Competencies "plus": the nature of written comments on internal medicine residents' evaluation forms.

Background: Comments on residents' in-training evaluation reports (ITERs) may be more useful than scores in identifying trainees in difficulty. However, little is known about the nature of comments written by internal medicine faculty on residents' ITERs.

Method: Comments on 1,770 ITERs (from 180 residents in postgraduate years 1-3) were analyzed using constructivist grounded theory beginning with an existing framework.

Results: Ninety-three percent of ITERs contained comments, which were frequently easy to map onto traditional competencies, such as knowledge base (n = 1,075 comments) to the CanMEDs Medical Expert role. Many comments, however, could be linked to several overlapping competencies. Also common were comments completely unrelated to competencies, for instance, the resident's impact on staff (813), or personality issues (450). Residents' "trajectory" was a major theme (performance in relation to expected norms [494], improvement seen [286], or future predictions [286]).

Conclusions: Faculty's assessments of residents are underpinned by factors related and unrelated to traditional competencies. Future evaluations should attempt to capture these holistic, integrated impressions.