Optimizing Clinical Reasoning Assessments With Analytic and Holistic Ratings: Examining the Validity, Reliability, and Cost of a Simplified Patient Note Scoring Procedure.

Purpose: Post-standardized patient (SP) encounter patient notes used to assess students' clinical reasoning represent a significant time burden for faculty who traditionally score them. To reduce this burden, the authors previously reported a complex faculty-developed scoring method to assess patient notes rated by nonclinicians. The current study explored whether a simplified scoring procedure for nonclinician raters could further optimize patient note assessments by reducing time, cost, and creating additional opportunities for formative feedback.

Method: Ten nonclinician raters scored patient notes of 141 students across 5 SP cases by identifying case-specific patient note checklist items. The authors identified the bottom quintile of students using the proportion of correct items identified in the note (percent-scores) and case-specific faculty-generated scoring formulas (formula-scores). Five faculty raters scored a subset of notes from low, borderline, and high-performing students (n = 30 students) using a global rating scale. The authors performed analyses to gather validity evidence for percent-scores (i.e., relationship to other variables), investigate its reliability (i.e., generalizability study), and evaluate its costs (i.e., faculty time).

Results: Nonclinician percent- and formula-scores were highly correlated ( r = .88) and identified similar lists of low-performing students. Both methods demonstrated good agreement for pass-fail determinations with each other (Kappa = .68) and with faculty global ratings (Kappa percent =.61; Kappa formula =.66). The G-coefficient of percent-scores was .52, with 38% of variability attributed to checklist items nested in cases. Using percent-scores saved an estimated $746 per SP case (including 6 hours of faculty time) in development costs over formula-scores.

Conclusions: Nonclinician percent-scores reliably identified low-performing students without the need for complex faculty-developed scoring formulas. Combining nonclinician analytic and faculty holistic ratings can reduce the time and cost of patient note scoring and afford faculty more time to coach at-risk students and provide targeted assessment input for high-stakes summative exams.