Clinical evaluations play a big part of grading for the third and fourth years of medical school. While they’re critically important for providing students with feedback and are also necessary to assess performance in a way that differentiates students for grades, they are often also a source of frustration because of how subjective they can be. Oftentimes, they consist of having residents and attendings grade students on a scale of 1-5 in various areas of competence (medical knowledge, procedural skills, compassion to patients, communication skills, etc.)—but one might argue that if you don’t click well with someone or if they aren’t often present at your best moments, then perhaps those evaluations will be less than representative of one’s performance.
The internal medicine rotation at my school uses what’s called a RIME scheme for evaluating student performance in the hospital instead of just the usual 1 to 5 grading scale. I haven’t yet been evaluated with this scheme, since I’m only at the beginning of my medicine clerkship, but from what I’ve been told about it and have read about it, it seems like a more appropriate measure of performance than just numbers. RIME stands for Reporter, Interpreter, Manager, and Educator, representing four domains of mastery in medicine, ranging from basic to advanced (in other words, an Educator is more advanced than a Reporter). Here’s an example to demonstrate. Let’s say a 5-year-old female has leukocyte esterase and nitrites present in her urine. A student at the level of Reporter would be able to see this in the lab results and say so while presenting the patient to the attending. A student at the level of Interpreter would not only see the results, but would comment on the significance, saying that the patient likely has a urinary tract infection. A Manager may take it one step further and suggest that empiric therapy is in order, as well as urine culture considering patient’s prior history of urinary tract infections. An Educator would take it further yet, perhaps teaching the team that the patient has a history of holding stool, which may have contributed to the recurrent infections, and behavioral therapy may play an important role in this patient’s long-term preventative health.
I find that the RIME scheme is not only a more descriptive assessment of performance than a numerical scale, as it also helps me to know what to aim for. If I just shoot for “5’s”, what does that even mean, compared to 3s or 4s? But now I know that goal here is to be able to pick up on findings, to understand their significance, to figure out plans for patients (which includes being their advocates and understanding their goals of care), and ultimately to be able to provide my team with new knowledge that will be helpful to the care of future patients as well. These categories cut across medical knowledge, communication, compassion, and other traditional domains of evaluation.
I haven’t yet mastered all the levels (not even close), and some days are better than others, but the RIME scheme allows me to know the expectations and to figure out how to meet them. Definitely a fan!