Lymphoscintigraphy of melanoma: lymphatic channel activity guides localization of sentinel lymph nodes, and gamma camera imaging/counting confirms presence of radiotracer in excised nodes.

UNLABELLED: Lymphoscintigraphy has become a standard preoperative procedure to map the cutaneous lymphatic channel for progression of nodal metastasis of melanoma of the skin. Lymphoscintigraphy was employed to visualize lymphatic channels as a guide to identify sentinel lymph nodes (SLNs). Excised tissue was imaged with a gamma camera to verify the findings of presurgical lymphoscintigraphy. Percent counts of SLN(s) among the total counts of the excised melanoma tumor or scar tissue and SLN(s) were calculated. METHODS: Eleven patients with cutaneous melanoma received four to ten intradermal injections of Tc-99m sulfur colloid at elual distances around the melanoma site. Images were made immediately after injection: 1 minute per image for 15 min; and then 5 minutes or 1,000,000 counts per image for 30 min. After surgery, the excised melanoma tumor or scar and SLN(s) were imaged/counted with a gamma camera. Percent counts of SLNs among the total counts of the excised melanoma tumor or scar tissue and SLNs were calculated. To validate the specimen count accuracy, an experimental phantom study was done. RESULTS: Linear lymphatic channels were identified between the injected sites and the SLNs in each patient. Gamma camera images demonstrated radioactivity in the SLNs of all patients, verifying the lymphoscintigraphy findings. Uptake in the SLNs of ten of the eleven patients ranged from 0.4 to 7.2% (mean 2.2%) of the total counts in excised tissue. We noted that a node with lower uptake should not be ignored because a lower percent of SLN activity does not necessarily rule out existing metastasis. In two of eleven patients, histopathologic showed metastases. One patient's melanoma on the middle back had lymphatic channel activity directed to both axillae. The results of the phantom study validated accuracy of our specimen counts. CONCLUSIONS: Because linear lymphatic channels existed between lymph nodes and the injected sites in all eleven patients, these lymphatic channels could be used as a guide for localizing SLNs. The SLNs indicated by presurgical lymphoscintigraphy were verified by postoperative gamma camera imaging, and radiotracer localization in the SLNs averaged 2.2%.

Secondary hyperparathyroidism: evidence for an association with papillary thyroid cancer.

The association between primary hyperparathyroidism and nonmedullary thyroid malignancies is well known. There is also, however, some evidence for an association between secondary hyperparathyroidism (SHPT) and thyroid cancer. We report three patients in whom invasive papillary thyroid carcinoma (PTC) was diagnosed before (one case) or at the time of (two cases) parathyroidectomy for SHPT. Three women (ages 23, 54, and 64 years) presented with bone pain and pruritus typical of SHPT. All three patients had biopsy-proven parathyroid bone disease and elevated parathormone levels (664, 1674, and 2051 pg/mL). All underwent subtotal parathyroidectomy and total thyroidectomy without complications. Pathology revealed diffuse parathyroid hyperplasia with multifocal invasive papillary thyroid carcinoma (two cases) and follicular variant of papillary thyroid carcinoma (one case). Two cases were associated with metastatic disease to local lymph nodes. The patients received adjuvant radioactive 131I, and remained tumor free 24 to 36 months after surgery with complete resolution of SHPT. We conclude: 1) PTC may accompany SHPT, 2) PTCs associated with SHPT may be locally aggressive although usually they are early tumors, 3) surgeons need to have an index of suspicion for thyroid tumor when operating on patients with SHPT, and 4) routine removal of the thymus as part of the operation for SHPT may have a secondary benefit in diagnosing PTC in the occasional patient.

Cancer pain management skills among medical students: the development of a Cancer Pain Objective Structured Clinical Examination.

Recent surveys suggest that most physicians have inadequate knowledge to assess and manage cancer pain; however, the important domain of clinical performance has not yet been clearly evaluated. The Objective Structured Clinical Examination (OSCE) has become a widely- used and accepted method to evaluate the clinical abilities of medical students. The purpose of this study was to develop and test a Cancer Pain OSCE for medical students evaluating their clinical competence in the area of cancer pain management. A four-component Cancer Pain OSCE was developed and presented to 34 third-year medical students during a sixteen-week combined medicine/surgery clerkship. The content of the objective criteria for each component of the OSCE was developed by a multidisciplinary group of pain experts. The OSCE was designed to assess the students' cancer pain management skills of pain history-taking, focused physical examination, analgesic management of cancer pain, and communication of opioid analgesia myths. Actual cancer survivors were used in the five-minute individual stations. The students were asked to complete a cancer pain history, physical examination, manage cancer pain using analgesics, and communicate with a family member regarding opioid myths. Clinical performance was evaluated using pre-defined checklists. Results showed the student's average performance for the history component was the highest of all four components of the examination. Out of 34 points possible on this clinical skills item, students on average (SD) scored 24.5 (5.2), or 72%. For the short-answer analgesic management component of the Cancer Pain OSCE, the overall score was 32%. Most students managed cancer pain with opioids, however, very few prescribed regular opioid use, and the use of adjuvant analgesics was uncommon. Student performance on the focused cancer pain physical examination was, in general, poor. On average students scored 61% on the musculoskeletal system, but only 31% on both the neurological and lymphathic examination. The overall percent score for the cancer pain OSCE was 48%. We conclude that the Cancer Pain OSCE is a useful performance-based tool to test individual skills in the essential components of cancer pain assessment and management. Of the four components of the Cancer Pain OSCE, medical students performed best on the cancer pain history and performed poorly on the cancer pain physical examination. Information gained from this study will provide a foundation on which future small-group medical student structured teaching will be based.

Cancer pain education: a structured clinical instruction module for hospice nurses.

The learning experience with the Cancer Pain Structured Clinical Instruction Module (SCIM), a highly structured skills training course for medical students, has been reported favorably. The purpose of this study was to present the Cancer Pain SCIM to registered nurses employed in a hospice setting. The goal of the study was to pilot test a structured cancer pain educational program for hospice nurses and to determine the perceived effectiveness of this course on the participants' cancer pain assessment and management skills. A multidisciplinary Cancer Pain SCIM was presented to 25 hospice nurses to improve their understanding of the management of cancer pain. The development group identified essential aspects of cancer pain management and then developed checklists defining specific station content. During the 2-hour Cancer Pain SCIM, nurses rotated through 8 stations in groups of 3, spending 15 minutes at each station. Eight instructors and 6 standardized patients, 5 of whom were survivors of cancer, participated in the course. All participants (students, instructors, and patients) evaluated the course, using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree). Nurses provided self-assessments of their perceived competence on important aspects of cancer pain management both before and after the SCIM. The self-assessment items used a 5-point scale ranging from 1 (not competent) to 5 (very competent). Twenty-five hospice nurses, averaging 4.1 years (range 1-30 years) postgraduation, participated in the Cancer Pain SCIM. Overall, nurses agreed that they improved on each of the 8 teaching items (P < 0.001). The average (SD) pretest score of 2.8 (0.72) improved to 3.8 (0.58) on the post-test (P < 0.001). Nurses believed that their mastery of specific clinical skills, taught in all 8 stations, improved as a result of participation in the course. Nurses strongly agreed (mean +/- SD) that it was beneficial to use patients with cancer in the course (4.6 +/- 0.82). Faculty members enjoyed participating in the course (4.9 +/- 0.35) and indicated a willingness to participate in future courses (4.7 +/- 0.49). Significant perceived learning among hospice nurses took place in all aspects of the Cancer Pain SCIM. Participating nurses, instructors, and patients with cancer appreciated the SCIM format. Nurses and faculty considered the participation of actual patients with cancer highly beneficial. The SCIM format has great potential to improve the quality of cancer pain education.

Cancer pain education: the use of a structured clinical instruction module to enhance learning among medical students.

The Structured Clinical Instruction Module (SCIM) is an educational format developed for the teaching of clinical and interpersonal skills. The purpose of this study was to develop and pilot-test a SCIM to enhance medical students' learning and understanding about cancer pain assessment and management. The Cancer Pain SCIM was presented to 34 third-year medical students. Eight instructors and six standardized patients (five cancer patients) participated in the course. All participants evaluated the course using a five-point Likert scale (1 = strongly disagree; 5 = strongly agree). Students self-assessed their clinical skills before and after the course using a five-point scale (1 = not competent; 5 = very competent). Students agreed [mean (S.D.)] very strongly that the SCIM was a valuable educational experience [4.4 (0.56)] and that it was beneficial to use actual cancer patients in the SCIM [4.5 (0.63)]. Students believed their skills in the assessment and management of cancer pain significantly improved after the course. The SCIM is a valuable and novel instructional format to teach essential skills in the assessment and management of cancer pain to medical students.

A multidimensional approach to breast cancer education.

BACKGROUND: This study was undertaken to present a multidimensional breast cancer education package (BCEP) to medical students in an effort to improve breast cancer education. METHODS: The students were exposed to a four-part BCEP consisting of a hands-on structured clinical instruction module (SCIM), a lecture, a problem-based learning (PBL) small-group discussion, and a written manual. Each component was evaluated with a questionnaire. Students responded to the items using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). RESULTS: The mean overall evaluations for the BCEP components were: SCIM, 4.6; lecture, 4.0; manual 3.8, and PBL discussion, 3.6. Highly rated qualities of the SCIM included organization (4.7), faculty preparedness (4.8), and opportunity to practice skills (4.5). The students agreed that the lecture (4.1), manual (3.8), and PBL discussion (4.2) had prepared them for the SCIM. CONCLUSION: This innovative BCEP effectively improved students' understanding of breast cancer.

Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: a 1-year follow-up.

While some recent research has examined the prevalence and severity of posttraumatic stress disorder (PTSD)-like symptoms following cancer treatment, no research has examined temporal change or stability in these symptoms in cancer survivors. Female breast cancer survivors (n=46) participated in an initial telephone interview and a follow-up interview 12 months later. PTSD symptoms associated with breast cancer were assessed using the PTSD Checklist-Civilian version (PCLC). In general, PTSD symptoms in this population did not diminish over time. While group analyses indicated that PCLC-total and subscale scores were stable across the two assessments, analyses of PCLC scores indicated that many patients exhibited fairly large (>0.5 S.D.) increases and/or decreases in PCLC-total or subscale scores. Some evidence suggested that decreases in PCLC scores between the two study assessments were associated with greater social support and experience of fewer traumatic stressors prior to breast cancer diagnosis. Most significantly, the research suggested that women with greater PTSD symptoms at the initial interview were less likely to participate in the follow-up interview. Implications of this for research and clinical management of PTSD in this population are discussed.

Need for comprehensive women's health continuing medical education among primary care physicians.

BACKGROUND: The Council on Graduate Medical Education's (COGME) Fifth Report on Women and Medicine states that "changes in undergraduate and graduate medical education, in addition to continuing medical education, are needed to address adequately the comprehensive health needs of women." Primary care physicians (PCPs) who completed residency training prior to the establishment of new guidelines for women's health education are dependent on continuing medical education (CME) to update their knowledge and skills. METHODS: Primary care physicians attending a university-based CME program in family medicine were surveyed (n = 300) about their need for CME in women's health topics. Responses were analyzed using chi-square analysis and Pearson correlations. Topics of interest were compared with women's health competencies published in 1997 by the American Board of Internal Medicine (ABIM) and in 1997 by the American Academy of Family Physicians (AAFP). RESULTS: Of 30 women's health topics listed, 22 were of interest to 50% or more of respondents and 11 were of very high interest (p < .05). Respondents most interested in women's health CME were most likely to believe CME would reduce the number of referrals currently required to evaluate women's breast problems. Topics of interest also align well with ABIM and AAFP competencies in women's health. CME in comprehensive women's health care is therefore of high interest to our respondents and topics of greatest interest are identified. IMPLICATIONS: Areas of interest correlate well with new requirements by ABIM and AAFP and should be targeted by CME programs.

Assessing the need for faculty development in women's health among internal medicine and family practice teaching faculty. The Women's Health Education Working Group (WHEWG).

Women's health education is an emerging interdisciplinary field that has recently received national attention. The American Board of Internal Medicine and the American Academy of Family Practice recently have published competencies in women's health for their residents, with increased attention to gynecological and mental health issues. Increasing women's health in the curricula of internal medicine (IM) and family practice (FP) residents will certainly require faculty development among IM and FP teaching faculty. We report a multiinstitution needs assessment among IM and FP teaching faculty for continuing medical education (CME) in multidisciplinary women's health topics. The survey (n = 100) asked whether faculty desired CME in 30 women's health topics. It also requested rates of referral to specialists for breast and menstrual problems and performance of tests commonly carried out in the care of women (e.g., endometrial biopsy, colposcopy, skin biopsy, and sigmoidoscopy) as measures of possible need for CME. Of the 69 respondents, 37% were IM physicians and 63% were FP physicians. Among the 30 women's health topics listed, breast cancer treatment alternatives, infertility for primary care providers, cervical dysplasia, medical treatment in pregnancy, vulvar disease, indications for pelvic ultrasound/endometrial biopsy, and menstrual disorders were of highest interest. The ranking of desirability of topics by IM and FP faculty correlated by .54 (Spearman rank, df = 28, p < 0.01). Analysis of variance revealed a significantly higher interest overall by IM than FP physicians, 58% vs. 42% (F = 4.1, df = 1, 50, p < 0.05). None of the IM teaching faculty performed endometrial biopsy or colposcopy compared with 57% of FP physicians, and only 12.5% of internists performed skin biopsy and sigmoidoscopy compared with 70% of FP physicians (F = 33, df = 1, 38, p < 0.001). We conclude that faculty development in women's health would benefit resident training in IM and FP, and topics of interest are identifiable. The correlation in interests between the IM and FP teaching faculty might make joint programs successful, although gynecological skills and knowledge clearly are needed more by IM teaching faculty. Obstetrics and gynecology (OB/GYN) faculty could be instrumental in improving women's health education among their IM and FP colleagues.

Rheumatoid symptoms following breast cancer treatment: a controlled comparison.

The prevalence of rheumatoid symptoms following breast cancer (BC) treatment was examined. Breast cancer patients (n = 111) who were a mean of 27.6 months postcompletion of BC treatment and 99 otherwise healthy women with benign breast problems (BBP) completed a self-report measure that assessed current joint pain, swelling, and stiffness, as well as measures of quality of life. Results supported a hypothesized link between BC and rheumatoid symptoms: (1) the BC group was more likely to report joint stiffness lasting more than 60 min following morning waking; (2) the prevalence of unilateral or bilateral joint point or swelling was greater (P < 0.10) in the BC group for four of 10 joint-symptom combinations examined, with differences between the BC and BBP groups in upper extremity joint swelling particularly pronounced; and (3) 41% of the BC group reported that current rheumatoid symptoms exceeded those experienced prior to diagnosis. Within the BC group, the data did not support postchemotherapy rheumatism as an explanation for rheumatoid symptoms. Rather, data suggested that symptoms were associated with surgical management of BC. Finally, among women in the BC group with the most severe joint pain, only a minority were receiving medication for these symptoms. Given the relationship between rheumatoid symptoms and quality of life, more systematic research examining potential contributing factors such as menopausal status, concurrent lymphedema, and weight gain is warranted.

Cancer pain assessment and management recommendations by hospice nurses. University of Kentucky, Lexington, Kentucky.

Pain is often the most prevalent symptom among cancer patients referred to hospice or palliative care programs. This study was designed to use performance-based testing to evaluate the skills of hospice nurses in assessing the severe pain of a cancer patient and the pain management recommendations they would present to the patient's primary care physician. Twenty-seven hospice nurses (ranging in experience from 1 month to 10 years) were presented with the same standardized patient with cancer pain. In Part A (7 minutes), one of the investigators checked for predetermined behaviors as the nurses performed the clinical pain assessment. In Part B (7 minutes), the nurses answered questions regarding their recommendations for pain management for the patient seen in Part A. In the admission pain assessment, hospice nurses did well in assessing pain intensity (85%), pain location (70%), and pain-relieving factors (59%). However, only 48% of the nurses adequately assessed the pain onset, and only 44% adequately assessed other symptoms the patient might be experiencing. In Part B, 96% of the nurses recommended opioids, 96% recommended the oral route of administration, and 82% recommended regular dosing of the opioids. Fifty-six percent of nurses included a breakthrough medication in their analgesic recommendations. All of the hospice nurses treated the patient's fear of addiction in an appropriate manner, and 93% of the nurses recommended increasing the patient's opioid dosage to treat the persisting pain problem. There were no significant differences among nurses with regard to length of time as a hospice nurse or hospice certification on any of the items in either Part A or Part B. Most practicing hospice nurses were judged to be competent in the assessment and management of the severe pain of the standardized cancer patient, although some deficits were noted. Regular oral opioids were the analgesics of choice. Co-analgesics were rarely recommended.

The relative contributions of interpersonal and specific clinical skills to the perception of global clinical competence.

BACKGROUND: The objective structured clinical examination (OSCE), an established instrument for evaluating resident competence, was used to test the hypothesis that faculty assessment of clinical competence in residents at various levels of training may be influenced more by general skills as a physician and less by competency in the actual skills being specifically tested. In this study, advantage was taken of the anticipated observation that general surgery residents did not demonstrate improvement in their ability to perform a focused neurological assessment over time. METHODS: An OSCE, which was administered to 56 general surgery residents at all levels of training, included the assessment of a specific clinical neurosurgical problem (sciatica). Univariate and multivariate analyses were used to evaluate the relationship between the global faculty judgment of competent or noncompetent and the other performance measures that were applied. RESULTS: At different levels of training, there was no observed difference in the specific skills being tested; nevertheless, junior and senior residents were more likely than incoming interns to be judged "competent" and received better evaluations of how well they introduced themselves to the patient. The competence judgment correlated significantly with all of the other performance measures, including the skills being tested. CONCLUSIONS: The perception of competence is not solely dependent upon the particular skills under scrutiny. General competence does not guarantee competence in each specific skill set of a medical specialty.

Interpreting the judgment of surgical faculty regarding resident competence.

BACKGROUND: It is reasonable to propose that competence is a multifaceted characteristic defined in part by some minimum level of knowledge and skill. In this study we examined the relationship between surgical faculty's judgment of clinical competence, as measured by a surgical resident objective structured clinical examination (OSCE), and the residents' objective performance on the skills being tested. METHODS: Fifty-six general surgery residents at all levels of training participated in a 30-station OSCE. At the completion of each station, the faculty proctor made several overall judgments regarding each resident's performance, including a global judgment of competent or not competent. The competence judgment was applied to the objective percentage performance score in three different ways to construct methods for determining competence based solely upon this objective percentage score. RESULTS: The average mean competent score (MCS) across the stations was 61%, and the average mean noncompetent score (MNCS) was 38%. The difference between MCS and MNCS for each station was very consistent. Upper threshold scores above which a judgment of competent was always made, and lower threshold scores below which a judgment of noncompetent was always made were observed. Overall, the average mean and threshold scores for competent and noncompetent groups were remarkably similar. For performance scores in the range between the threshold competent and noncompetent scores at each station, measures other than objective performance on the skills being evaluated determined the judgment of competent or not competent. CONCLUSIONS: Empirically determined minimum acceptable standards for objective performance in clinical skills and knowledge appeared to have been subconsciously applied to the competence judgment by the faculty evaluators in this study. Other factors appeared to have become determinate when the objective performance score fell within a range of uncertainty.

Postoperative radiation therapy for primary vs. recurrent squamous cell carcinoma of the head and neck: results of a comparative analysis.

BACKGROUND: There is little literature comparatively evaluating the results of postoperative radiation therapy (RT) for patients with squamous cell carcinoma (SCC) of the head and neck treated for primary versus recurrent disease. METHODS: Between 1981 and 1993, 174 patients with SCC of the head and neck, 143 with primary and 31 with recurrent disease, were treated with standard postoperative RT. RESULTS: Patients treated for primary disease had 5-year local-regional control (LRC) and disease-specific survival (DSS) rates of 69% and 54%, respectively, as compared with 46% and 32%, respectively, for patients treated for recurrent disease (P = 0.03 and 0.04, respectively). On multivariate analysis, only tumor type (primary vs recurrent) significantly influenced LRC (P = 0.003) and only primary tumor site (oral cavity vs nonoral cavity) significantly influenced DSS (P = 0.04). Among the patients treated for recurrent disease, site of recurrence (undissected vs dissected tissue) significantly influenced both LRC and DSS (P = 0.008 and 0. 001, respectively). CONCLUSIONS: Patients with recurrent SCC of the head and neck do poorly as compared with those with primary disease when treated with standard postoperative RT, particularly when the recurrence is within previously dissected tissue. This patient group should be targeted for alternative treatment strategies.

Cancer survivors as standardized patients: an innovative program integrating cancer survivors into structured clinical teaching.

BACKGROUND: Increasingly, standardized patients are involved in medical education; however, reports of cancer survivors functioning as standardized patients have not been available. This study describes the participation of cancer survivors as standardized patients in structured clinical teaching. METHODS: Forty-two cancer survivors, 354 trainees, and 54 faculty members took part in the structured clinical instruction modules (SCIMs) at five academic institutions. After completing the SCIMs, the cancer survivors answered evaluation questionnaire items concerning their perceptions of the course, and all participants (cancer survivors, faculty members, medical students, and residents) rated the benefit of the participation of cancer survivors. The evaluation items were rated on a five-point scale ranging from 1 = "strongly disagree" to 5 = "strongly agree. RESULTS: The evaluation responses were very positive, and the cancer survivors expressed a strong willingness to participate in future courses. Faculty members, residents, and medical students all rated the benefit of using cancer survivors highly. CONCLUSIONS: The participation of cancer survivors in structured clinical teaching was considered beneficial not only by the cancer survivors themselves, but also by the faculty members, residents, and medical students who were involved in the educational program. The role of cancer survivors in the education of physicians needs to be expanded.

Surgical teaching quality makes a difference.

BACKGROUND: This study examined the influence of the quality of faculty members' teaching on student performance in a third-year surgery clerkship. METHODS: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member's overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. RESULTS: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination (P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. CONCLUSIONS: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.

Advances in the pathogenesis and treatment of thyroid cancer.

Thyroidectomy remains the mainstay of treatment for thyroid carcinoma. The extent of surgical resection, however, remains controversial as most patients will have excellent long-term prognosis and because some of the standard staging and prognostic information are not available at the time of surgical resection. The different staging and risk group definitions for thyroid carcinoma are not superior to the Tumor-Node-Metastasis classification of the American Joint Commission in Cancer (AJCC), which is universally available and accepted and should be used to report treatment outcomes. Recent advances in the molecular pathogenesis of thyroid malignancy will help identify high-risk patients who would benefit from aggressive surgical resection and adjuvant treatment.

Physical symptoms, distress, and breast cancer risk perceptions in women with benign breast problems.

Physical symptoms, general and breast cancer-specific distress, and perceived breast cancer risk were assessed in 66 women with benign breast problems (BBP) and 66 age-matched healthy comparison (HC) women. BBP women reported significantly greater worry about breast cancer than HC women. Breast symptom incidence and breast cancer risk perceptions were found to mediate group differences in breast cancer worry. Hierarchical regression analyses indicated that perceptions of control over a potential breast cancer prognosis moderate the impact of breast symptoms on reports of breast cancer worry. Implications for risk counseling with BBP women are discussed.

Assessing residents' clinical performance: cumulative results of a four-year study with the Objective Structured Clinical Examination.

BACKGROUND: The Objective Structural Clinical Examination (OSCE) is an objective method for assessing clinical skills and can be used to identify deficits in clinical skill. During the past 5 years, we have administered 4 OSCEs to all general surgery residents and interns. METHODS: Two OSCEs (1993 and 1994) were used as broad-based examinations of the core areas of general surgery; subsequent OSCEs (1995 and 1997) were used as needs assessments. For each year, the reliability of the entire examination was calculated with Cronbach's alpha. A reliability-based minimal competence score (MCS) was defined as the mean performance (in percent) minus the standard error of measurement for each group in 1997 (interns, junior residents, and senior residents). RESULTS: The reliability of each OSCE was acceptable, ranging from 0.63 to 0.91. The MCS during the 4-year period ranged from 45% to 65%. In 1997, 4 interns, 2 junior residents, and 2 senior residents scored below their group's MCS. MCS for the groups increased across training levels in developmental fashion (P < .05). CONCLUSIONS: Given the relatively stable findings observed, we conclude (1) the OSCE can be used to identify group and individual differences reliably in clinical skills, and (2) we continue to use this method to develop appropriate curricular remediation for deficits in both individuals and groups.