Performance-based assessment of internal medicine interns: evaluation of baseline clinical and communication skills

To assess baseline clinical and communication skills of entering internal medicine interns in performance of the medical interview and in written documentation of the clinical encounter.

Over three years, entering internal medicine interns at the University of New Mexico Health Sciences Center have taken an OSCE during their first week of training. Each year the process was refined based on feedback from both residents and faculty. This year, the intern examination consisted of four standardized cases. Twenty-two interns performed a focused interview and physical examination on each actor patient. For three of the cases, the intern wrote a chart note following the interview. After the fourth case, a trained faculty member who had watched the interview via a television monitor gave immediate feedback to the intern about his or her communication skills. The standardized patients were trained to complete checklists that included history, physical exam, and communication items for each intern. The written notes were graded using templates devised for each case that covered key historical and physical exam findings, problem identification, differential diagnosis, clinical reasoning, and logical diagnostic or treatment plans. The interns filled out an anonymous evaluation of the exercise where they were asked about whether the cases were appropriate for their level of training, and about how prepared they felt for the examination. The results for each set of skills were then reported to the interns and their supervising clinic attendings. For comparison, they were given the performance standards expected of fourth-year medical students at our institution. The videotaped encounters and the written notes are available for the faculty and trainees to review either together or independently.

This exercise has given the faculty a detailed view of baseline clinical and written documentation skills of our entering interns. Overall, the residents demonstrated at least minimal competency in history taking and communication skills, but not in performing the expected focused physical exam. Their written reports showed adequate documentation of historical items but not of pertinent physical findings. The interns did not consistently make a problem list, provide a differential diagnosis, or show clinical reasoning despite being instructed to do so. There was great variation in performances between interns. Analysis of the interns' evaluations of this exercise showed that they felt it covered appropriate material, and they felt sufficiently prepared. Several interns had never done an OSCE prior to this exam. Written comments were positive about getting structured feedback early in their training. This format has allowed the identification of specific deficiencies in clinical skills for each of our interns, and this information will be used to guide our clinic preceptors in their teaching and in future evaluations. It would be ideal to design a second OSCE based on cases specific to internal medicine for the third-year residents, and compare skills developed over time.