Integrating narrative assessments in medical education by overcoming the existing challenges

Abstract

Narrative assessments in medical education have a broad scope and they extend way beyond the boundaries and limitations of traditional grading methods. Acknowledging the merits of narrative assessments in the making of a complete healthcare professional, every institution should aim to structurally introduce these forms of qualitative assessments within their set-ups. Although narrative assessments offer multiple merits, we cannot ignore the presence of the challenges that are linked with them and there is an immense need to address these potential challenges, and we will essentially require thoughtful planning, regular training of teachers, and consistent efforts to refine the process of narrative assessments. In conclusion, in the field of medical education, narrative assessment has significant scope and merits to offer to facilitate the growth of medical students. However, we must be systematic in our approach to integrate these assessments in a meaningful manner and take specific measures to overcome the associated challenges.

Introduction

Narrative assessments in medical education have a broad scope and they extend way beyond the boundaries and limitations of traditional grading methods.[1] These assessments have the potential to ensure a holistic evaluation of medical students, including their academic attributes, communication skills, professionalism, and other competencies.[1,2] Teachers can use these assessments to assess the clinical reasoning and decision-making skills of medical students.[2] This is accomplished by measuring the abilities of students to apply their theoretical knowledge to practical scenarios and make sound clinical judgments.[1,2] Further, there is a scope for teachers to provide specific feedback to individual students depending on their background, attributes, and learning experiences.[3] Finally, as teachers give detailed and specific feedback, it becomes a source of promoting introspection among students through introspection, which in turn aids them to become better by making continuous efforts.[3]

Integration of Narrative Assessments

Acknowledging the merits of narrative assessments in the making of a complete healthcare professional, every institution should aim to structurally introduce these forms of qualitative assessments within their set-ups.[1] In the knowledge domain across the different professional years in undergraduate teaching, narrative assessments can be used to assess the knowledge, critical thinking, problem-solving, and abilities of students to apply their existing knowledge in practical settings.[1] In the domain of clinical and practical skills, with the help of narrative assessments can target history taking, physical examination, clinical reasoning, communication skills, teamwork, professionalism, and the ability of students to apply their theoretical knowledge for managing patients.[2,3]

During internship or residency training, narrative assessments can aid in evaluating the performance of the student in authentic settings, especially about their ability to manage clinical skills, leadership skills, collaboration with professionals from other disciplines, etc.[3] In short, narrative assessments have immense scope across different stages of medical training, and thus, it is our responsibility to use them effectively to help students.[1,2,3] However, for all this to happen, the institution must plan and organize workshops in narrative medicine targeting both teachers and students to encourage them to explore its use in healthcare. It is also advised to incorporate narrative reflections and/or patient narratives in clinical postings and promote the usage of digital storytelling platforms in assessments.

Identified Challenges and Potential Solutions

Although narrative assessments offer multiple merits, we cannot ignore the presence of the challenges that are linked with them [Table 1], and the most important being the subjectivity, as different teachers might interpret and evaluate the performance of students in a different manner.[2] In other words, there is a lack of standardization, mainly because different teachers may use different criteria to assess students and thus the process can lack uniformity.[2] In continuation, there is also a scope for ambiguity, wherein students might interpret the written feedback differently resulting in confusion.[2] As teachers will be the ones who will be carrying out narrative assessments, any reluctance on their part (supporting only traditional grading) or being not aware of the principles about the same will become a major challenge in the implementation.[4] Further, variability in feedback delivery might also emerge as a cause of concern and justifies the need to conduct faculty development programs.[3]

Table 1.

Identified challenges and potential solutions

Identified challenges		Potential solutions
Scope for subjectivity		• Frame clear criteria and rubrics for evaluating different competencies • Train teachers about the basics of narrative assessments and strategies that can be adopted to minimize subjectivity • Include number of assessors to ensure that we can incorporate views of different people and thus minimize individual subjectivity • Create a platform for teachers so that all can collaborate and gradually refine the process of assessment • Encourage self-assessment by students, allowing them to reflect on their own performance and contribute to the objectivity of the assessment process
Difficulty in carrying out comparisons		• Create standard benchmarks to facilitate consistent comparisons between students • Train faculty members in methods to compare performance of students effectively
Lack of quantification		• Do not look at narrative assessments in isolation, rather always look them in collaboration with results of quantitative assessments (such as scores, rating scales, etc.) • Even within narratives, specific examples and/or benchmarks can be added to measure observable behaviors
Presence of ambiguity		• To frame a structured system for follow-up and understanding of feedback between teachers and students • Train teachers in delivering the feedback clearly and effectively to students • Encourage students to get clarified their queries
Inconsistency in feedback delivery		• Formulate structured template for feedback delivery to bring uniformity • Create a culture of teamwork between teachers to align their feedback styles and be consistent • Carry out peer review of narrative assessments to identify and address any deviations in feedback delivery
Shortage of time		• Teachers can adopt technology, in the form of templates or digital platforms, to streamline the process of assessments • Instead of writing every time common statements, teachers can use predefined phrases and customize them based on the need • Specific time can be allocated for teachers to focus on narrative assessments, including the provision of constructive feedback
Large number of students		• Adopt peer-assisted grading to streamline the workload among educators • Teachers can adopt technology, in the form of templates or digital platforms, to reduce their work
Resistance to change		• Train teachers about the need and benefits of narrative assessment • Invite external experts who have delivered encouraging results through narrative assessments • Create a platform for teachers to interact and resolve their concerns and queries
Untrained teachers		• Medical Education Unit to organize faculty development programs on principles, criteria, and best practices • Institution can organize peer mentoring sessions, wherein experienced teachers can guide others • Create a platform for teachers so that all can collaborate and gradually refine the process of assessment
Confidentiality concerns		• Frame clear guidelines on confidentiality and ethical considerations • Sensitize teachers on the importance of keeping their narrative assessments confidential

It is quite obvious that it is a time-consuming process to perform assessments, and the presence of a large number of students or multiple responsibilities assigned to teachers, both can prove to be a significant barrier to successfully planning and executing narrative assessments.[1,2] In contrast to traditional assessments, narrative assessments tend to lack quantification, and thus we must devise a mechanism at institutional level to convert qualitative feedback to measurable outcomes.[3] This will even aid in measuring the progress of students over a period of time and in carrying out comparisons. From the administrative perspective, confidentiality concerns and accountability issues might also emerge and they need to be carefully and systematically addressed at the institution level.[4] There is an immense need to address these potential challenges, and we will essentially require thoughtful planning, regular training of teachers, and consistent efforts to refine the process of narrative assessments, and all these have been enlisted in Table 1.[1,2,3,4]

Conclusion

In conclusion, in the field of medical education, narrative assessment has significant scope and merits to offer to facilitate the growth of medical students. However, we must be systematic in our approach to integrate these assessments in a meaningful manner and take specific measures to overcome the associated challenges.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.