Simulated Encounters Research Articles

Introducing Telepsychiatry to Medical Students with Simulated Patients: An Innovation by Necessity

This article was migrated. The article was marked as recommended. Introduction: The abrupt discontinuation of medical student-patient contact due to the covid-19 pandemic resulted in a rapid change to virtual teaching. Student education was restructured to include online cases, small group discussions, synchronous and asynchronous lectures, and modified problem-based learning and team-based learning sessions. However, the key focus of the clerkship experience, contact with patients, was missing. Process: The Psychiatry Clerkship directors have previously provided complex simulated encounters to students using video-taped encounters of physician-simulated patient interactions to teach and assess student note writing skills. This concept was adapted to a live encounter for individual students on the psychiatry clerkship. Students reviewed the patient chart, performed the encounter, provided an oral patient presentation to faculty, and wrote a patient note. Individualized feedback was provided for each step of the process. Outcomes: The process was well received by students and faculty and provided an opportunity to directly observe student skills despite distancing from direct patient care. The simulated patients had a very positive experience and appreciated the opportunity to advance their own skills while contributing to student's education. Discussion: Removing students from clinical sites stimulated the rapid development of a process to observe learners involved in patient encounters. These educational sessions allowed direct observation of skills required in the initial evaluation of a patient presenting to psychiatry for care.

Medical University of South Carolina College of Medicine.

Medical University of South Carolina College of Medicine.

University of Michigan Medical School.

University of Michigan Medical School.

Texas Tech University Health Sciences Center School of Medicine, Lubbock.

Texas Tech University Health Sciences Center School of Medicine, Lubbock.

Inter-cultural and cross-cultural communication through physicians' lens: perceptions and experiences.

ObjectivesThis study aimed to explore Swedish physicians’ perceptions regarding physician-patient communication in an Iranian context and to obtain a deeper understanding of their lived experience when encountering Middle Eastern and Swedish patients in their daily work. MethodsThis is a multi-method study, including conventional content analysis in combination with phenomenological methodology. A triangulation approach to data collection and analysis was used. Serving the purpose of the study, twelve Swedish physicians with previous experience of Middle Eastern patients were purposely selected to participate in the study. They watched a video showing simulated patient encounter in an Iranian context. The video served as a trigger. Semi-structured interviews were conducted focusing on the participants’ perceptions of the video and their lived experiences. Constant comparative analysis was used for a deep understanding of the data. ResultsThe core themes were cultural diversity, doctor-centeredness, and patient-centeredness. Cultural diversity was a convergent theme and included trust, interpersonal interaction, context, and doctor dominancy. Patient-centeredness and doctor-centeredness were divergent themes and included doctors’ authority, equity, the experience of illness, and accountability. ConclusionsThe participants confirmed large cultural differences in doctor-patient communication when encountering Iranian and Swedish patients. Inter-cultural and cross-cultural competencies were made visible. To be able to appreciate other cultures’ health values, beliefs, and behaviors, increased cultural competence in health care is of importance.

Minimizing Defensiveness in Clinician Education about Implicit Bias: Lessons Learned from a Community‐Engaged Randomized Clinical Trial

AbstractResearch ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contribute to healthcare disparities. How to design an educational intervention to equip clinicians with skills to mitigate implicit bias without inducing defensiveness is unclear. COmmuNity‐engaged SimULation Training for Blood Pressure Control (CONSULT‐BP) Trial is a 5‐year clinical trial educational intervention designed in collaboration with racial, ethnic, and socioeconomically diverse representatives of the local patient community. CONSULT evaluates clinician trainee awareness of and defensiveness about implicit bias pre‐ and postexposure to a face‐to‐face simulation training with standardized patients (SPs) from local racial and ethnic communities.Study DesignPre‐post analysis of trainee bias awareness and defensiveness in the context of a clinical trial that evaluates the impact of an educational intervention to improve clinicians’ interaction skills with diverse populations. Participants completed two, in‐person educational sessions, 5 weeks apart. Learning components included the following: online modules on health disparities, implicit bias, and patient‐centered care; and face‐to‐face simulation encounters with diverse SPs. Four Implicit Association Tests (IATs) were used to measure implicit and explicit bias, and to promote self‐reflection. We measured pre/post bias awareness using a 7‐item Bias Awareness Scale and defensiveness using a 3‐item pre/post measure of reaction to feedback on implicit bias scores. We also collected trainee feedback about the educational experience.Population StudiedGraduate medical and nurse practitioner trainees, including internal medicine, family medicine residents, and nurse practitioner students. We present preliminary findings from CONSULT year 1 cohort (N = 86).Principal FindingsBoth before and after, the intervention participants slightly agreed that they are objective that bias does not affect their decision‐making, disagreed that society treats all groups equally, and that all people have equal opportunity. After the intervention, participants were significantly more likely to disagree with the statement that bias is no longer a problem in patient care (P = .00). In response to feedback on their IAT scores, participants were more likely to agree that the IAT reflects “something about my thoughts or feelings, unconscious or otherwise” (48% pre, 54%, post). Preintervention, 76% agreed that “the IAT captures something important about me” but only 58% agreed postintervention. When asked if the IAT reflects something about their “automatic thoughts and feelings” concerning racial/ethnic bias, 75% agreed preintervention and 65% agreed postintervention. Qualitative feedback from trainees reported that the intervention was a burden on their, taking numerous IATs was redundant, and identified an unmet need to address patient bias toward medical providers.ConclusionsDefensiveness about implicit bias scores increased after exposure to our educational program to mitigate implicit bias. Trainees identified challenges with our educational approach and study design.Implications for Policy or PracticeWe learned of the need to include trainee participants during the design phase of this type of training experience and refined our educational intervention for subsequent cohorts. Without sacrificing essential elements of education, investigators amended the study for years 2‐5 to a single session, one IAT per participant, streamlined content in educational modules and included more in‐person education by an educator with the experience and skills needed to facilitate discussion on this highly charged and complicated topic.Primary Funding SourceNational Institutes of Health.

Supplemental Material for Can Simulated Patient Encounters Appear Authentic? Development and Pilot Results of a Rating Instrument Based on the Portrayal of Depressive Patients

Supplemental Material for Can Simulated Patient Encounters Appear Authentic? Development and Pilot Results of a Rating Instrument Based on the Portrayal of Depressive Patients

Mastery Learning Ensures Correct Personal Protective Equipment Use in Simulated Clinical Encounters of COVID-19.

IntroductionThe correct use of personal protective equipment (PPE) limits transmission of serious communicable diseases to healthcare workers, which is critically important in the era of coronavirus disease 2019 (COVID-19). However, prior studies illustrated that healthcare workers frequently err during application and removal of PPE. The goal of this study was to determine whether a simulation-based, mastery learning intervention with deliberate practice improves correct use of PPE by physicians during a simulated clinical encounter with a COVID-19 patient.MethodsThis was a pretest-posttest study performed in the emergency department at a large, academic tertiary care hospital between March 31–April 8, 2020. A total of 117 subjects participated, including 56 faculty members and 61 resident physicians. Prior to the intervention, all participants received institution-mandated education on PPE use via an online video and supplemental materials. Participants completed a pretest skills assessment using a 21-item checklist of steps to correctly don and doff PPE. Participants were expected to meet a minimum passing score (MPS) of 100%, determined by an expert panel using the Mastery Angoff and Patient Safety standard-setting techniques. Participants that met the MPS on pretest were exempt from the educational intervention. Testing occurred before and after an in-person demonstration of proper donning and doffing techniques and 20 minutes of deliberate practice. The primary outcome was a change in assessment scores of correct PPE use following our educational intervention. Secondary outcomes included differences in performance scores between faculty members and resident physicians, and differences in performance during donning vs doffing sequences.ResultsAll participants had a mean pretest score of 73.1% (95% confidence interval [CI], 70.9–75.3%). Faculty member and resident pretest scores were similar (75.1% vs 71.3%, p = 0.082). Mean pretest doffing scores were lower than donning scores across all participants (65.8% vs 82.8%, p<0.001). Participant scores increased 26.9% (95% CI of the difference 24.7–29.1%, p<0.001) following our educational intervention resulting in all participants meeting the MPS of 100%.ConclusionA mastery learning intervention with deliberate practice ensured the correct use of PPE by physician subjects in a simulated clinical encounter of a COVID-19 patient. Further study of translational outcomes is needed.

Child Abuse Response Simulation for Advanced Practice Nursing Students.

The purpose of this project was for advanced practice nursing students to gain experience taking a history from a parent or caregiver and communicating the treatment plan for an infant in which child abuse is suspected. Fifty-three students participated in a 1:1 simulated encounter with a standardized patient acting as the mother of an infant with a leg injury that reportedly resulted from a fall from the couch. Students received feedback from the standardized patient via an assessment tool and debriefed with faculty immediately after the simulation. All students demonstrated empathy, acknowledged the mother's emotions, and communicated the concern for abuse. Additionally, all students explained the x-ray findings, need for hospital admission, and referral to investigative agency for further evaluation. Simulations designed to provide advanced practice nursing students with experience interviewing a parent and responding in the case of suspected child abuse are an important method of preparing them for initial clinical encounters.

Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus

BackgroundAppropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians. ObjectiveThe objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE. MethodsWe used pretest–posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance. ResultsThe MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62–55.77) at pretest to 94.23% (IQR: 92.13–100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31–100 vs. 92.31%; IQR: 88.46–96.15; p = .13). ConclusionsOur SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting.

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process.

Objectives Uncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians' clinical reasoning process. Methods In this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt's clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.). Results Thirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection. Conclusions These results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

How biased are you? The effect of prior performance information on attending physician ratings and implications for learner handover.

Learner handover (LH), the process of sharing of information about learners between faculty supervisors, allows for longitudinal assessment fundamental in the competency-based education model. However, the potential to bias future assessments has been raised as a concern. The purpose of this study is to determine whether prior performance information such as LH influences the assessment of learners in the clinical context. Between December 2017 and June 2018, forty-two faculty members and final-year residents from the Department of Medicine at the University of Ottawa were assigned to one of three study groups through quasi-randomisation, taking into account gender, speciality and rater experience. In a counter-balanced design, each group received either positive, negative or no LH prior to watching six simulated learner-patient encounter videos. Participants rated each video using the mini-CEX and completed a questionnaire on the raters' general impressions of LH. A significant difference in the mean mini-CEX competency scale scores between the negative (M = 5.29) and positive (M = 5.97) LH groups (P < .001, d = 0.81) was noted. Similar findings were found for the single overall clinical competence ratings. In the post-study questionnaire, 22/28 (78%) of participants had correctly deduced the purpose of the study and 14/28 (50%) felt LH did not influence their assessment. LH influenced mini-CEX scores despite raters' awareness of the potential for bias. These results suggest that LH could influence a rater's performance assessment and careful consideration of the potential implications of LH is required.

HI I CARE: A mnemonic device to frame safe patient encounters and support simulation experiences for novice nursing students

BackgroundRemembering the many safety behaviors and patient care activities expected during a patient encounter can be difficult for novice nursing students. The HI I CARE mnemonic device was created to assist novice nursing students to remember and organize key safety behaviors and patient care activities. Subsequently, the mnemonic device was drafted into a checklist to be used as a performance support tool for students’ first simulation experience. MethodsA survey was designed and administered to beginning nursing students to explore their perception if the HI I CARE mnemonic device helped to (1) reduce anxiety prior to simulation experiences; (2) plan, organize, and deliver care; and (3) integrate classroom learning into the simulated patient encounter. ResultsOverwhelmingly, participants agreed or strongly agreed that the HI I CARE mnemonic helped to achieve these goals. ConclusionThe HI I CARE mnemonic device and correlating checklists are effective performance support tools that can be used to help novice nursing students to recall key safety behaviors and organize patient care activities in the nursing skills laboratory and the simulation setting. This mnemonic device, as a performance support tool, offers associate degree nursing students the opportunity to develop optimal habits that exemplify the safe patient encounter.

Implementation and Impact of a Serious Illness Communication Training for Hematology-Oncology Fellows.

Effective communication between providers and patients with serious illness is critical to ensure that treatment is aligned with patient goals. We developed and tested an implementation strategy for incorporating the previously developed Serious Illness Conversation Guide (SICG), a clinician script, into hematology-oncology fellowship training at a single US academic medical center. Between December 2017 and April 2018, we trained 8 oncology fellows to use and document the SICG. The training included associated communication skills-such as handling emotion and headlining-over 7 didactic sessions. Implementation strategies included training 4 oncology faculty as coaches to re-enforce fellows' skills and an electronic medical record template to document the SICG. We assessed effectiveness using 4 approaches: (1) SICG template use among fellows in the 12months following training, (2) fellow confidence pre- and post-intervention via survey, (3) performance in 2 simulated patient encounters, and (4) semi-structured interviews after 12months. Fellows successfully implemented the SICG in simulated patient encounters, though only 2 of 6 fellows documented any SICG in the clinical practice. Most fellows reported greater confidence in their communication after training. Thematic analysis of interviews revealed the following: (1) positive training experience, (2) improved patient preference elicitation, (3) selected SICG components used in a single encounter, (4) prioritize other clinical duties, (5) importance of emotion handling skills, (6) no faculty coaching receive outside training. Despite acquisition of communication skills, promoting new clinical behaviors remains challenging. More work is needed to identify which implementation strategies are required in this learner population.

Participation in a System-Thinking Simulation Experience Changes Adverse Event Reporting.

System failures are contributing factors in the thousands of adverse events occurring in US healthcare institutions yearly. This study explored the premise that exposure to a simulation experience designed to improve system thinking (ST) would impact adverse event reporting patterns. An intervention-control study was used to explore impacts of participation in a simulation designed to improve ST on adverse event reporting. Each summer Bachelor in Nursing Science students along with medical students participate in a week-long simulation-based interprofessional patient safety course. During the 2017 course, Friday Night in the ER, a table-top simulation designed to develop ST was included. As part of the school nursing's simulation program, students are asked to report adverse events observed or committed during simulation encounters into a simulated adverse event reporting system outside the simulation-based interprofessional patient safety course. Adverse event reporting system data were used to examine patterns of adverse event reporting in control and intervention groups studied. Findings demonstrated differences in proportions of reported adverse events. The proportion of reported adverse events by students with the second and terminal semesters of course work combined and the 2016 and 2018 control groups combined demonstrated statistically significant differences, P < 0.001. Additional analysis revealed that the intervention group reported more medication-related events, whereas the control group reported more failure to rescue and airway-related events. Exposure to a simulation designed to develop ST seems to impact adverse event reporting. These findings support the idea that ST may change safety monitoring behaviors.

Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department

IntroductionEmergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management,...

Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice.

AimsThis research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video‐enhanced feedback and deliberate practice, undertaken at the start of four‐month sub‐specialty rotations.MethodsThree prospective, non‐randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break‐even analysis evaluated cost‐effectiveness.ResultsThere was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI −0.068 to −0.001). The break‐even analysis demonstrates cost‐effectiveness for the intervention.ConclusionSimulated clinical encounters using personalised, structured, video‐enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost‐effective with potential to reduce avoidable harm.

Development and Validation of a Novel Measure for the Direct Assessment of Empathy in Veterinary Students.

Empathy is a requisite clinical skill for health professionals and empathy scores have been positively associated with professionalism, clinical competency, confidence, well-being, and emotional intelligence. In order to improve empathy in the veterinary field, it is critical to measure the construct of empathy accurately. Most research has relied on self-reporting measures to assess empathy, while some studies have recently implemented the use of simulated client encounters in veterinary education. Building on this research, the aim of the current study was to develop and validate a novel quantitative assessment tool-the Empathy Clinical Evaluation Exercise (ECEX)-designed to measure empathy based on directly observable behaviors, using simulated clients. To evaluate empathy, evaluators used the ECEX to assess the performance of student clinicians in a simulated client encounter, which contained a pre-determined number of opportunities designed to elicit empathic responses from student clinicians. Statistical analysis suggests the test has a high degree of inter-rater reliability. In addition, there was moderate correlation between average empathy scores using ECEX and previously validated measures of empathy, compassion satisfaction, and burnout. Using these methods, we found the majority of students we studied had increased empathy scores at the completion of their primary care rotations. These results provide preliminary support for the use of the ECEX as a direct and quantitative tool for the assessment of empathy. Health professionals could use this novel empathy assessment tool to teach students, evaluate teaching strategies, and improve communication competencies in a wide variety of clinical settings. Our broad aim was to examine the utility of a direct and quantitative assessment tool for measuring empathy-the ECEX-in order to answer the following questions: (1) Does the tool have good inter-rater reliability? (2) Does the tool correlate with previously validated empathy measures? and (3) Does the tool correlate with similar constructs of compassion fatigue and burnout? Our secondary aim was to evaluate the change in empathy scores over the course of a 4-month (16-week) primary care rotation (pre- to -post).

Using a self-regulated learning-enhanced video feedback educational intervention to improve junior doctor prescribing

Introduction: Medical school graduates in the UK consistently report feeling underprepared for the task of prescribing when embarking on practice. The effective application of self-regulated learning (SRL) approaches and feedback on complex tasks are associated with improved outcomes in practice-based clinical skills.Aims: This study aimed to investigate the effectiveness of an educational intervention using SRL-enhanced video feedback for improving the prescribing competency of junior doctors.Methods: A prospective cohort study was designed to compare intervention and control cohorts of junior doctors undertaking simulated clinical encounters at the beginning and end of their 4-month rotation through renal medicine.Results: The improvement in prescribing competency for the intervention cohort was significant (p < 0.001) with large effect size (d = 1.42). Self-efficacy improved in both cohorts with large (control cohort p = 0.026, r= 0.64) and medium (intervention cohort p = 0.083, d = 0.55) effect sizes. Goal setting and self-monitoring skills improved in the intervention cohort only with medium effect size (p = 0.096, d = 0.53).Conclusions: SRL-enhanced video feedback is effective for improving prescribing competency and developing SRL processes such as goal setting and self-monitoring skills in simulated clinical encounters. Further research is required to evaluate transferability to other clinical sub-speciality contexts and investigate the effectiveness of the intervention for improving prescribing in non-simulated settings.

Postdebriefing Supervised Practice Improves Clinical Performance During Simulation-Based Cardiopulmonary Resuscitation Encounter

Context Simulation is commonly incorporated into medical and health programs as a method of skill practice and evaluation and can be effective at improving athletic training student learning outcomes when purposefully designed. Objective The purpose of this study was to determine what level of impact participation in supervised practice after debriefing within a simulation-based cardiovascular emergency scenario using the Laerdal SimMan in a university simulation center in the United States had on athletic training students' clinical performance. Design Quantitative quasi-experimental cohort design with repeated measures study. Patients or Other Participants Convenience sample of undergraduate athletic training students (n = 46) enrolled in a professional program at a university in the Midwest. Intervention(s) Participation in supervised practice of cardiopulmonary resuscitation skills after debriefing in a simulation. Main Outcome Measure(s) Clinical competency with associated cardiopulmonary resuscitation skills using the Laerdal Learning Application software program that interfaces with the simulation hardware. Results There was a statistically significant interaction between groups (F1,10 = 18.70, P &amp;lt; .05, η = 652) indicating participants in the supervised practice after debriefing group were significantly higher (mean = 0.72, SD = 0.05) than those that did not have supervised practice after the debriefing (mean = 0.17, SD = 0.05). Conclusions The design and development of a simulation experience is optimized when there is deliberate consideration of what components and exposure to these learning components will lead to certain outcomes. Even though supervised practice after debriefing has been identified as optional for skill-based simulations, the current study demonstrates that the supervised practice of clinical skills component is vital within emergency cardiovascular simulation encounters for participants to increase clinical competency.