Education Research: Moving Beyond "Outstanding": Neurology Program Directors' Perspectives on the MSPE Clerkship Summaries.

Background and Objectives: As standardized metrics in residency selection change, residency program directors increasingly rely on narrative components of the Medical Student Performance Evaluation (MSPE) clerkship summaries. However, wide variability in structure, language, and transparency limits their usefulness for high-stakes decision making. The aims of this study were to explore neurology and child neurology program directors' perspectives on the utility of MSPE neurology clerkship summaries and to identify features that enhance or undermine their value in residency selection. Methods: We conducted a qualitative study using semistructured interviews with US neurology and child neurology residency program directors. Participants reviewed and discussed 4 constructed MSPE neurology clerkship summary cases developed from deidentified authentic MSPE excerpts and designed to reflect variation in structure and content. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analysis informed by theories of narrative assessment and discourse. Trustworthiness was supported through analytic memos, peer debriefing, and investigator triangulation. Results: Thirteen program directors participated, and 6 themes emerged: (1) Participants valued honest and transparent narratives but perceived candid discussion of limitations as risky for students; (2) institutional variability in grading systems, access to neurology experiences, and evaluator practices limited fair comparison of applicants; (3) narratives were most useful when clearly structured, concise, and transparent about how evaluations were synthesized; (4) comparative information was viewed as essential for decision making, despite its susceptibility to bias; (5) program directors consistently reported that coded language was difficult to interpret and should be avoided; and (6) nonspecific laudatory comments diminished narrative value, whereas brief, concrete behavioral examples enhanced credibility and interpretability. Discussion: Neurology clerkship summaries in the MSPE remain influential yet imperfect tools for residency selection. Program directors favor narratives that are structured and specific and avoid coded or vague language. Targeted faculty development and adoption of shared narrative frameworks represent actionable strategies to improve fairness, clarity, and trust in narrative assessment within neurology education.