Education Research: Evaluating acute altered mental status

Background: Clinical evaluation of hospitalized patients with acute altered mental status (AMS) is a common task of interns, regardless ofmedical specialty. The effectiveness ofmedical education to ensure competence in this area is unknown. Objective: To measure competency of new interns in the evaluation and management of AMS using an Objective Structured Clinical Examination (OSCE). Methods: A cohort study was conducted with 61 medical school graduates entering internship at a single teaching hospital in 2006. Interns from all major specialty fields were included. The OSCE consisted of a 12-minute simulated encounter with a human patient simulator and nurse actor. Each intern’s performance was graded by the same neurologist, using criteria agreed upon by consensus of the neurology faculty. Competency in obtaining a history, performing a neurologic examination, generating a differential diagnosis, and ordering diagnostic studies was graded. Overall performance was scored on a percentage scale from 0 to 100. Results: Overall performance scores ranged from 19 to 43 with a mean of 31.4 (SD 5.6). Hypoglycemia was identified as a potential cause of AMS by 72.1% of interns, while fewer identified urinary tract infection (45.9%) and seizure (13.1%). While many interns ordered a CXR (86.9%) and head CT (80.3%), few requested a toxicology screen (21.3%) or lumbar puncture (3.3%). Only 41% of interns performed a neurologic examination. Conclusion: New interns are not well-prepared to evaluate patients with altered mental status in the inpatient setting as measured by an Objective Structured Clinical Examination. Neurology 2008;71:e50–e53