- PRIME+ —
- professionalism, reporter, interpreter, manager, educator, plus suggesting an area for focused improvement and development.
- RIME —
- reporter, interpreter, manager, educator
This article continues the Council on Medical Student Education in Pediatrics’ series on the skills of, and strategies used by, excellent clinical teachers. Here, we provide a practical framework and helpful tips for writing student evaluations that will inform both students and their medical schools.
—Susan Bannister, Editor, Council on Medical Student Education in Pediatrics Monthly Feature
In the present age of competency-based evaluations, faculty complete more forced-choice performance rating scales. Nonetheless, the narrative evaluation that tells the “story” of the learner remains critical, providing context that helps students understand the feedback they receive and clerkship directors understand the “big picture” of each student’s performance. For medical students, narrative evaluations can be included in the Medical Student Performance Evaluation that summarizes their performance in the first 3 years of medical school and becomes part of their residency applications. In this article, we review a framework that can help preceptors write narratives that more fully reflect observed performance.
The Current State of Evaluations: Difficult to Interpret
Despite many clinical observations, intelligent and accomplished faculty can suffer writer’s block when trying to write meaningful descriptions of students.1 Consider the following examples that we have received:
“Needs to work on follow-through of plans and communicating with staff. Will refer to clerkship director.”
“Very pleasant. Fun to work with. Seemed to enjoy Ped ED setting. Overall, performed as expected.”
“Exceeded all expectations. Very bright and organized.”
“Although a likable person, at times he appeared to be confused during the rotation.”
“Development of treatment plans will improve with experience. Continue reading to improve fund of knowledge”
Although truthful and honest, these written narratives do not provide enough information on current performance and do not specify areas for focused attention in subsequent learning experiences.
A Tool to Help Write Better Student Evaluations
A widely used tool for improving written evaluations was developed by Dr Louis Pangaro at the Uniformed Services University. Known as RIME, it classifies important observable trainee behaviors and skills into 4 easily observed domains: reporter, interpreter, manager, and educator.2 In an individual clinical encounter, learners may demonstrate behaviors from several domains.3
The RIME Framework: A Review
“R” for reporter refers to the student’s ability to obtain information from a patient or family interview, to review a medical record, and to report findings coherently in oral presentations and written notes.
Interpreter is the “I” in RIME. This domain addresses how well a learner can interpret data collected from the history, physical examination, medical record, laboratory data, and radiologic studies; prioritize the most urgent problems; and formulate a well-reasoned differential diagnosis.
RIME continues with “M” for manager. As a manager, a student would formulate diagnostic and therapeutic patient plans and manage all aspects of care for the most common complaints. Management includes performing simple procedures and managing one’s own time.
The “E” in RIME is for educator, which includes students’ abilities to educate themselves via self-directed learning, appropriately accepting and responding to feedback, and critical interpretation of the medical literature. Students can teach by locating relevant articles, and also can teach patients about health conditions.
RIME and PRIME+
As Pangaro described reporter, interpreter, manager, and educator, professionalism was explicitly incorporated within each domain.4 We propose the addition of a “P” to RIME to specifically highlight professionalism; with this reminder, professionalism is less apt to be omitted from written narratives. The “P” reminds evaluators to incorporate comments about professionalism into each RIME domain. A “plus” at the end reminds the evaluator to suggest an area for focused improvement and development, giving students feedback that will help them progress along the continuum of medical education.3,5,6
Using the Language of PRIME+ in Written Narratives
Here are 2 good examples of narrative comments that use the PRIME+ framework to provide useful descriptions of students’ performance. With several descriptions like this, a clerkship director could assess a student’s progress, provide meaningful feedback to the student about performance in the clerkship, and formulate strong statements for the Medical Student Performance Evaluation.
Jane was always on time, reliable, and dependable such that I always knew the information she provided was accurate. She was able to report data succinctly and gather complete histories while simultaneously maintaining excellent rapport with families. She performed good differential diagnoses, was able to interpret lab data, PFTs, etc, and to independently find resources to help her when she came across data she had not encountered previously. Jane could synthesize good plans, and managed patients well, always spending additional time to ensure family understanding of instructions. She responded well to feedback with appreciation and an upbeat attitude, worked diligently on fund of knowledge, and was able to educate families and patients well on various illnesses; always the professional, spending more time and effort whenever it was required by the situation.
Professionally, John was prompt, appropriately groomed, friendly, and had an energetic style much appreciated by patients and staff. As a reporter, John needs to continue to work on completeness and organization; excellent efforts are made, but he can lose the big picture by focusing on the wrong detail. As an interpreter, he continues to have short differentials and elementary understanding of how to organize and evaluate complex, or multiproblem patients. Manager skills are adequate, as John generally did well calling back patients and following up on labs and studies, and did not fall behind on documentation. He needs to continue to develop longer-term planning for more complex patients; having trouble synthesizing different aspects of psychosocial dimensions all pertaining to 1 patient. Educator: John reviewed a randomized trial on 2 different steroids in the treatment of asthma. He seemed minimally prepared and had only very basic understanding of how to interpret and use information from an RCT. Of many potential areas of improvement, would start in the reporter domain by increasing details in histories, increasing completeness of histories, and overall organization of presentations.
Using PRIME+ in Daily Practice
Once familiar with PRIME+, a busy pediatrician can keep short daily notes on learners in each of the domains. Office-based preceptors, who often work one-on-one with students, can use these notes to give formative feedback after each encounter or at the end of the day. Hospital-based pediatricians can keep a PRIME+ table of learners on their team, and then use these organized notes to write evaluations. Because RIME domains relate directly to the work of a physician, the framework helps a preceptor organize observations from daily work into a useful narrative. When listening on rounds or reading notes, teachers can assess reporter skills. In taking an overnight phone call from a student, one can note interpretation of patient data. Manager skills can be evaluated via timely completion of office visits or in coordination of patient care. In all interactions, the teacher can be actively considering where the student is in relation to curriculum goals, and what he or she needs to do to progress to the next level.
Written narratives can be challenging to write and are critically important in medical student and resident education. PRIME+ can provide structure for observation, formative feedback, and for writing summative evaluations at the end of a clinical experience. Using PRIME+ to structure your observations and evaluations, written narratives can be more effective, specific, and meaningful.
- Accepted February 13, 2014.
- Address correspondence to Alison V. Holmes, MD, MPH, Dartmouth-Hitchcock Medical Center, Pediatrics, Rubin 552, One Medical Center Dr, Lebanon, NH 03756. E-mail:
Dr Holmes wrote the original first draft of the article; did most of the re-drafting of the article; sought, read, and reviewed all the references; and led the process of rewrites with the Council on Medical Student Education in Pediatrics editorial committee; Drs Peltier and Lopreiato contributed much of the content to the outline of the first draft of the article, assisted with multiple re-drafts of the article, and wrote individual sections of the article; Dr Hanson contributed substantial new content to the article, assisted with multiple re-drafts of the article, and wrote individual sections of the article; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Pangaro L,
- Holmboe ES
- 6.↵The Association of American Medical Colleges. AAMC Pediatric program focuses on competency-based learning. Available at: https://www.aamc.org/newsroom/newsreleases/343836/05312013.html#.UrhA3yize2w. Accessed December 23, 2013
- Copyright © 2014 by the American Academy of Pediatrics