How Are You Assessing Students’ Clinical Decision-Making Skills?

Benefits of the Aquifer Internal Medicine Clinical Decision-Making exam in the key features format:

  • Included with your Aquifer Internal Medicine subscription
  • A unique and effective tool for assessing the clinical decision-making skills of your students
  • Designed to assess students’ ability to prioritize a differential diagnosis, select which historical, physical exam, or testing data are necessary to diagnose the problem, and identify the most appropriate management of the problem
  • Created by expert CDIM educators, trained by international experts in writing and reviewing key features questions
  • Built to include a strategic sampling of key conditions and decisions from the CDIM national curriculum
  • Brings a popular international exam format to US medical schools for the first time
  • Supported by validity evidence gathered in two multi-institutional studies published in Academic Medicine and Medical Teacher
  • Able to provide individual, class, and case-level performance

Why Use the Exam?

The CDME provides the unique ability to assess your students’ individual abilities to apply their knowledge to make the decisions needed to provide quality patient care. The typical evaluations of student clinical decision-making­—by residents and attendings working with students in a clinical setting—are important, but are limited due to the realities of clinical practice. The CDME helps to overcome some of these challenges and provides a way to enhance your understanding of students’ skills.

  • Students’ decisions can be assessed at each important step in the diagnostic and management process. The exam presents patients with undifferentiated symptoms and walks through different stages of patient care in a way that isn’t always feasible in clinic or on the wards.
  • Without the presence of residents, attending physicians and other team members, decisions on the exam reflect only the student’s own clinical reasoning skills.
  • The exam exceeds the typical number of cases included in a clinical evaluation, offering 15 carefully selected cases covering key Internal Medicine problems outlined in the CDIM curriculum.

Inside the Key Features Format

The exam includes 15 cases which cover a strategic sample of the CDIM curriculum. Each exam case starts with a clinical vignette providing a realistic patient scenario, including relevant history, exam, and test results.

Exam cases include 2-3 questions requiring students to use prioritized critical decision-making skills to solve a clinical problem. Questions are designed to identify critical steps, essential steps, and critical errors in the clinical decision-making process. Exam cases are solved in stages:

  • Data gathering (history, physical, investigation)
  • Problem definition
  • Management
Sample Question:

On-Demand Video: Assessing Key Clinical Decisions with an Online Exam

Watch educators from around the country discuss how they incorporate the CDME into their assessment programs.

The unique key features scoring system focuses on the actions that are ESSENTIAL to correctly navigate a clinical scenario. Students must prioritize their decisions, selecting only the options that matter most—reflecting the realities of the practice of medicine and testing a key management skill.

Students may decide to take multiple actions at once, just as we do in authentic practice. They receive partial credit for each correct decision. In a portion of cases assessing high value care, they may be penalized for over-ordering.

Reporting provides detailed results for each exam case by cohort and individual student in addition to overall exam performance statistics. Results reports provide the Aquifer Internal Medicine case number that corresponds to the content of each exam case, providing an opportunity for remediation.

The Clinical Decision-Making Exam (CDME) is available to any Aquifer Internal Medicine subscriber—the choice of how to integrate the exam and its performance data is up to each program. The exam was designed to be used as a complementary assessment during the third-year Internal Medicine clerkship, specifically to test clinical decision-making skills­. Current users are using the exam summatively as part of the clerkship grade, as a mid-clerkship exam, for remediation, and as an Acting Internship (Sub-Internship) exam. It could also play a role in longitudinal integrated clerkship assessments.

The Clinical Decision-Making Exam was developed in the key features format by a group of experienced CDIM educators under the guidance of an expert in the key features approach. The exam was rigorously developed, blueprinted, and pilot tested before a multi-institutional validation study.

The validation study for this exam was published in Academic Medicine in 2019. Validity Evidence for a Brief Online Key Features Examination in the Internal Medicine Clerkship presents a range of evidence supporting the use of the Key Features Exam as a complementary assessment during the third-year Internal Medicine clerkship, specifically to test clinical decision-making skills. This publication is the result of a multi-institutional validation study led by Valerie Lang, MD, MHPE, Aquifer Academic Director for Assessment, and a team that included Aquifer Educators Consortium members Dr. Kirk Bronander and Dr. Heather Harrell.

Meanwhile, the assessment is continually validated. In February 2022, a second validated form was added to the CDME offerings, which gives schools the ability to remediate, have validated practice exams, or simply rotate which scored exam they offer.

  1. Page G, Bordage G, Allen T. Developing key-feature problems and examinations to assess clinical decision-making skills. Academic medicine: Journal of the Association of American Medical Colleges 1995;70:194-201.
  2. Page G, Bordage G. The Medical Council of Canada’s key features project: a more valid written examination of clinical decision-making skills. Academic Medicine 1995;70:104-10.
  3. Farmer EA, Hinchy J. Assessing general practice clinical decision making skills: the key features approach. Australian Family Physician 2005;34:1059-61.
  4. Trudel JL, Bordage G, Downing SM. Reliability and validity of key feature cases for the self-assessment of colon and rectal surgeons. Annals of Surgery 2008;248:252-8.
  5. Amini M, Moghadami M, Kojuri J, et al. An innovative method to assess clinical reasoning skills: Clinical reasoning tests in the second national medical science Olympiad in Iran. BMC research notes 2011;4:418.
  6. Fischer MR, Kopp V, Holzer M, Ruderich F, Jünger J. A modified electronic key feature examination for undergraduate medical students: validation threats and opportunities. Medical Teacher 2005;27:450-5.

Learn More

Download our printable Clinical Decision-Making Exam brochure to share with your colleagues.

View Brochure

To arrange a trial of the exam for your program, please contact our Exam Administrator.

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Listen to the Aquifer Educator Connection Podcast with Dr. Valerie Lang, Associate Professor of Medicine, Associate Professor of Clinical Nursing, University of Rochester School of Medicine and Dentistry, who was instrumental in the development and validation of the Aquifer Internal Medicine Clinical Decision Making Exam, and now serves as its Academic Director. In this podcast, Dr. Lang explains why the exam was developed and the benefits of integrating it into an overall assessment program to achieve a more comprehensive picture of students’ clinical competence.

Full show notes can be found here.

Exam Requests

For security purposes, an Aquifer exam may be requested only by your institution’s designated Course Administrator, Clerkship Administrator, and/or Clerkship Director. If you meet this criteria, and need to request an exam, please complete our Exam Request Form.