Change in action: using positive deviance to improve student clinical performance

At our medical college many students have lower ratings in their clinical performance once they start their clinical years (third year). This is contrary to their results in other written exams. Some students demonstrate better clinical performance. We used the six-step Positive Deviance (PD) Conceptual Framework to identify and disseminate the strategies employed by the successful students to improve group clinical performance. Fifty 3rd year students (of a 5-year MBBS program) rotating through internal medicine were assessed mid-rotation with mini-CEX and 360° evaluations. Twenty students (40%) who performed well were invited for in depth interviews in order to identify positive deviant behavior in their clinical skills learning practices. The seven students (14%) who reported novel behaviors were asked to develop strategies for dissemination of their learning behavior in their peers. They decided to work in small groups with their peers, using the identified PD behaviors to encourage learning of history taking and examining skills in their peers. Group performance was assessed at the end of rotation, using mini-CEX and 360° evaluation in comparison to a subsequent group of students in the same year that did not work in PD peer learning groups. For the 360° evaluation the EP(2) (generalizability coefficient) was 0.92 and for the mini-CEX the EP(2) was 0.95, taking into account the variances between participants, groups, time and the interactions effects; thus indicating good reliability of both the assessment methods. A statistically significant difference (p < 0.05) was seen for improvement in medical interviewing skills and clinical judgment on the mini-CEX exam and 360 evaluation (p < 0.0001) in the PD group. Positive Deviance approach can help highlight behaviors among medical students, which contribute to success but may go unnoticed. Learning strategies based on the PD framework can improve student's group performance.