Evaluating Clinical Performance in Physical Therapy With Simulated Patients

Abstract

ABSTRACT: The purpose of this study was to investigate the feasibility of using a simulated patient (SP) to evaluate clinical performance in physical therapy. Sixteen subjects performed a history and physical examination of an SP with shoulder pain. The subjects' history taking, physical examination, and communication skills were evaluated by the SP and the investigator. A clinical reasoning test was also administered to the subjects. Subjects found the SP to be very realistic. Interrater and intrarater reliability of the SP met acceptable levels. The evaluation instruments possessed good construct validity, demonstrating higher levels of performance in the more experienced subjects. The use of an SP and a series of well-designed evaluation instruments were found to possess a high degree of validity and reliability.for measuring clinical performance. Key Words: Evaluation, Simulated patient. SIMULATED PATIENTS One of the challenges facing physical therapy educators is the reliable and valid measurement of clinical performance. A variety of mechanisms have been used to measure this construct, but one that has been used quite frequently in medicine and that has great application for physical therapy is the standardized or simulated patient (SP). Barrows1 was the first person to formally develop a procedure for live patient simuladons. He defined a simulated patient as a person who has been carefully coached to accurately portray a specific patient when given the details of the history and physical examination.2 EDUCATIONAL APPLICATIONS AND ADVANTAGES OF SIMULATED PATIENTS Simulated patients have been used extensively in medicine and other disciplines with excellent results. A large number of published works, mostly from medicine, describe these educational applications and are identified in Table 1.3-16 Although SPs are undoubtedly used in physical therapy programs, published reports of their applications are scarce. One of the main advantages cited in the literature is that the SP can be trained to present a case in an unvarying way. Thus, SP responses are reproducible, unlike those of real patients whose symptoms and clinical presentation may vary. This reproducibility ensures that all students see, physically feel, and experience the same patient presentation. Clinical presentations of varying complexity can be selected according to students' level of education. This ensures that curriculum content is appropriately represented and that students are given fair and equal opportunities to demonstrate their learning. Simulated patients are also more accessible than real patients and can be used in nonclinical environments such as the classroom or tutorial setting. They are also safe to use with inexperienced students, eliminating many of the ethical and safety risks associated with the use of real patients. This is particularly useful when the management of emergency or highrisk situations needs to be practiced prior to implementation on real patients. Simulated patients can be used for development of a wide variety of skills in such areas as interviewing, counseling, data gathering, physical examination, psychosocial assessment, and clinical decision making.3 Students are also quite enthusiastic about the use SPs.17,18 SIMULATED PATIENTS AND EVALUATION OF STUDENT PERFORMANCE A variety of methods are currently used to evaluate clinical performance and problem solving in health science programs. One example is the patient management problem. The patient management problem is a written or computer-driven test that uses a clinical vignette and a series of staged questions that are elicited depending on the actions taken by the student in working through the problem. This method has been criticized by educators who state that it is difficult to find consensus among experts regarding the appropriate interventions and pathways for the test. 19,20 Cueing is also a problem in this test, as it does not discriminate candidates any better than more traditional multiple-choice formats. …