ABSTRACT
PURPOSE: Direct observation (DO) enables assessment of vital competencies, such as clinical skills. Despite national requirement that medical students experience DOs during each clerkship, the frequency, length, quality, and context of these DOs are not well established. This study examines the quality, quantity, and characteristics of DOs obtained during pediatrics clerkships across multiple institutions. METHOD: This multimethod study was performed at 6 U.S.-based institutions from March through October 2022. In the qualitative phase, focus groups and/or semistructured interviews were conducted with third-year medical students at the conclusion of pediatrics clerkships. In the quantitative phase, the authors administered an internally developed instrument after focus group discussions or interviews. Qualitative data were analyzed using thematic analysis, and quantitative data were analyzed using anonymous survey responses. RESULTS: Seventy-three medical students participated in 20 focus groups, and 71 (97.3%) completed the survey. The authors identified 7 themes that were organized into key principles: before, during, and after DO. Most students reported their DOs were conducted primarily by residents (62 [87.3%]) rather than attendings (6 [8.4%]) in inpatient settings. Participants reported daily attending observation of clinical reasoning (38 [53.5%]), communication (39 [54.9%]), and presentation skills (58 [81.7%]). One-third reported they were never observed taking a history by an inpatient attending (23 [32.4%]), and one-quarter reported they were never observed performing a physical exam (18 [25.4%]). CONCLUSIONS: This study revealed that students are not being assessed for performing vital clinical skills in the inpatient setting by attendings as frequently as previously believed. When observers set expectations, create a safe learning environment, and follow up with actionable feedback, medical students perceive the experience as valuable; however, the DO experience is currently suboptimal. Therefore, a high-quality, competency-based clinical education for medical students is necessary to directly drive future patient care by way of a competent physician workforce.
