Education research: evaluating acute altered mental status: are incoming interns prepared?

Clinical evaluation of hospitalized patients with acute altered mental status (AMS) is a common task of interns, regardless of medical specialty. The effectiveness of medical education to ensure competence in this area is unknown. To measure competency of new interns in the evaluation and management of AMS using an Objective Structured Clinical Examination (OSCE). 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. 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. 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.