Faculty Development Resources
Evaluation
The R.I.M.E Student Evaluation Framework
Guidelines for Completing the RIME Clinical Evaluation Form
Although the 1996 Clerkship Directors in Internal Medicine Evaluation Task Force Survey found that descriptive evaluation by instructors (faculty and residents) was the most commonly used method of evaluation, comprising on average 62.5% of the student’s final grade, only 21% of the clerkship directors indicated satisfaction with the method. They are considered to be subjective, inflated, and unreliable. To enhance the credibility and reliability of the clinical evaluation process, Dr Louis Pangaro[1] developed the RIME Model. Subsequent research has determined that the model has a reliability of 0.85 and its ability to predict future performance in residency training has been documented.
Student performance is described as a progression of developmental steps: Reporter, Interpreter, Manager, and Educator. Advancement to the next step requires mastery of the previous level. While some students may achieve one or more skills at the next developmental level, their final status will be the level of complete mastery. In other words, all boxes are checked below each description of core requirements for the various levels.
Students should have basic or entry-level Reporter skills at the time they begin their clerkship. The clerkship experience will allow them to achieve consistency in bedside skills and to develop interpersonal relationships with patients that enables them to “take ownership” in patient care. Mastery of the Reporter level is a necessary but not sufficient condition for a Proficient grade. By the end of their internal medicine clerkship, students must have become Interpreters who are able to organize, prioritize, synthesize, and interpret clinical problems.
The four stages are defined below. The framework emphasizes a developmental approach, and distinguishes between basic and advanced levels of performance for both ward and clinic rotations. Each step represents a synthesis, a final, “common pathway” of skills, knowledge and attitude. Faculty are no longer required to make qualitative judgments about students’ performance but rather document their progress toward competency using criterion-referenced evaluation.
Reporter The student can accurately gather and clearly communicate the clinical facts on his/her own patients. The step requires the basic skill to do a history and physical examination, and the basic knowledge to know what to look for. It emphasizes day-to-day reliability, for instance, being on time, or checking a patient’s test results. Implicit is the ability to recognize normal from abnormal, and the confidence to identify a new problem. This step requires taking “ownership” in patient care. These skills are often introduced to students in their preclinical years, but now they must be mastered as a “passing” criterion.
Interpreter Making a transition from “reporter” to “interpreter” is an essential step in the growth of a third year student, and often the most difficult. At a basic level, the student must prioritize among problems identified. The next step is to offer a differential diagnosis. Because students cannot be expected to have the “right answer” all the time, we define success as offering at least three reasonable diagnostic possibilities for new problems. Follow-up of tests provides another opportunity to “interpret” the data (especially in the clinic setting). This step requires a higher level of knowledge and more skill in selecting the clinical findings that support possible diagnoses in specific patients. The student has to make the transition, emotionally, from “bystander” to see himself/herself as an active participant in patient care.
Manager This takes even more knowledge, more confidence and judgment in deciding when action needs to be taken, and to propose options . Once again we can’t require students to be “right” with each suggestion, so we ask them to include at least three reasonable options in their diagnostic and therapeutic plan. A key element is to tailor the plan to the particular patient’s circumstances and preferences.
Educator This means to go beyond the required basics of self-directed learning, to read deeply, and to share new learning with others. Defining important questions to explore in more depth takes insight. Having the drive to look for hard evidence on which action can be based, and having the skill to know whether the evidence will stand up to scrutiny, are qualities of an advanced trainee; sharing leadership in educating others takes maturity.
Professionalism Medicine is a profession that requires not only the mastery of a large body of knowledge and the acquisition of clinical skills, but also altruism, compassion, and integrity. In addition to fulfilling all academic requirements, students are required to display attitudes, personal characteristics, and behaviors consistent with high standards of professional conduct. In order to successfully complete the medicine clerkship, students must demonstrate that they can provide leadership in patient care, while respecting the views and interests of all members of the health care team, the patient and patient's family. You are asked to assess students’ professional attributes as well as their skills and expertise.
[1] Pangaro, L A New Vocabulary and Other Innovations for Improving Descriptive In-Training Evaluations. Acad Med 1999; 74: 1203-1207
