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Purpose: Ensuring examiners in different parallel circuits of Objective Structured Clinical Exams (OSCEs) collectively judge to the same standard is critical to the chain of validity. Recent work suggested that the examiner-cohort (i.e. the particular group of examiners) a candidate meets could significantly alter outcomes for some candidates. Despite this, examiner-cohort effects are rarely examined as fully-nested data (i.e. no cross-over between the students judged by different groups of examiners) limit comparisons. This study aimed to replicate and further develop a novel method called Video-based Examiner Score Comparison and Adjustment (VESCA), so that it can be used to enhance quality assurance of distributed or national OSCEs. Method: Six volunteer students were filmed on all12 stations in a summative OSCE. In addition to examining live performances, examiners from all 8 separate examiner-cohorts collectively scored the same pool of video performances. Examiners scored videos specific to their station. Video scores provided linkage within otherwise fully-nested data, enabling comparisons by Many Facet Rasch Modelling. Analysis primarily compared and adjusted for examiner-cohort effects. Additional analyses compared examiners’ scoring when videos were embedded (interspersed between live candidates within the OSCE) or judged later via the internet. Results: Having accounted for differences in students’ ability, different examiner-cohorts scores for the same ability of student ranged from 18.57(68.7%) to 20.49(75.9%), Cohen’s d=1.3. Score adjustment changed up to 16% of students’ classification (pass-fail/ fail-pass) depending on modelled cut score. Internet and embedded video scoring showed no difference in mean scores or variability. Examiners’ accuracy did not deteriorate over the 3 week scoring period allowed for internet-based scoring. Conclusions: Examiner-cohorts produced a replicable significant influence on OSCE scores which was unaccounted for by typical assessment psychometrics. VESCA offers a promising means to enhance validity and fairness in distributed OSCEs or national exams, whilst internet-based scoring may enhance VESCA’s feasibility.

Purpose To report on the implementation of a telephone medicine curriculum as part of the core clerkship in pediatrics for students at Johns Hopkins University School of Medicine and evaluate the curriculum's effect on student performance on a telephone medicine case as part of a required objective structured clinical exam (OSCE). Method Using a prospective cohort design with a convenience sample of third-year medical students during the 2016-2017 and 2017-2018 academic years, the authors compared the OSCE scores of students assigned to the curriculum to both historical and concurrent control groups of students who had not received the curriculum. Additionally, the authors compared the costs of the recommended testing by students in each group using the 2018 Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule. Results Students assigned to the telephone medicine curriculum (students in the intervention group) had a significantly higher mean overall score on the simulated OSCE telephone medicine case compared to the students in the control groups who did not receive the curriculum (the mean score for students in the intervention group was 7.38 vs 6.92 for students in the control groups, P = .02). Additionally, the intervention group had statistically significantly lower costs for their recommended testing compared to the control groups (the median value for tests ordered by students in the intervention group was $27.91 vs $51.23 for students in the control groups, P = .03). CONCLUSIONS;: Implementing a dedicated telephone medicine curriculum for medical students improves their overall performance and delivery of high-value care via telephone medicine as part of an OSCE. Medical educators should pursue ongoing research into effective methods for teaching medical students and residents how to navigate digital encounters.

Problem When medical students with disabilities fail, identifying the underlying cause is challenging. Faculty unfamiliar with disability-related barriers or accommodations may falsely attribute academic struggles to disability. Fear of legal action may prompt inappropriate promotion of students with disabilities who are struggling to meet competencies. Therefore, a clear understanding of the origin of difficulty is critical to determining an appropriate response to the student's failure, including revision of accommodations, academic remediation, probation, and dismissal. Approach A large Midwestern medical college created an innovative approach to differentiate between disability-related barriers and academic deficits by creating a diagnostic objective structured clinical examination (OSCE). The goal of this OSCE was to determine the need for additional or refined accommodations versus clinical remediation, and to guide future decision making about a student on academic probation. Using 3 simulated cases that drew on a cross-section of clinical knowledge, a team of clinical and disability specialists observed a disabled student to determine the origin of that student's difficulties in a clinical rotation. Outcomes Using the diagnostic OSCE, the team quickly identified clinical reasoning and fund of knowledge deficits, and need for further accommodations. As a result, the team was able to remediate the clinical deficits, augment the current accommodations in vivo, and determine the potential impact on performance. The team approach was documented and facilitated the legally required interactive process for determining additional barriers, efficacy of existing accommodations, and need for additional reasonable accommodations. All parties reported a positive experience. The collective knowledge and expertise of the team helped confirm the origin of the deficit: a fundamental lack of knowledge and reasoning skills versus a disability-related barrier. Next steps The next step is to formalize this process to ensure appropriate evaluation of students with disabilities.

Purpose To describe the effect of transgender health-related objective structured clinical examination (THOSCE) case exposure on learner activation regarding gender-affirming care. Method A modified grounded theory approach was applied to identify the educational value of THOSCE cases. Focus groups with current and former primary care internal medicine residents who participated in THOSCE cases were conducted in 2018-2019. Transcripts were analyzed and coded until saturation to identify themes. Results Eighteen (72%) eligible learners participated in the focus groups. Themes were identified relating to gender-affirming care, and modified grounded theory analysis was used as a framework to organize the themes into 4 stages of learner activation: (1) believing the learner role is important, (2) having the confidence and knowledge necessary to take action, (3) taking action to maintain and improve one's skills, and (4) staying the course even under stress. Conclusions Residents were grateful for the opportunity to practice the skills involved in transgender health in a simulation. Many felt unprepared and were concerned about how they were perceived by the standardized patient and faculty. Residents identified feeling more comfortable with gender-affirming language in the inpatient setting, which may provide an opportunity for learning in the future. Residents identified the psychosocial skills of gender-affirming care as more directly relevant while biomedical aspects of gender-affirming care seemed less accessible to residents, given the lack of outpatient experience. The authors propose a staged approach to teaching the skills of gender-affirming care using simulation to address learners of all levels.

Qualitative research approach could be as important as quantitative one, particularly in medical education, as long as it meets the common goal of both—improving the quality of education. In contrary to the end—i.e. achieving the common goals, the means of both approaches of inquiry is different. Their dissimilarity in the means or process is not confined to data collection techniques, study designs or analysis methods; but, they also differ in assumptions about the world, reality, science and knowledge. Implicitly or explicitly, these assumptions are revealed in a researcher's discussion about philosophical assumptions and research paradigms. The researcher's inclination towards any of paradigms and assumption in light of the most common philosophical concepts such as ontology, epistemology and methodology results in choice of either of the dominant research paradigms to follow such as objectivism/positivism and interpretivisim/constructivism. This is common practice in the quantitative-qualitative dichotomy of research world disregarding the emerging mixed approach with predominantly pragmatism paradigm. Besides framing the methodology of the study, researcher's explicit description of philosophical assumptions and paradigms helps readers easily understand study findings. Many authors from both dominant traditions fail to describe this important aspect of the research in their published works. In our study, the ontological and epistemological assumptions led us choose interpretivist/constructivist paradigm and phenomenological qualitative approach with Collaizi's descriptive phenomenological analysis adapted to our context. The experience and lesson learned from the study found to be worse sharing in a modified and extended construct of methodology part. Therefore, this article deals with philosophical positions, research paradigms and traditions that led to the specific qualitative approach from the perspective of methodology part in our study about objective structure clinical examination (OSCE) experience in a medical department., Highlights • Qualitative research approach can be as important as quantitative approach. • A research approach can be determined by preference to certain research paradigm. • Major philosophical concepts in research are ontology, epistemology and methodology. • Disclosing one's research paradigm help research readers easily understand findings. • Collaizi's seven step descriptive phenomenology fits for our OSCE experience study.

Background and objectives Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies. Design, setting, participants, & measurements Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey. Results A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3–4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing “proficiency in ordering” acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format. Conclusions The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_08_CJASNPodcast_19_09_.mp3

Purpose To inform curricular development by assessing the ability of third-year medical students to address a patient's spiritual distress during an acute medical crisis in the context of an objective structured clinical examination (OSCE) case. Method During March and April 2010, 170 third-year medical students completed an eight-station videotaped OSCE at Albert Einstein College of Medicine of Yeshiva University. One of the standardized patients (SPs) was a 65-year-old man with acute chest pain who mentioned his religious affiliation and fear of dying. If prompted, he revealed his desire to speak with a chaplain. The SP assessed students' history taking, physical examination, and communication skills. In a postencounter written exercise, students reported their responses to the patient's distress via four open-ended questions. Analysis of the postencounter notes was conducted by three coders for emergent themes. Clinical skills performance was compared between students who reported making chaplain referral and those who did not. Results A total of 108 students (64%) reported making a chaplain referral; 4 (2%) directly addressed the patient's religious/spiritual beliefs. Students' clinical performance scores showed no significant association with whether they made a chaplain referral. Conclusions Findings suggest that the majority of medical students without robust training in addressing patients' spiritual needs can make a chaplain referral when faced with a patient in spiritual crisis. Yet, few students explicitly engaged the patient in a discussion of his beliefs. Thus, future studies are needed to develop more precise assessment measures that can inform development in spirituality and medicine curricula.

Despite the goal of objective structured clinical examinations (OSCEs) to be objective, examiner biases may influence scores. Examiner familiarity with candidates is a potential bias that has not been well studied.To determine the effect of familiarity, OSCE scores for 158 internal medicine residents were analyzed by whether examiners were familiar with them, based on previous clinical encounters, and if previous impressions were positive or negative. A hierarchical multivariable analysis of variance was performed to control for resident, examiner, and level of training.Across 480 interactions (50 examiners, 158 residents), multivariable analysis showed that positive familiarity was associated with a significant increase in ratings (+0.37 on a 5-point scale), comparable to the difference between first- and third/fourth-year residents.Familiarity with candidates is a significant source of examiner bias in OSCE scores. Consideration should be paid to the influence of examiners' previous knowledge of examinees and attempts made to mitigate this bias.

Background and Purpose. Designing evaluative experiences that can objectively assess clinical performance in didactic settings to ensure adequate skills preparation allows students to be "practice ready" to perform in clinical settings. Objective structured clinical examinations (OSCEs), commonly used by health professions, effectively assess clinical performance of students; however, little literature exists about using OSCEs to assess clinical skills with primarily neuromuscular populations. This project investigated the ability to assess clinical performance in neuromuscular physical therapy using OSCEs. Method/Model Description and Evaluation. Examination stations were developed, validated for content by experts, field tested on recent graduates, pilot tested, and analyzed for reliability. An 8-station OSCE tested performance of examination and intervention procedures, interaction with patients, interpretation of observations, and analysis of clinical situations via 4 interactive, standardized patient stations and 4 scenario-based, written/video stations. Third-year doctor of physical therapy students (n = 66) in their last didactic semester before a 6-month final clinical rotation participated in the pilot testing over a 1-year period. Outcomes. Test stations were valid and reliable (Cronbach's alpha = 0.72). Factor analysis confirmed 2 components to the OSCE, isolating domains representing standardized patient stations and written/ video stations. All stations significantly correlated with the total OSCE score, and significant correlations were identified among patient interaction stations (r = .533 to .884). OSCE scores were highly correlated to the final grade in the course and overall grade point average (GPA). Discussion and Conclusion. Aside from higher than normal anxiety prior to and after the OSCE, students' perception of ability to perform examinations, interventions, or interpret results did not change before and after the OSCE. Successful use of OSCEs in physical therapy programs to assess knowledge and skills related to the management of patients with neuromuscular dysfunction is feasible. More studies investigating the relationship between OSCE performance and clinical performance need to occur. Keywords: Physical therapist education, Student outcomes, Neurology, OSCE. BACKGROUND AND PURPOSE Clinical performance in professional health programs constitutes one of the major efforts that physical therapy faculty consistently work to improve. Valid academic measurement of clinical competency on real patients prior to placement in the clinical setting is needed. In recent years, research has focused on the use of objective structured clinical examinations (OSCEs) and standardized patients (SP) to improve this important assessment of students, while simultaneously attempting to recreate a realistic patient-care scenario during student assessment.1 There is a need to design instructional and evaluative experiences that can clearly and objectively assess students' clinical performance in an academic setting, before going into the clinical setting where they will be working with actual patients. Adequate skill preparation and academic assessment of their clinical performance while still in the classroom allows the students to be "practice ready" for performing in the clinical setting. It also serves as a method to ensure a baseline level of safety and knowledge before the student is in clinical practice with patients. A need to explore various methods of assessing performance is important to college/university accrediting agencies and specialized accreditation agencies, such as the Commission of Accreditation of Physical Therapy Education (CAPTE). Multiple CAPTE accreditation criteria are directly related to this topic, one of the primary being criteria F-21, pertaining to the "determination of student readiness to engage in clinical education."2(PB16) The intent of this criterion is to ensure that "the student is prepared to interact safely with patients/clients. …

When interpreting performance scores on an objective structured clinical examination (OSCE), are all checklist items created equal? Although assigning priority through checklist item weighting is often used to emphasize the clinical importance of selected checklist items, the authors propose the use of critical action analysis as an additional method for analyzing and discriminating clinical performance in clinical skill assessment exercises. A critical action is defined as an OSCE checklist item whose performance is critical to ensure an optimal patient outcome and avoid medical error. In this study, the authors analyzed a set of clerkship OSCE performance outcome data and compared the results of critical action analysis versus traditional checklist item performance scores.OSCE performance scores of 398 third-year clerkship students from 2003 to 2006 at the University of Virginia School of Medicine were analyzed using descriptive statistics and a logistic regression model. Through a consensus process, 10 of 25 OSCE cases were identified as containing critical actions.Students who scored above the median correctly performed the critical actions more often than those scoring lower. However, for 9 of 10 cases, 6% to 46% of higher-scoring students failed to perform the critical action correctly.Failure to address this skill assessment outcome is a missed opportunity to more fully understand and apply the results of such examinations to the clinical performance development of medical students. Including critical action analysis in OSCE data interpretation sharpens the eye of the OSCE and enhances its value in clinical skill assessment.

Purpose To determine the psychometric properties and validity of an OSCE to assess the competencies of Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP) in graduate medical education. Method An eight-station OSCE was piloted at the end of a three-week Quality Improvement elective for nine preventive medicine and endocrinology fellows at Mayo Clinic. The stations assessed performance in quality measurement, root cause analysis, evidence-based medicine, insurance systems, team collaboration, prescription errors, Nolan's model, and negotiation. Fellows' performance in each of the stations was assessed by three faculty experts using checklists and a five-point global competency scale. A modified Angoff procedure was used to set standards. Evidence for the OSCE's validity, feasibility, and acceptability was gathered. Results Evidence for content and response process validity was judged as excellent by institutional content experts. Interrater reliability of scores ranged from 0.85 to 1 for most stations. Interstation correlation coefficients ranged from -0.62 to 0.99, reflecting case specificity. Implementation cost was approximately $255 per fellow. All faculty members agreed that the OSCE was realistic and capable of providing accurate assessments. Conclusions The OSCE provides an opportunity to systematically sample the different subdomains of Quality Improvement. Furthermore, the OSCE provides an opportunity for the demonstration of skills rather than the testing of knowledge alone, thus making it a potentially powerful assessment tool for SBP and PBLI. The study OSCE was well suited to assess SBP and PBLI. The evidence gathered through this study lays the foundation for future validation work.

PurposeTo investigate whether and how use of an online remediation system requiring reflective review of performance and self-assessment influenced students’ performance on objective structured clinical examination (OSCE) station repeats (subsequent to failure on the first attempt) and their

PURPOSE To investigate the influence of testing context and rotation order on third-year medical student performance on a common objective structured clinical examination (OSCE) station in both obstetrics-gynecology (ob-gyn) and psychiatry rotations. METHOD Archival OSCE performance data (in the form of a 25-item binary content checklist) from one class of third-year medical students (n = 141) at Saint Louis University (2002-03) were aggregated and analyzed. RESULTS Despite the fact that the station was identical in both OSCEs, students were, in general, less likely to inquire about ob-gyn issues on the psychiatry OSCE and less likely to inquire about psychiatric issues on the ob-gyn OSCE, regardless of order of rotation. Order did have a positive effect on some results, such that students were more likely to mention menopause and vaginal dryness on the psychiatry OSCE if they had already had the ob-gyn rotation. CONCLUSION The testing context may influence student approaches to patients in ways that bias their collection and interpretation of information. OSCE evaluations may better approximate true clinical context and complexity by presenting case scenarios that reflect a broader range of diagnostic possibilities than those limited to the recently completed rotation.

Purpose. To compare four standard-setting procedures for an objective structure clinical examination (OSCE). Methods. A 12-station OSCE was administered to 84 students in each of the final (fourth-) year medical classes of 1996 and 1997 at Dalhousie University Faculty of Medicine. Four standard-setting procedures (Angoff, borderline, relative, and holistic) were applied to the data to establish a cutoff score for a pass/fail decision. Results. The procedures yielded highly inconsistent results. The Angoff and borderline procedures gave similar results; however, the relative and holistic methods gave widely divergent results. The Angoff procedure yielded results reliable enough to use in decision making for a high-stakes examination, but would have required more judges or more stations. Conclusions. The Angoff and borderline procedures provide reasonable and defensible approaches to standard setting and are practical to apply by non-psychometricians in medical schools. Further investigation of the other procedures is needed. Acad. Med. 2000;75:267‐271.

Background The Medical Council of Canada (MCC) administers an objective structured clinical examination for licensure. Traditionally, physician examiners (PE) have evaluated these examinees. Recruitment of physicians is becoming more difficult. Determining if alternate scorers can be used is of increasing importance. Method In 2003, the MCC ran a study using trained assessors (TA) simultaneously with PEs. Four examination centers and three history-taking stations were selected. Health care workers were recruited as the TAs. Results A 3 × 2 × 4 mixed analyses of variance indicated no significant difference between scorers (F1,462 = .01, p = .94). There were significant interaction effects, which were, localized to site 1/station 3, site 3/station 2, and site 4/station1. Pass/fail decisions would have misclassified 14.4–25.01% of examinees. Conclusion Trained assessors may be a valid alternative to PE for completing checklists in history-taking stations, but their role in completing global ratings is not supported by this study.

The objective structured clinical examination (OSCE) has been the focus of a lot debate with respect to reliability and validity. Much of the controversy surrounding these components lies in a lack of comparison with a "gold standard." Further work is needed to improve the evaluation of clinical skills to the point that a gold standard can truly be said to exist.

To evaluate the effectiveness of binary content checklists in measuring increasing levels of clinical competence.Fourteen clinical clerks, 14 family practice residents, and 14 family physicians participated in two 15-minute standardized patient interviews. An examiner rated each participant's performance using a binary content checklist and a global process rating. The participants provided a diagnosis two minutes into and at the end of the interview.On global scales, the experienced clinicians scored significantly better than did the residents and clerks, but on checklists, the experienced clinicians scored significantly worse than did the residents and clerks. Diagnostic accuracy increased for all groups between the two-minute and 15-minute marks without significant differences between the groups.These findings are consistent with the hypothesis that binary checklists may not be valid measures of increasing clinical competence.

PURPOSE To assess the educational value of an objective structured clinical examination (OSCE) administered in three consecutive years (1992-93 to 1994-95) to first-year residents in a family practice residency. METHOD Each year an OSCE was administered early in a family practice residency based at the University of North Carolina at Chapel Hill School of Medicine. The OSCE encompassed eight to ten stations, each 15 minutes long: ten minutes for tasks and five minutes for feedback. After the OSCE, focus groups with participating faculty and residents assessed the strengths and weakness of specific stations as well as the overall OSCE structure. Each year the residents' OSCE scores were correlated with their scores on the American Board of Family Physicians In-Training Examination (ITE). Pearson product--moment correlation coefficients were calculated for both the composite ITE scores and the clinical set problem scores. Test reliability was measured by Cronbach's alpha. In the spring of 1995 the faculty completed global evaluations of all the residents in the program at the time, including 16 of the 17 residents who had participated in the OSCEs. The faculty rated the residents in four areas, and a four-point scale was based on the percentile ranges a resident's rating could fall into for each area. Correlation coefficients were calculated for the OSCE scores and the faculty's perceptions of the residents' overall performance. RESULTS The OSCE scores correlated significantly with the faculty's global assessments of knowledge and clinical skills, but not with in-training examination scores. Concurrent validity and reliability estimates did not support using an OSCE for decisions about the residents' competency. The faculty valued the opportunity to observe basic skills for the whole group of residents; the residents found the experience educational but stressful and valued the immediate performance feedback included at each station. CONCLUSION The OSCE is a useful tool for teaching basic clinical skills and for forming initial impressions of interns' clinical styles and abilities, but it should be used with caution for summative assessments.

PURPOSE To examine the issue of test security when the same stations on an objective structured clinical examination (OSCE) are repeated across clerkship rotations. Specifically, is there a significant difference in students' scores on stations repeated in three or four rotations within a single academic year? METHOD The sample consisted of 15 stations in the OSCE given at the end of the third-year surgery clerkship at the Southern Illinois University School of Medicine from 1989-90 through 1993-94. Each station was administered three or four times a year. One-way analyses of variance with contrast coding to test for linear trends were used. Results were considered significant at or below the .05 level. RESULTS Only three of the 15 stations showed significant linear trends. A two-part couplet orthopedic station showed a significant decreasing linear trend (p=.0001). Two stations showed significant increasing linear trends: a general surgery couplet station (p=.0004) and a plastic surgery station with an essay question (p=.0253). CONCLUSION There was no consistent evidence that students scored increasingly higher on OSCE stations repeated throughout the year. Thus, it would appear that a clerkship can repeat OSCE stations within an academic year without risk of a trend toward increasing scores.

Objective: Laparoscopic surgery is a required skill for all graduating residents in obstetrics and gynecology. We designed a laparoscopic observed structured clinical experience (Lapar-OSCE) to introduce and advance basic laparoscopic surgical skills. Methods: The Council on Resident Education in Obstetrics and Gynecology training guidelines were used to determine our cognitive and technical objectives. Two half-hour lectures were followed by an OSCE with four skills stations. Program participants were evaluated cognitively with a 25-question examination, and each participant was objectively rated on level of technical confidence in performing 20 common laparoscopic tasks before the OSCE and after the skills stations were complete. Results: There were 29 program participants, including 18 ob-gyn residents, 7 medical students, and 4 staff members. The overall technical confidence survey score improved from 61.7 to 79.6 (P = 0.005), and the examination scores improved from 51.5% to 95.1% (P = 0.0003). Technical confidence scores and cognitive scores improved at all year levels. Conclusion: Our Lapar-OSCE improved both laparoscopic technical confidence and laparoscopic surgical knowledge in our department. We believe that a standardized program for evaluating and improving operative laparoscopic technique will improve operator confidence and skill and may decrease operative time, complications, and anesthesia exposure in our patient population.

Objective This study sought to design, implement, and evaluate a unique educational curriculum in inpatient geriatrics for internal medicine housestaff. Description Traditionally the didactic curriculum on an inpatient geriatrics unit varies according to the attending faculty on service, the types of patients admitted, and preferences of the housestaff and students-in-training. However, a more structured educational curriculum would allow for comprehensive attention to, and a detailed exploration of, the principles of geriatric care necessary to effectively treat all hospitalized older adults. We have developed a unique curriculum using an unfolding case that is followed by an OSCE, which assesses the knowledge and skills gained by the learners. An unfolding case is one that evolves over time and is unpredictable to the learners when they begin participating in the curriculum. It is well suited to postgraduate training and assessment since the learner must develop a differential diagnosis, discuss possible work-ups, and use the work-ups' results to reassess the case as it unfolds. Our scripted case, administered by a geriatrics fellow rotating on the unit, follows an ambulatory geriatric patient from her admission throughout her treatment and until the end of her stay. It culminates in a decision-making session about her functional ability and hence her discharge plans. Moreover, several topics relevant to inpatient geriatrics, including dementia, delirium, falls, urinary incontinence, wound care, and depression, are covered in three one-hour sessions. Written examinations or pre- and post-testing after an intervention are better suited to the early years of medical training but provide poor measures of curriculum mastery and clinical competency. Alternatively, our OSCE approach uses "stations" and "interstations" that provide a structured and timed opportunity to test these skills and assess specific areas of knowledge. We have designed a five-station, five-interstation OSCE that is conducted one week after the unfolding case-based conferences have ended. Learners are evaluated by attending physicians and given immediate feedback after each station and interstation. Discussion This newly developed project has been implemented as a standardized curriculum on our inpatient geriatrics unit since September 2001. Thus far, it has been extremely well received by housestaff because of real-time assessment and review of the materials covered during the month. In addition, this progressive approach has provided an excellent forum for geriatrics fellows to develop teaching skills. Attending physicians have shown their support, finding the content to be appropriate and relevant to inpatient geriatrics. Finally, this didactic approach will be continued on our unit and a modified version is being developed and piloted for other unit staff.