Relationship Between Academic Performance and Student Self-Assessment of Clinical Performance in the College of Podiatric Medicine and Surgery

Student self-assessment of clinical performance is recognized as a valued activity in the development of lifelong learning skills and has been extensively integrated into health sciences educational programs.¹ This form of evaluation is particularly important for medical students if they are to concentrate their study efforts in areas of identified knowledge or clinical competency gaps. Another benefit is recognizing one's strengths and weaknesses to provide competent and safe patient care.² Critics of self-assessment cite the lack of correlation between self-assessment and observed performance.^3,4

Published studies in health professional education examining the relationship between academic performance and clinical self-assessment are limited but are consistent in identifying the tendency of students with lower grade point averages (GPAs) self-assessing their clinical performance at a higher rating compared with students with higher GPAs.^2,5,6 Several theories have been offered to explain this finding, with the most popular explanation being a defense mechanism on the part of weaker students to compensate for academic performance not at the level of many of their peers.⁵

The purpose of this study was to examine the relationship between academic achievement in the first 3 years of podiatric medical school and student self-assessment of clinical performance in the Des Moines University College of Podiatric Medicine and Surgery (Des Moines, Iowa) during the third-year clinical curriculum. To our knowledge, no such educational research study exists for podiatric medical education.

Methods

The podiatric medical curriculum at Des Moines University is a 4-year program. In the first 2 years of the curriculum, students complete basic science, clinical medical systems, and podiatric medicine–specific courses. Course work is completed early in the third year. There is an emphasis in the third and fourth years on clinical training. During the third year, podiatric medicine clinical training occurs at the Des Moines University Foot and Ankle Clinic, supplemented with additional podiatric and nonpodiatric medicine rotations in the greater Des Moines area. Fourth-year clinical rotations occur throughout the United States using an expanded number of preceptors (clinical supervisors). The clinical training of third-year students is very consistent across the class with respect to preceptors, training sites, and experiences compared with that of fourth-year students.

Third-year podiatric medical students from the classes of 2012, 2013, and 2014 were included in the study (N = 140). Only students completing the program in the customary 4 years were included in this study. Students requiring greater than 4 years to complete the program and students leaving the program for personal or academic reasons were excluded from the study. Academic achievement for podiatric medical school was based on the individual student overall GPA, on a 4.0 scale, after completion of the first 3 years of the curriculum, with higher GPAs reflecting better academic achievement. Student GPAs identify the overall success of courses completed during that period.

Before the start of clinical rotations, students receive a comprehensive orientation on procedures, policies, and expectations regarding the clinical competencies. Students are also given a clinical manual that reinforces the agenda presented during the orientation program. The third-year clinical competencies are classified into five major domains (Professionalism, Medicine, Radiology, Surgery, and Biomechanics/Orthopedics). Each domain represents a series of expanded competencies. Each expanded competency has a detailed narrative that explains the necessary performance mastery required to successfully complete the clinical competency. For this study, the expanded competencies were condensed into a competency statement representing each of the five major domains.

Students completed an assessment of their performance for each of the five domain statements. Each domain was rated on a 5-point Likert scale (from 1 [poor] to 5 [excellent]). The assessment was completed at the end of the first 12 weeks of their third-year clinical rotations (PRE) and a second time at the conclusion of the third year 28 weeks later (POST). The mean self-assessment (SA) score for the PRE and POST surveys for all combined competencies was determined for each student. Student clinical experiences at Des Moines University are prescribed during the third year and are essentially identical for all students.

Note that the clinical faculty receive formal training on clinical teaching skills, including providing continuous feedback on student performance in the areas of medical record documentation as well as communication and performance of clinical skills.

Means (SDs) were calculated for all the dependent variables for the three cohorts. A one-way analysis of variance was conducted to compare the classes for GPA, SA-PRE, SA-POST, and SA-change using the Tukey post hoc test when applicable. The SA-PRE, SA-POST, SA-change, and GPA scores were correlated using the Pearson product-moment correlation coefficient to assess the relationship between academic performance and self-assessment for each individual class separately and for the pooled data. Statistical analyses were performed using a commercially available software program (IBM SPSS Statistics for Windows, version 22; IBM Corp, Armonk, New York).

Results

Student descriptive characteristics are reported in Table 1. Overall, there were no differences among the cohorts regarding academic GPA; however, the self-assessment of the 2014 class was significantly lower than that of the 2012 and 2013 cohorts. Although the SA-change from PRE to POST for the 2014 class was also lower, it was not statistically significantly different than that of the other two cohorts.

Table 1

Descriptive Characteristics for GPA and Clinical Performance Self-Assessment (SA) for Each Class

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The cumulative GPA was not correlated with the self-assessment as measured by the SA-PRE, SA-POST, and SA-change when performed for each class separately or for the pooled data (Table 2). Low significant positive correlations were found between SA-PRE and SA-POST scores for the 2012 and 2014 classes as well as for the pooled data (r = 0.414, 0.415, and 0.459 at P < .01, respectively), indicative of a low degree of agreement between SA-PRE and SA-POST scores (Table 3). Also, low-to-moderate positive correlations were found between SA-POST and SA-change (r = 0.547, 0.305, 0.707, and 0.497 at P < .05, respectively), reflecting no ceiling effect and that the clinical year experience had a moderate positive effect on self-assessment. However, moderate-to-strong negative correlations were found between SA-PRE and SA-change for all three classes and the pooled data (r = −0.535, −0.822, −0.574, and −0.542 at P < .01, respectively)

Table 2

Relationship Between Academic Cumulative Grade Point Average and Clinical Performance Self-Assessments (SAs)^a

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Table 3

Relationship Between Clinical Self-Assessments (SAs) of Third-Year Students^a

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Discussion

Self-assessment has been recognized as a necessary skill to lifelong learning. It is reported to offer a variety of benefits to the learning, including enhancement of student performance, critical awareness, and reflection on learning.¹ Woolliscroft et al⁵ demonstrated that medical students with lower GPAs tended to rate their clinical performance higher in the initial clinical performance self-assessment. They concluded that students have well-developed internal representations of their abilities that do not meet the reality of their performance, a defense mechanism to compensate for weaker previous performance. Edwards et al² identified a similar result when comparing the predicted clerkship performance and class rank of medical students. This self-monitoring phenomenon, described as metacognition, metamemory, or metacomprehension, is demonstrated when weaker students who for whatever reason do not recognize that they lack knowledge may not put forth the effort needed to acquire that knowledge, despite having a greater need to do so than their academically higher-performing peers. It has been suggested that students may develop a more realistic appraisal of their abilities if they are given more specific and intensive feedback during the clerkship.²

In this study, no statistically significant relationship was identified between academic performance and self-assessment of clinical performance across the three classes. This finding may be due to an explicit understanding of clinical competency expectations associated with the comprehensive orientation students receive before the start of their clinical training. The Office of Clinical Affairs makes student expectations clear at the beginning of the third year and provides students with a clinical manual that is helpful in providing clear guidelines related to student competencies. Having this understanding, students seem to objectively evaluate their clinical performance independent of previous academic achievement. Another factor that may have influenced student self-assessment in this study is the role of the clinical faculty in providing feedback to students on their professionalism and clinical performance at the completion of each clinical rotation.

The limitations of the study include enrolling only three classes, involving only one institution, and having no formal reliability or validity study on the clinical self-assessment evaluation instrument. Additional studies comparing student self-assessment with preceptor evaluation and the use of student self-assessment in assessing the curriculum may help further define the value of student self-assessment.

The results of this study comparing student academic performance with clinical performance self-assessment differ from those of previously published studies in allopathic medical education. This difference may be attributed to the orientation students receive on professionalism and clinical expectations before the start of clinical training and the expectations of teaching faculty to provide continuous feedback to students on their clinical performance.