This study aimed to evaluate the relationship between absenteeism and a variety of assessment metrics in the Neurology Clerkship setting. Results showed that increased total absences did not impact overall performance on the various graded components, but rather only absences defined as “other” in nature (e.g., illness, personal absence, religious holiday) had an impact on certain graded components of the clerkship.
Overall, analysis revealed an association between MS year and performance on the SPEX. For physical exams such as the SPEX, MS year could be used as an instrumental variable to model students’ previous clerkship experience. It is reasonable to expect that students with less clerkship experience (e.g., MS2) would be more negatively impacted by accruing absences than students with more clerkship experience (e.g., MS4), but the corollary was observed in our analysis. Although these findings seem unexpected at first, perhaps MS2 students are more nervous going into physical exams and thus prepare more than more senior students who have completed physical exams in other clerkships. Additionally, this finding could be a result of clerkship engagement as opposed to knowledge and skills, suggesting that MS2 students who are new to their clinical clerkships are more engaged than more senior students who may have already selected a specialty and are more focused on applying for internship.
In terms of significant findings related to absenteeism, only the NBME scores were significantly affected by absences characterized as “other” in nature. As previously discussed, the NBME scores were more normally distributed than the CPA or SPEX measures, this greater variability in student’s scores potentially explains why significant differences in this measure were able to be distinguished. Significant differences in the SPEX and CPA scores, on the other hand, would be harder to distinguish given the sample size and limited range of variability; most students are high performing on these measures. The insignificant CPA findings were not altogether unexpected due to the known restricted use of the five-point scale on this assessment; whereby most students routinely receive scores of between 4 or 5 on a 5-point scale.
Additionally, our study showed that there was no significant impact on overall clerkship grade. This is likely because the negative relationships between the NBME scores and “other” absences might not be educationally significant due to the relatively small impact on student performance. As an example, using results from our regression models, an MS3 student with average performance and one total “other” absence would be expected to achieve the same CPA mean score, the same SPEX percent correct score, and an NBME percent score that is approximately 2.36 points less as compared to a similar MS3 student without an absence. Since there were no other significant findings for the other graded outcomes, some graded outcomes were not available for analysis, and the final clerkship grade is categorized into Fail, Pass, High Pass, and Honors (with no students in our sample achieving a grade of Fail), it is not surprising that there was no significant impact on overall clerkship grade. Despite the potential for some students to receive slightly lower NBME or knowledge scores because of increased absences, it is possible that these students are buffering this impact with higher scores in other areas.
Furthermore, absenteeism can be used as a marker of professionalism (Burns et al. 2017) which is often a consideration in overall clerkship final grades. Although no differences were found on the CPA outcome in this study due, at least in part, to the known restricted use the assessment tool’s scale, it is possible that groups of students, even among those who have absences from clerkships, are different from one another in ways that we were not able to identify in this study. Some students may be repeat offenders with repeatedly high absence requests across all clerkships (which may show patterns of absenteeism that reflect in CPAs across clerkships) and others may have had individual personal or educational events that occurred only during the NCC. We are not able to comment on any potential differences between these two groups of students as data from other clerkships was not available. Future study and collaboration with other departments would allow for tracking of absences longitudinally and further clarification. More broadly, future studies in this area could potentially examine the relationship between absenteeism and professionalism issues.
It is also important to consider the possibility that the models support only a weak relationship between absences and assessments because the current policy of the NCC at JHUSOM states that students are only permitted two excused absences during their four-week rotation. Therefore, if students miss additional days after this two-day limit, they are required to make up the missed curricular activities. For students with multiple absences, it is possible that make-up activities are effective replacements for missed activities and thus the impact of missed educational opportunities and exposure are, to some degree, recovered.
Further study is recommended since this analysis is limited by the small sample size, only approximately two academic years of data, and a small sample of MS2 and MS4 students, as well as a lack of predictor variables that might assist with explaining the factors that influence student performance in clinical clerkships. To best understand and represent these relationships, regression models should include all relevant independent variables that assist with explaining the variability in the dependent variable. In thinking about student performance, relevant independent variables might include student-related information (e.g., number of previous clerkships, learning ability), clerkship-related information (e.g., preceptor engagement, clinical learning environment), as well as other less direct information such as age or even socioeconomic status (SES) of a student’s family. For example, a student with a lower SES might be struggling with issues like food access that could affect their clerkship engagement or academic performance. For the current study, availability of information was limited. It is possible that absences do impact certain demographics of students (e.g., age, gender, racial/ethnic) more or less, but our study was not able evaluate this. Finally, as this study is entirely correlational, one limitation of this research is the inability to determine causality in regard to the impact of absences on clerkship performance.
Despite the limitations of this study, there remains significant opportunity for further exploration on the impact of absences on student performance in a clinical rotation setting. In the current study, the timing of the students’ absences (e.g., beginning, middle, or end of the clerkship) was not tracked. Perhaps students who miss time from the beginning of the clerkship will perform worse than their peers who do not have absences, as they could more easily fall behind their peers on learning the new material. Additionally, whether the student misses time away from an outpatient versus an inpatient clinical rotation setting could impact their performance on later assessments. This aspect of absence timing was also not explored in the current study.
Finally, as the literature has already suggested, conceivably students who are more self-regulated or self-directed will perform better despite missing time from curricular activities (Kauffman et al. 2018). In the current study, we did not measure learning style or preference of the students but adding this measure and exploring the impact on multiple assessment measures, or even attempting to replicate previous research in a different setting would be telling. This study does show that student absences in a clinical clerkship setting, with a sample of primarily third year medical students, does have a statistically significant and negative impact on a students’ performance on the NBME. It provides support to the literature that suggests that absences have a negative impact for medical students outside of the classroom or lecture hall and provides backing to clerkship directors who wish to limit students’ missed time from clerkship activities. Ultimately, additional supporting research, especially with a larger sample of students, could replicate and even expand on these findings and potentially show impacts on other performance measures as well.