Does performance on United States national board of medical examiners reflect student clinical experiences in United Arab Emirates?

This article was migrated. The article was marked as recommended. Background: A number of medical schools around the world use the United States National Board of Medical Examiners Subject Examinations as a clerkship assessment of student performance, yet these exams were blueprinted against the United States national core clerkship curriculum which might not be the same as the local curricula to which they are applied in other parts of the world. In this study, we investigated the correlations between the internal medicine clinical experiences at United Arab Emirates University with student performance on the National Board of Medical Examiners subject of internal medicine (NBME). Methods: One hundred and seven junior clerkship students out of 145 (74%) who finished their Internal Medicine clerkship during academic years 2014-2015 and 2015-2016 participated in this study. The students’ clinical experiences were measured by the clinical learning evaluation questionnaire (CLEQ) and by the logged number of meaningful patient contacts during their internal medicine clerkship. Results: Linear regression analysis showed no significant association between performance on the subject test and student clinical experiences measured by the CLEQ or the number of logged patients. NBME scores were weakly correlated with OSCEs scores (ɸ 0.20). Conclusions: The study findings raised uncertainties about the suitability of using NBME in the clerkship assessment program in the United Arab Emirates.


Introduction
Undergraduate medical curricula strive to produce future doctors equipped with clinical knowledge and skills sufficient to practice and improve patient care.Medical schools use standardized examinations to measure student clinical competency as one check on the curriculum's effectiveness.The National Board of Medical Examiners Subject Exams (NBMESE) is a highly regarded tool used in the assessment of the clinical knowledge that students acquired during clerkship (Bass et al., 1997;Elnicki, Lescisin and Case, 2002).Furthermore many reports in the United States (US) highlight the relationship of NBME scores with the quality of clinical teaching and student clinical experiences (Nahum, 2004;Griffith et al., 2009;Ramchandani, 2011;Dong et al., 2014;Myers et al., 2014;Ouyang, Cuddy and Swanson, 2015;Casey et al., 2016).
Because of NBMESE's high reliability, benchmarking function, and practicality of administration, many medical schools outside the US, including United Arab Emirates University (UAEU), use the NBME Subject Exams for clerkship assessment of student academic achievement (Colthart et al., 2008).However, uncertainties exist as to how well the NBMESEs' scores correlate with the clerkship clinical experiences of medical students in schools outside the US (Tekian and Boulet, 2015).The differences in clinical learning environment, the patients' population, and health care practices might contribute to significant variations in clinical teaching and student clinical experiences between countries and even regions within the same country.These differences might alter the utility of the NBMESE as a valid measure of student clinical knowledge acquired during the clerkship outside the US (Griffith et al., 2009).Interestingly, even some Canadian medical schools report discrepancies between outcomes of NBMESEs and in-house Canadian written exams (Hermanson et al., 2004;Veale et al., 2011).
The aim of this study was to investigate the relationship between UAEU students' clinical experiences and their performance on the NBMESE-internal medicine exam to get better understanding of the utility of NBME scores in assessing student clinical knowledge gained from clerkship teaching, as well as the relationship between those scores and student clinical experiences.
Given this background, the objective of this study is to explore the Impact of UAEU clinical experiences on the scores of the NBME internal medicine subject examinations; Relationship between NBME scores and scores on the in-house objective structural clinical exams (OSCEs); Impact of pre-clerkship academic achievement on outcomes of NBME internal medicine subject examinations.

Methods
The College of Medicine and Health Sciences, United Arab Emirates University (UAEU) is the first medical school to be established in UAE and in recent years it matriculates between 70 and 100 students annually.At the time of this study, UAEU offered a traditional six-year curriculum: two years of pre-medical sciences followed by a two-year pre-clinical program and capped by a two-year clinical program where the core clinical specialties were taught in clerkships.
The internal medicine clerkship program occurs in teaching hospitals affiliated with UAE University.The clinical teaching activities over and above apprenticeship include bedside teaching, hospital ward rounds, night duties, small group conferences and case discussions.The clerkship program assesses students' clinical competencies by exams designed in-house, including an objective structured clinical exam (OSCE).The subject examinations provided by NBME are used for assessment of clerkship cognitive learning outcomes.The NBMESEs assess the student's understanding and ability to apply clinical knowledge in relation to the physician's tasks of solving patient problems and promoting health (NBME, 2016).The NBMESE-internal medicine is an obligatory end of clerkship exam for junior clerkships at UAEU since 2009.The NBME reported that the norm group mean scores for internal medicine were 73.3 (AE9) for the academic year 2014-2015 and 74.7 (AE8.9) for the academic year 2015-2016.
The study sample was limited to junior clerkship medical students' in the academic years of 2014-2015 and 2015-2016.A sample size of 106 respondents would yield results within +/-5% confidence intervals at 95% confidence level.
Data collected for each student included demographics, post-clerkship exam scores on NBME and OSCEs, and the preclerkship scores of the final end of pre-clinical-years comprehensive exit written exams.The internal medicine junior clerkship coordinators provided the scores for NBME and OSCEs for each student who rotated on Internal Medicine junior clerkship during the academic years 2014-2015 and 2015-2016.The pre-clerkship scores were provided by the examination office of the College of Medicine and Health Science.We studied the influence of prior academic achievement by using the pre-clerkship scores as a control variable.High achievers and low achievers were defined as students with a pre-clerkship score above or below the mean score of the study cohort.

Student Clinical experiences
The Clinical Learning Evaluation Questionnaire (CLEQ) was used to measure student clinical teaching experiences (Appendix 1).The CLEQ measures the student perception of the quality of undergraduate clinical teaching in a clinical placement.The students score the number and quality of the clinical cases they see, their involvement in the patient care, and the quality of clinical supervision and organisation of the patient-doctor encounter.The CLEQ was validated to measure the effectiveness of undergraduate clinical teaching in Saudi medical schools and thus was deemed to be sensitive enough to measure the effectiveness of undergraduate clerkship clinical teaching in the UAEU local context (Al-Haqwi, Kuntze and vander-Molen, 2014).
In a selected response format, the students reported the number of meaningful patient encounters they had.A meaningful patient encounter is defined as involvement of the student in interviewing the patient or performing the physical examination and not where a patient is described or presented in the student's presence.The students were asked to rank on a Likert scale the importance of teaching methods; textbook and online resources, self-practice (solving MCQs questions, practicing clinical skills), faculty teaching sessions (morning report, tutorial, etc.), and clinical experiences (patient workups, bedside teaching, etc.) in preparation for the post clerkship examinations of NBMESE and OSCEs.

Administration of the questionnaire
To determine local contextual relevance, the questionnaire was piloted on 11 medical clerkship students.It was validated for the time required to complete it, whether the questions were appropriate, clear, concise, and unambiguous, and whether the instructions were easy to understand and meaningful.All the students were able to answer the questionnaire within 10 minutes.
The questionnaire was administered on 27 September 2015 using online survey software, SurveyMonkey (http://www.surveymonkey.com/).The respondents were instructed that their responses to the questions should be based on their experience during their clinical rotations and not on their general impressions.Completion of the survey signified informed consent.The research protocol was approved by the ethical committee of Al Ain district in UAE .A weekly reminder was sent (a total of five reminders), but no incentives were provided (Cohen, Manion and Morrison, 2013).

Statistical analysis
The respondents received identification codes, so their response data and examination scores were entered into analyses without using their names.The mean values and standard deviations (SD) were calculated for the continuous variables of the scores of the NBMESEs, scores of the OSCEs, final clerkship scores, and the final pre-clinical scores.To allow comparisons, the scores of pre-clerkship and end-clerkship exams were converted to Z scores (10 (Z) +70).
The rating of CLEQ items in Likert format produced ordinal data.Therefore, medians and interquartile ranges (IQR) were used to calculate the central measure summary for the scores of the items and the subscales of the CLEQ-measure.A reverse score was counted for the negative statements.
We performed a univariate linear regression analysis to investigate the effect of the pre-selected potential variables on student academic achievement.The outcome of interest was student score on the NBMESE as continuous variable (Table 1).The independent variables were the scores of the CLEQ subscales, the number of patient contacts, student gender, and the pre-clerkship scores.
Comparisons of continuous variables were made using Student's t test.R square (R 2 ) values represented the predictive power of the pre-clerkship scores for student performance, and the predictability of NBMESE for OSCE performance.Mann-Whitney and Pearson Chi square tests were used to compare study subgroups, as appropriate.The Statistical Package for the Social Sciences (IBM SPSS; Version 21) was used for all statistical analyses.Test statistics with P values less than 0.05 (two-sided) were considered statistically significant.

Results/Analysis
One hundred and forty-five medical students were invited to participate in this study.The ages of the 145 invited students ranged from 22 to 27 years, with an average of 23.3 years (SD AE 0.72).Twenty-six of them (17.9%) were men.Out of the 145 students who were invited, 107 students agreed to participate and completed the questionnaire, giving a response rate of 74%.There is no significant difference between responders (n = 107) and non-responders (n = 38) in age, or scores of pre-clerkship or end of Internal Medicine clerkship exams (Table 1).
Overall the respondents rated the internal medicine clerkship to be satisfactory in providing clinical cases for teaching, adequate clinical supervision, and organisation of doctor-patient encounters (IQR 4-5).However, the authenticity of the clinical experiences was rated to be less satisfactory (IQR 3-5, p = 0.002).The number of patients examined by the students varied widely between individual students.On average, each student clerked a minimum of 33 patients (SD AE 14) during the 8 weeks of the internal medicine junior clerkship.
Table 2 shows the impact of pre-clerkship achievement on the student clinical experience.The students' perceptions of the qualities of the clerkship learning environment were independent of their prior academic achievements, as there was no significant difference between high and low achievers in their ranking of the CLEQ items or the number of meaningful patient contacts they had during the internal medicine junior clerkship rotation.

NBMESE performance:
The study group overall mean NBMESE score was low compared to the NBME norm group (46AE11 vs 74AE9, p<0.001).Linear regression analysis showed no significant association between NBME performance and clinical experiences as measured by the CLEQ or number of logged patients (Table 3).
Student performance in NBMESE was weakly correlated with their performance in OSCEs (phi correlation coefficient ɸ 0.20), and with their performance in local MCQ (phi correlation coefficient ɸ 0.26).The ability of NBMESE scores to predict OSCE outcomes (11%, R 2 = 0.11) and local MCQ outcomes (19%, R 2 = 0.19) was limited.A substantial number (41%) of UAEU students who scored below the class mean on the NBMESE were able to score above the class mean in OSCEs, and 39% of the students who scored above the class mean in NBMESE performed below the class mean in OSCEs (Table 4).The same figures were applied to local MCQ exams (Table 4).
On a Likert scale, the students ranked their clinical experiences, teaching sessions, and self-practice to be more important in preparation for OSCEs than the NBMESE exam (p = 0.001, Figure 1).They perceived reading textbooks and online resources to be more helpful in preparation for NBMESE exams than the clinical teaching.

Discussion
Our study examined the relationship between UAEU student NBMESE performance and their clinical experiences acquired during internal medicine clerkship.Student clinical experiences were measured empirically using the newly constructed clinical learning environment questionnaire (CLEQ) which was deemed to be the most suitable for the UAE context (Al-Haqwi, Kuntze and vander-Molen, 2014).The study findings indicated the limited ability of NBMESE to predict student clinical experiences in UAE.The NBMESE scores have a low degree of correlation with UAEU clinical experiences and the UAEU student scored on average 37% lower than the NBME norm cohort, Table 1.
The study finding of the association of the pre-clerkship scores with better performance on NBMESE exams is in line with the recently published report on the correlations of the scores of the NBMESE exams with the scores of the USMLE step-1 pre-clerkship exam in US (Casey et al., 2016).This association could be related to the similarity of the NBMESE and pre-clerkship exams in assessment of student understanding of the mechanisms of disease.However, the other NBMESE domains related to clinical tasks such diagnosis and management could be less related to the UAEU clinical learning experiences.In their preparation for the NBMESE, the respondents indicated that reading medical textbooks and online resources are of more importance than their clerkship clinical experiences.The NBMESE as a high stake examination for UAEU students could be potentially counterproductive as it might have created considerable stress for students trying to maintain a balance between reading textbooks to pass NBME and seeing more patients which would improve their clinical experience (Cobb et al., 2013).
A recent study by Holtzman et al ( 2014) reported a wide variation in the performance of international medical students in the domains of the clinical tasks compared to domains of mechanism of diseases related to the text book knowledge (Holtzman et al., 2014).Although, the UAEU undergraduate medical curriculum is benchmarked with the US national core medical curriculum, the difference in patient population and sociocultural factors might have contributed to the   The results of this study must be interpreted with caution due to several limitations.The study covered a relatively small sample of students and data were collected only from the junior internal medicine clerkship rotation.It would have been a stronger study if other UAEU clerkships were included and other NBMESEs considered.The student perceptions of clinical experience could be biased by single outstanding events rather than reflecting the quality of the actual clinical teaching experiences (Woloschuk et al., 2011;Schiekirka and Raupach, 2015).Also the perceived low authenticity of the clinical experiences could have negatively affected student academic performance, as authenticity reflects the degree of student inclusion into the clinical placement climate (Billett, 2002;Strand et al., 2013).
The reliability of NBMEs is reported to be high, but the reliability coefficient of our in-house OSCEs is not measured (Hoffman, 1993).Processes that assure the good reliability of our in-house OSCEs include the use of faculty as examiners, standardised scoring rubrics with global rating, an adequate number and length of OSCEs stations, and frequent reuse of volunteer patients from the examination pool (Pell et al., 2010).Despite these limitations, its low student performance and low degree of correlation with UAEU clinical experiences might indicate a low degree of utility for use of NBMESEs as a summative assessment tool for internal medicine clerkship in UAE (Fielding, 2008;Dong et al., 2014;Casey et al., 2016).If these results are confirmed through further study, the scores of the NBMESEs should not be used to determine pass-fail decisions in UAEU and the relative weight of NBMESE scores in the computed final composite clerkship scores should be considered carefully (Fielding, 2008).Creating a national standardised written clerkship exam blueprinted against UAE clinical learning experiences would have a positive impact on future Emirati doctor clinical experience.

Conclusion
The ability of NBME scores to reflect on the UAE student clinical experience is modest.A longitudinal cross-clerkship evaluation that includes other core clerkships would be necessary to provide more reliable information on the value of NBMESE to assess the student clinical experiences across multispecialty clinical learning environment in UAE.

Take Home Messages
Low correlation between UAEU students' performance in NMBESE and their clinical experiences.
Reading text books is perceived to be more important in preparation for NBMESE exams than UAEU clinical teaching.
NBMESE as summative clerkship exam might adversely influence student study habit and clinical learning environment in UAEU internal medicine clerkship.I have the opportunity to deal with patient as a real doctor.I have the opportunity to deal with the patient as a whole and not limited to a certain system or organ.I have the opportunity to apply my previous knowledge in patient care.

Notes On Contributors
I have the opportunity to apply a patient-centred approach.I have the opportunity to take responsibility for patient care.I have the opportunity to communicate with patients and their families.Factor III: Clinical supervision: My supervisors have good communication skills.I have been respected by my supervisors.
The supervisors are committed for teaching.
The way my supervisors deal with medical students is satisfactory.I think supervisors have good teaching skills.I have rarely received a good feedback on my clinical performance from my supervisor.I think that some supervisors could be considered as role models.Factor IV: Organization of the doctor-patient encounter: The

Richard Hays James Cook University
This review has been migrated.The reviewer awarded 4 stars out of 5 The title of this paper raises the question: What does the USA national licensing exam have to do with the UAE?The answer is both not much and a lot, depending on the lens in the viewer.The exam itself is strongly based on USA medical education -teaching, learning experience and assessment.Because the exams determine eligibility to practice, a huge business has grown out of preparation for the assessments rather than (or in parallel to) local institutional assessments.US institutions 'buy' or follow closely the NBME item style model and US students often purchase 'shelf' tests for additional practice.
Because so many international medical graduates want to work in the USA, many international medical programs use the retired item bank to assist their students prepare for this.Further, many medical schools around the world now use the NBME retired item bank (the questions are of high quality and come with item performance data) as formative assessment.Anecdotally, a similar mis-match between institutional and NBME assessment scores has been found in Australia.This most likely reflects differences in curriculum sequence, emphasis and assessment, rather than a comment on the quality of either Australian or USA medical graduates.The most important message here is that assessment needs to reflect the learning experiences of medical students -constructive alignment is important!This paper is therefore a welcome addition to the literature, as it should provoke thinking about what band how we assess medical students.It would be interesting to hear of similar experiences in other countries.
© 2019 Masters K.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Ken Masters
Sultan Qaboos University This review has been migrated.The reviewer awarded 4 stars out of 5 An interesting paper dealing with the use of the US national board of medical examiners reflect student clinical experiences in the UAE, and the suitability of the examination outside of the US.The authors begin by describing the problem of the suitability of the examination.Although there are many international standards, there are also many variations, and there is great difficulty in standardising this type of examination, even if the focus is on knowledge -if it were easy, there would simply always be only one international qualifying examination.Medical schools have to teach curricula that take into account the local environment and culture, and examinations need to match the teaching.This, in of itself, points to the type of problem facing the researchers in the UAE.The findings of a lack of correlation between the NBMESE scores and the students' clinical experience is problematic, but the authors do not automatically assume that the fault lies with the NBMESE, as the students also reported low authenticity of the clinical experiences, and the authors note that this could have a negative impact on the scores.I think the main value of the paper is that the authors have highlighted a problem in the use of the NBMESE in the UAE.(It should serve as a heads up to other countries and regions using the NBMESE (and other international examinations) that perhaps a similar investigation should be undertaken).I would suggest that the next stage is to try to investigate much more deeply exactly where the problem lies.For this, a more detailed analysis of the various testing systems would need to be undertaken.This may require a much closer collaboration with the NBMESE to examine the test items, the question format, the language and terminology, the assumptions, etc., and how these match to what is taught.The solution may be local adjustments of the test (which is fairly common in other fields), adjustments to the teaching methods and students' training and other examinations, or (most likely), a combination of all.Either way, a useful paper that points ahead to a great deal of work to be done.I look forward to seeing a more detailed study in the future, in which the researchers have attempted a resolution to the problem.

Magnus Hultin Umeå University
This review has been migrated.The reviewer awarded 3 stars out of 5 Thank you for an interesting paper on the discrepancies between performances on NBMESE and the locally defined OSCE.To better understand the differences it would be helpful if you either had references to the full curriculums to both NBMESE and to the comparable curriculum at the UAB University?Are the observed differences comparable to the problems observed for IMGs taking US exams?
Competing Interests: No conflicts of interest were disclosed.

Michael Ryan Virginia Commonwealth University School of Medicine
This review has been migrated.The reviewer awarded 2 stars out of 5 Summary: The authors studied the relationship between third year medical student performance on the NBME subject examination in Internal Medicine with their perception of clinical experiences at a single institution in the United Arab Emirates.The authors found that students performed markedly worse on the subject examination that the NBME-provided means.They did not find a relationship between scores on this examination with the perceived quality of clinical experiences.The authors conclude that the subject examination may not accurately represent the patient care experiences of learners in UAE and that the country should consider the development of an alternative examination for their country.Strengths: The authors provide a good review of the literature on the topic and selected an instrument with validity evidence to measure clinical experiences of their learners.In general, the statistical analysis is appropriate and well thought out.Areas for improvement: The premise of this manuscript is that the subject examination test knowledge acquired during clinical care experiences and that this is the case in the US.I wouldn't say that is accurate.The subject examinations are designed to assess knowledge obtained by the conclusion of the clerkship.Whether that is obtained in the course of caring for patients vs. self-reading is not specifically stated by the NBME.In addition to that issue, the authors could strengthen this paper by looking at other measures of knowledge in their population to see if this is an issue with the Medicine examination specifically, or all examinations intended for a US audience.The scores were so low here that it made me wonder what the scores on exams like Step 1, Step 2, and other subject exams were.We would need to know what those scores are like to determine if this is an issue with clinical experience or a more global issue with the content of the exam, familiarity, etc. Comments by sectionAbstract: Represents the manuscript relatively well.I would have liked to see the data regarding performance of this population compared to the mean though.Introduction: -I was confused by the statement that the UAEU undergraduate medical curriculum is benchmarked with the US national core medical curriculum.Similarly there's a statement that the subject exam is benchmarked to the US curriculum.There is no standardized US curriculum.Methods-Expand on the model of teaching in UAEU.
The authors state "apprenticeship," but follows by saying "shadowing."-Several elements of this section appear to be results.For example, the study population, % men, response rate to survey, etc-Statistical analysis chosen requires more detail.-Number of patients reported relies on self-report.This seems to be a significant threat to validityResults-The authors remark on pre-clerkship scores.What are these?- The authors analyze by "high" and "low" achievers but don't discuss how these groups were created.-Performance on the subject exam is incredibly low compared to the national average.This raises the concern of whether this performance has anything to do with the experience on the medicine rotation or reflects a larger issue with test familiarity or overall knowledge base.Discussion/Conclusions-The premise that UAE should consider developing a test that better reflects learning among its students is reasonable.But, I don't know that it is supported by the findings here.The authors showed that students performed poorly on the NBME examination, but that alone doesn't mean the examination is not appropriate.It depends on the goal of assessment.If the goal is to prepare students for USMLE, there is substantial evidence that the subject examinations are correlated with that examination.If the goal is to mirror clinical experiences, then I agree, they may want to pursue a test that is more related to the clinical experience.
Competing Interests: No conflicts of interest were disclosed.

P Ravi Shankar American International Medical University
This review has been migrated.The reviewer awarded 4 stars out of 5 I enjoyed reading this article examining the correlation between student performance in the NBME subject exam and student clinical experiences.NBME offers exams which are standardized and which could be administered easily using a secure platform.NBME is widely administered in Caribbean offshore medical schools.There is a tendency toward standardization and certifying exams the world over.I am of the opinion that big and diverse nations like the United States, China and India will have to be careful while designing exit exams as the clinical experience in different parts of the country and in different medical schools may be different.This article points out how NBME may not accurately reflect the clinical experiences of students in the United Arab Emirates.The authors base this assumption primarily on the CLEQ and the logged patients.The NBME measures primarily knowledge and the knowledge component could be tested using another locally created exam.Single response MCQs are easy to grade, objective and can cover a wide range of topics but may not test all knowledge domains or competencies.The authors mention the limitations of their study clearly.This article will be of interest to all medical educators.
Competing Interests: No conflicts of interest were disclosed.
disparity between the UAEU student NBMESE performance and the US student NBME performance(Griffith et al.,  2009).To enhance student clinical learning, the clerkship exams should be blueprinted to their contextual clinical experiences, the patient population, and the contextual approach for solving patients' problems(Lucas, Benedek and  Pangaro, 1993; McManus et al., 1998; Cilliers et al., 2010; Rentea et al., 2015; Archer et al., 2016).

Figure 1 .
Figure 1.Medians and interquartile ranges of student rating for the importance of clinical teaching methods in preparation for NBME and OSCE.1= least important, 7= most important Dr Omran Bakoush: Professor & Consultant of Nephrology, Department of Internal Medicine, College of Medicine & Health Science, UAEU, Al Ain, UAE.ORCID https://orcid.org/0000-0003-1447-9836Dr Ali Al Dhanhani: Assistant Professor & Consultant of Rheumatology, Department of Internal Medicine, College of Medicine & Health Science, UAEU, Al Ain, UAE.Dr Saif Alshamsi: Assistant Professor & Consultant of Internal Medicine, Department of Internal Medicine, College of Medicine & Health Science, UAEU, Al Ain, UAE.Prof Janet Grant: Director of the Centre for Medical Education in Context (CenMEDIC) and Emeritus Professor of Education in Medicine at Open University, UK.Dr John Norcini: President & CEO of Foundation for Advancement and International Medical Education and Research, Philadelphia, USA.Appendices Appendix 1: The study questionnaire The students asked to rank on scale 1-5 (1= poor, 2= fair, 3= good, 4= good, 5= excellent) the following CLEQ factors: Part I: The clinical learning environment questionnaire (CLEQ) Factor 1: Provision of cases: I have seen a sufficient number of clinical cases.I have seen a sufficient number of new clinical cases.I have seen a good variety of clinical cases.I have seen many interesting clinical cases.I have seen some cases with positive clinical findings.I have seen some unusual/rare clinical cases.Factor II: Authenticity of clinical experiences: I have the opportunity to have the first contact experiences with patients.I am actively involved in the patient care.

Table 1 .
Comparison of responding and non-responding CMHS fifth-year medical students during the academic years 2014 -2016.
Except for gender, values are given as mean (standard deviation).

Table 2 .
The interquartile ranges of scores of students' ratings for CLEQ measure, the mean number of contacts with patients, and the mean scores of clerkship exams, of low achievers compared to high achievers.
High achievers and low achievers were defined as students with a pre-clerkship score above or below the mean score of 81.6% for the study cohort.The scoring scale for CLEQ items 1-5 (1= poor, 2= fair, 3= good, 4= good, 5= excellent).

Table 3 .
Univariate linear regression analysis: Predicting the outcome of NBME internal medicine subject exam.
Beta= Regression Coefficient; SE= standard error; t= t-value for beta.

Table 4 .
Cross tabulation: predictability of NBME performance for OSCEs outcome and in-house-MCQ outcome.
objectives of the clinical rotations are clear.Students have some input for the organization and development of the clinical rotations.I have the opportunity to prepare before the clinical encounter.I have the opportunity to reflect and read after the clinical encounter.I have the opportunity to discuss clinical cases with my supervisors.I have the opportunity to share the clinical cases with other students.The number of students in the clinical sessions is appropriate.The time spent with my patients is adequate for my clinical learning.I have the opportunity to utilize skills lab and simulation for clinical cases.I think the assessment of the clinical learning is aligned with objectives.I was given enough assignments during my clinical rotation.Reference Source Strand, P., Sjoborg, K., Stalmeijer, R., Wichmann-Hansen, G., et al. (2013) Development and psychometric evaluation of the Undergraduate Clinical Education Environment Measure (UCEEM).Med Teach.35(12), pp.1014-1026.Reference Source Tekian, A. and Boulet, J. (2015) A longitudinal study of the characteristics and performances of medical students and graduates from the Arab countries.BMC Med Educ.15, p. 200.Reference Source Veale, P., Woloschuk, W., Coderre, S., McLaughlin, K., et al. (2011) Comparison of Student Performance on Internally Prepared Clerkship Examinations and NBME Subject Examinations.Canadian Medical Education Journal.2(2), pp.e81-e85.Woloschuk, W., Coderre, S., Wright, B. and McLaughlin, K. (2011) What factors affect students' overall ratings of a course?Acad Med.86(5), pp.640-643.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.