiveness at the cut score with apparent confusion over terms such as "borderline pass". It is amplified by a well reported failure to fail.

METHODS

A borderline grade (meaning performance is neither a clear pass nor a clear fail) was introduced in a high stakes undergraduate medical clinical skills exam to replace a borderline pass grade (which was historically resolved as 50%) in a 4 point scale (distinction, pass, borderline, fail). Each Borderline grade was then resolved into a Pass or Fail grade by a formula referencing the difficulty of the station and the performance in the same domain by the student in other stations. Raw pass or fail grades were unaltered. Mean scores and 95%CI were calculated per station and per domain for the unmodified and the modified scores/grades (results are presented on error bars). To estimate the defensibility of these modifications, similar analysis took place for the P and the F grades which resulted from the modification of the B grades.

RESULTS

Of 14,634 observations 4.69% were Borderline. Application of the formula did not impact the mean scores in each domain but the failure rate for the exam increased from 0.7 to 4.1%. Examiners and students expressed satisfaction with the Borderline grade, resolution formula and outcomes. Mean scores (by stations and by domains respectively) of students whose B grades were modified to P were significantly higher than their counterparts whose B grades were modified to F.

CONCLUSIONS

This study provides a feasible and defensible resolution to situations where the examinee's performance is neither a clear pass nor a clear fail, demonstrating the application of the resolution of borderline formula in a high stakes exam. It does not create a new performance standard but utilises real data to make judgements about these small number of candidates. This is perceived as a fair approach to Pass/Fail decisions.

Enhancing the defensibility of examiners' marks in high stake OSCEs

BACKGROUND

Most assessments in health professions education consist of knowledge-based examinations as well as practical and clinical examinations. Among the most challenging aspects of clinical assessments is decision making related to borderline grades assigned by examiners. Borderline grades are commonly used by examiners when they do not have sufficient information to make clear pass/fail decisions. The interpretation of these borderline grades is rarely discussed in the literature. This study reports the application of the Objective Borderline Method (version 2, henceforth: OBM2) to a high stakes Objective Structured Clinical Examination undertaken at the end of the final year of a Medicine program in Australia.

METHODS

The OBM2 uses all examination data to reclassify borderline grades as either pass or fail. Factor analysis was used to estimate the suitability of data for application of OBM2. Student's t-tests, utilising bootstrapping, were used to compare the OBM2 with 'traditional' results. Interclass correlations were used to estimate the association between the grade reclassification and all other grades in this examination.

RESULTS

The correlations between scores for each station and pass/fail outcomes increased significantly after the mark reclassification, yet the reclassification did not significantly impact on students' total scores. Examiners, students and program leaders expressed high levels of satisfaction and the Faculty's Curriculum Development Committee has decided that the OBM2 will be used for all future clinical examinations. Implications of the OBM2 are discussed.

CONCLUSIONS

The OBM2 provides a feasible, defensible and acceptable solution for classification of borderline grades as either pass or fail.