Self-assessment Of Communication Skills Research Articles

Artful oncology: A comprehensive psychosocial oncology curriculum for hematology/oncology fellows.

9008 Background: Of patients with cancer, 46% experience significant psychosocial distress, a factor linked to higher morbidity, mortality and costs of care. Oncologists themselves face psychosocial distress, particularly during their fellowship training, with as many as 38% of hematology/oncology (H/O) fellows reporting burnout during training. The ACGME recognizes this risk and has recently included well-being skills in their professional milestones, in addition to milestones for assessing psychosocial issues and communication skills for addressing these complex patient needs, which are often a source of distress among clinicians. Very few published curricula are available to address these layered learning needs among H/O fellows. Methods: “Artful Oncology” is a multifaceted curriculum for H/O fellows focusing on four pillars: 1) monthly didactic lectures about psychosocial issues within cancer care; 2) bimonthly narrative medicine seminars reflecting on didactic themes; 3) quarterly communication skills training conducted with standardized patients; and 4) monthly cancer survivorship support group facilitation. This curriculum was instituted with the inaugural class of H/O fellows at Inova Schar Cancer Institute in 2021 (total 6 fellows to date) with iterative improvements. Outcomes were measured through self-assessed communication skills, scored feedback for each didactic, annual Physician Belief Scale (PBS) surveys, quarterly Professional Quality of Life (ProQOL)-Health and abbreviated Maslach Burnout Inventory (MBI) surveys. Results: Fellows rated didactics as being relevant to their work, prepared to implement the skills learned into clinical practice, and would recommend these sessions to others (average 4.58, 4.59, and 4.67 out of 5-point Likert scale). Among 19 evaluated didactic topics evaluated to date, the most highly rated sessions included Oncology Psychiatry, Integrative Approaches to Symptom Management, Hospice Behind the Scenes, and Moral Injury/Moral Distress (average 5.0); lowest rated included Mindfulness, Sexual Health, Recognizing Depression, Grief, and Adolescents/Young Adults (average 4.29). PBS scores numerically improved from 2022 to 2023 (78 to 68.8 out of 160, lower being associated with a more psychosocial approach to patient care). MBI and ProQOL Health scores were largely unchanged (<2 point difference on average). Self-assessed communication skills averaged across rising fellows increased from 4.38 to 7.44 out of 10 between 2022 and 2023. Conclusions: The Artful Oncology curriculum numerically improved self-assessed communication skills and attitudes regarding the physician role within psychosocial aspects of patient care. Didactic sessions were rated as highly relevant, actionable, and recommended by H/O fellows. Study of this curriculum over a longer timeframe with larger numbers of fellows is ongoing to better evaluate effects.

Communication training in otorhinolaryngology education : Comparison of an online and aclassroom-based training course

Communication skills are among the most important key qualifications of the medical profession. To what extent these can also be acquired online in medical education in otolaryngology is investigated in this study. Avoluntary online training for the teaching of communication skills was compared with acorresponding face-to-face format. The question of the extent to which acceptance of the two formats and students' self-assessment of their communicative skills differed was investigated. In the online training, students were prepared for the topic asynchronously via avideo. Thereafter, they were able to conduct consultations with simulation patients online and synchronously. The face-to-face training was comparable in structure and duration and took place in an earlier semester. The acceptance of both seminars was assessed by aquestionnaire with 19items on afive-point Likert scale. Self-assessment of communication skills was measured by a10-cm visual analog scale pre/post with 16items. Both formats achieved high acceptance with an average score (M) of 2.08 (standard deviation, SD = 0.54) for the online format and M = 1.97 (SD = 0.48) for the face-to-face event. Students' self-assessments of communication skills showed atwofold increase in the online group (M = 1.54, SD = 0.94) compared to the face-to-face group (M = 0.75, SD = 0.87). This study shows that teaching communication skills in the online format was well accepted and resulted in significant changes in students' self-assessment of communication skills.

Outcome of Communication Training in Veterinary Studies: Influence on the Perception of the Relevance of Veterinary Competencies and Self-Assessment of Communication Skills.

Since communication skills contribute significantly to professional success among veterinarians, there is a particular focus on developing communication classes in veterinary curricula. At Freie Universität Berlin, an e-learning course covering the basics of communication and a practical communication course based on role plays with and without simulation persons have been established. The outcome of these communication courses on the assessment of the relevance of several veterinary competencies and on the self-assessment of communication skills using the SE-12 questionnaire was investigated. For this purpose, students were surveyed before and after the e-learning course as well as before and after the practical course. Veterinarians were also surveyed on the relevance of veterinary competencies. The relevance of communicative competencies for professional success was rated significantly higher by the students after completing the practical course than by the other students and the veterinarians. Self-assessment of communication skills showed little increase after the e-learning course, but a significant increase after the practical course. Thus, an effective outcome of the communication classes was observed mainly after the practical course. However, the effect of the e-learning course cannot be ruled out since the students participating in the practical course have also completed the e-learning course beforehand.

Effect of a One-Time Communication Training Session on Dental Students' Self-Efficacy Expectancy.

An implementation of training units that provide evidence for improving students' communication skills in the dental curriculum is now more than ever of utmost importance. This study aimed to investigate how students assess their skills after communication training and whether this training also increased students' self-efficacy expectancy. A total of 32 male and 71 female students with a mean age of 25.6 ± 3.9 years participated in the study. Self-assessment of communication skills and self-efficacy expectancies were collected at two time points using Likert scales. Our study shows that the communication training, consisting of a practical exercise with actors and an online theory module, significantly improved the students' self-assessment of their communication skills and also improved some aspects of self-efficacy expectancy. These results indicate that, in addition to the practical and technical-theoretical training of students, communication training is essential in the dental curriculum. In summary, this study showed that a one-time practical exercise with actors together with an online theory module could improve both the self-assessment of communication competence and some aspects of self-efficacy expectancy, which demonstrates the importance of training communication skills alongside practical and technical-theoretical training.

Medical Students’ Self-Assessment of Communication Skills During COVID-19 Pandemic at Tabriz University of Medical Sciences

Background. In addition to patient satisfaction and treatment compliance by patients, appropriate physician-patient communication leads to development of a relationship between physicians and patients based on trust. The purpose of this study was self-assessment of medical interns and stagers of Tabriz University of Medical Sciences in communicating with the patients during COVID-19 pandemic. Methods. The population of this cross-sectional study included all medical stagers and interns at Tabriz University of Medical Sciences, Iran from November to December, 2020. The research tool was a standard questionnaire of Interpersonal Communication Skills Scale developed by Vakili et al. to assess interpersonal communication skills. After the online questionnaires were filled by the students, we calculated and compared the mean score of self-assessment of communication skills for the medical stagers and interns. Additionally, we compared the mean scores of students’ self-assessment in term of educational level, gender, wards and on duty hours during a week. Results. In this study, a total of 152 medical stagers and interns participated. More than half of the participants were female (55.92%). The mean self-assessment score of the participants was 93.83±9.78. The mean self-assessment score of medical stagers and interns was 93.15±8.13 and 94.51±12.26, respectively. There was no statistically significant difference in self-assessment score of patient communication based on educational level and ward (surgical and non-surgical), but the mean score of self-assessment was significantly higher in females (P=0.044). Conclusion. Most medical interns and stagers had an average self-assessment score regarding patient communication during COVID-19 pandemic. So, appropriate training can improve medical students’ communication skills. However, the communication skills required for medical students may vary depending on whether they are dealing with a pandemic or non-pandemic situation.

Art Therapy and Applied Improvisation: High Impact Learning Strategies to Enhance Communication and Professional Identity

ABSTRACT Students who engage in high-impact learning initiatives such internships, capstone research projects, and collaborative activities report gains in personal development that include growth in self-confidence, increase in independent work and thought, and a sense of accomplishment. These are integral to professional identity and competency in graduate training of art therapists. The authors projected that students who participate in applied improvisation workshops would identify an impact on their personal and professional development through increased skill development and confidence. Program evaluation found applied improvisation and art therapy workshops for the enhancement of graduate art therapy students’ clinical skills to be successful in increasing students’ self-assessment of communication skills and enhancing a sense of professional identity and overall competency.

Effectiveness of online communication skills training for cancer and palliative care health professionals: A systematic review.

To determine the reported effect of online communication skills training (CST) on health professional (HP) communication skills and patient care outcomes in cancer and palliative care. Primary research published in English between January 2003 and April 2019 was identified in bibliographic databases including Medline, Embase and Proquest (Prospero: CRD42018088681). An integrated mixed-method approach included studies describing a CST intervention and its effect, for cancer or palliative care HPs, delivered online or blended with an online component. Included studies' outcomes were categorised then findings were stratified by an evaluation framework and synthesised in an effect direction plot. Risk of bias was assessed using Joanna Briggs Institute's tools. Nineteen included studies (five randomised controlled trials, 11 pre-post, two post-test and one qualitative study) evaluated a CST intervention (median duration=3.75h; range 0.66-96h) involving 1116 HPs, 422 students and 732 patients. Most interventions taught communication skills for specific scenarios and approximately half were delivered solely online and did not involve role plays. Online CST improved HPs' self-assessed communication skills (three studies, 215 participants), confidence (four studies, 533 participants), and objective knowledge (five studies, 753 participants). While few studies evaluated patient outcomes, CST may benefit observed communication skills in care settings (two studies, 595 participants). Online CST benefits oncology HPs' subjectively-reported communication skills and confidence, and objective knowledge. Translation to patient outcomes requires further investigation. The quality of research varied and few studies had a control group. We recommend improvements to study design, evaluation and implementation.

Rehearsal simulation for antenatal consults.

BackgroundRehearsal simulations are patient-specific case- matched tasks performed immediately prior to the actual task, with the objective of improving performance.ObjectiveHow does rehearsal simulation for antenatal consults impact how residents learn to engage in difficult conversations with families?Study DesignResidents in the NICU performed case-matched video recorded rehearsal simulations, followed by actual antenatal consults. The purpose of antenatal consults is to prepare parents expecting a complication with their baby before birth. Questionnaires assessed changes in resident confidence and self-assessment of communication skills. Residents were interviewed for qualitative data to explore the overall impact of rehearsal simulation on their learning and performance.ResultsThirteen residents participated. Rehearsal simulation improved confidence with a more organized approach of medical content and better communication techniques, allowing for a shift of focus from a checklist approach to building rapport and displaying empathy.ConclusionsWhile rehearsal simulation did not prepare residents for unexpected parent responses, trainees’ increased confidence with medical content organization and communication techniques created space for reflection-in-action and compassionate approaches.

Physician Self-assessment of Shared Decision-making in Simulated Intensive Care Unit Family Meetings

Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them. To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.

Comparing the learning effects of debriefing modalities for the care of premature infants.

The aim of this study was to compare the learning effects of debriefing methods used in the simulation of prematurity care by measuring: (i) academic self-efficacy; (ii) confidence in performance; (iii) self-assessed communication skills; and (iv) satisfaction. We employed a quasi-experimental design with three experimental groups that experienced instructor-directed, self-directed, and video-assisted, self-directed debriefing, respectively. Participants were 146 senior nursing students from three nursing schools. To compare learning effects, the same developed scenario for prematurity care was applied to all three groups. Significant differences were observed in the mean scores for the study variables among the three groups. The post-hoc analysis showed that the video-assisted, self-directed debriefing group obtained the highest mean score difference for confidence in performance, self-assessed communication skills, and satisfaction with the debriefing method. Thus, video-assisted, self-directed debriefing could be the most effective debriefing method for students.

Development of a self-assessment tool for resident doctors’ communication skills in India

PurposeEffective communication skills are essential for resident doctors to provide optimum patient care. This study was conducted to develop and validate a questionnaire for the self-assessment of resident doctors’ communication skills in India.MethodsThis was a mixed-methods study conducted in 2 phases. The first phase consisted of questionnaire development, including the identification of relevant literature, focus group discussions with residents and experts from clinical specialties, and pre-testing of the questionnaire. The second phase involved administering the questionnaire survey to 95 residents from the Departments of Medicine, Emergency Medicine, Pediatrics, and Surgery at the All India Institute of Medical Sciences, New Delhi, India in April 2019. Internal consistency was tested and the factor structure was analyzed to test construct validity.ResultsThe questionnaire consisted of 3 sections: (A) 4 items on doctor-patient conflicts and the role of communication skills in avoiding these conflicts, (B) 29 items on self-assessment of communication skills in different settings, and (C) 8 items on barriers to practicing good communication skills. Sections B and C had good internal consistency (Cronbach α: 0.885 and 0.771, respectively). Section C had a 2-factor solution, and the barriers were classified as ‘training’ and ‘infrastructure’ factors.ConclusionThis appears to be a valid assessment tool of resident doctors’ communication skills, with potential utility for identifying gaps in communication skills and developing communication skills modules.

Communication Course for Pediatric Providers Improves Self-efficacy.

Communication is essential to building a trusting, clinician-patient relationship. Multiple studies have demonstrated the effects of experiential communication training on patient experience and provider well-being and resiliency. To date, no studies have described an organization-wide communication training program for pediatric clinicians. The objective of this study was to evaluate the impact of a pediatric-focused communication course on provider satisfaction, self-efficacy, and burnout. Texas Children's Hospital, in collaboration with the Academy on Communication in Healthcare, designed and implemented a pediatric focused communication course entitled Breakthrough Communication. Pre, immediate-post, and 3-month postcourse completion online surveys were sent to participants 1 day before, 1 day after, and 3 months after course completion. Participant demographic information, self-assessment of communication skills, the Maslach Burnout Inventory Human Services Survey, and postcourse satisfaction data were collected. Participants reported high course satisfaction and improved self-efficacy in all measured skill sets both following and 3 months after course completion. Trends indicating a reduction in provider burnout improved in 2 of the 3 Maslach Burnout Inventory domains; however, statistical significance was not achieved. A pediatric-focused communication course was well received by multi-specialty clinicians within a large, academic health care organization. This course enhanced clinician self-efficacy with newly learned pediatric encounter specific communication skills.

Breaking bad news to patients with spinal cord injury in Turkey – physiatrists’ perspective

Objective: To explore Turkish physiatrists’ experiences and opinions about breaking bad news (BBN) to patients with spinal cord injury (SCI).Design: A cross sectional study.Setting: Turkey.Participants: Sixty-nine physiatrists completed a questionnaire about experiences and opinions regarding BBN and self-assessment of communication skills (CS).Results: Eleven percent of specialists and 53% of residents were trained on basic CS. All participants believed that physiatrists should play a role in BBN and the majority reported that they delivered the bad news in their clinic. Sixty-seven percent believed that the primary responsibility belongs to physiatrists. Sixty-eight percent reported that the most appropriate time for BBN is during rehabilitation. Self-assessments of CS were considered satisfactory in most steps of SPIKES protocol. Twenty percent told absolute truth to patients while 80% stated that they did so sometimes or partially. Only 41% confirmed that they do not use unrealistic statements to comfort patients. Fewer than 60% stated that they performed the most appropriate and excellent behaviors for items in “empathy” section.Conclusion: Physiatrists had different opinions about the style of BBN. Self-assessments of CS were optimistic, however physiatrists were not fully satisfied with their empathy skills.

Hearing Our Patients’ Voices in Pediatric Education: A Multi-Institution Resident Self-Assessment of Communication Skills With Patients

Hearing Our Patients’ Voices in Pediatric Education: A Multi-Institution Resident Self-Assessment of Communication Skills With Patients

Learning Doctor-Patient Communication - Evaluating the effectiveness of the communication training course at Leipzig University from the students' point of view.

Objective: At the University of Leipzig, the requirements of the Licensing Regulations for Doctors (Approbationsordnung für Ärzte) for the practical training of communication skills are actively implemented by a two-semester communication course. During this course, student tutors impart the basics of interpersonal as well as selected aspects of doctor-patient communication using interactive training methods. This article reports on the effect the training has on the self-assessed communication skills of the medicine students.Methods: The students’ self-perceived communication skills were assessed, both at the beginning and after the completion of the first and second course semesters using questionnaires related to the course’s learning goals. Pre-post comparisons were then carried out. 142 students (of 163 students in total) participated in the survey at the start of the course, of which 117 completed the T2-questionnaire at the end of the first course semester. Only the 84 students who also completed the questionnaires in the second course semester were included in the statistical analysis. These responses were analysed using both descriptive and inferential statistics.Results: The comparison of the self-assessments between the four measurement points showed that statistically significant learning progress for all assessed communication skills had taken place from the point of view of the students. The largest changes between measurements, and therefore the greatest learning progress, could be seen in knowledge related skills.Conclusion: From the students’ point of view the communication training contributes significantly to the acquisition of communication skills. The results suggest that this “hands-on” course concept is suited to successfully enhance the students’ communication skills. The course concept should therefore be retained for both the course in its current form as well as for any extension of the course into the clinical part of medical school. However, further assessments on the exam results and long-term effects should take place.

Simulator-Based Air Medical Training Program Christoph Life: From Concept to Course

ObjectiveChristoph Life is a simulator-based air medical training program and a new and innovative educational concept. Participants pass different scenarios with a fully equipped and movable helicopter simulator. Main focuses of the program are crew resource management (CRM) elements and team training. Information about expectations end effectiveness of the training is sparse. MethodsDuring a 2-day training, participants learn CRM basics and complete various emergency medical scenarios. For evaluation, we used an anonymous questionnaire either with polar questions or a 6-coded psychometric Likert scale. The Wilcoxon test was used for statistical analysis. The significance level was set at P < .05. ResultsThirteen teams of emergency physicians and specially trained paramedics underwent Christoph Life. It was evaluated largely positively and considered very helpful for daily work (5.7 ± 0.5) and avoiding mistakes (5.7 ± 0.5). The quality of participants' knowledge about CRM basics (3.5 ± 1.2 vs. 5.4 ± 0.7, P < .001), self-assessment of communication skills (4.2 ± 0.7 vs. 4.8 ± 0.8, P = .02), and active reflection of communication aspects (3.9 ± 0.9 vs. 5.5 ± 0.5, P < .001) could be strikingly increased. ConclusionsThere is a considerable demand for intensified training on the part of the users. We were able to show that a simulator-based air medical training program is a helpful training tool with an obvious subjective benefit for the participants’ nontechnical skills.

Correlations between Medical Students’ Self Assessment of Communication Skills and Patient-Physician Interaction Assessed by Standardized Patients in Clinical Performance Examination

The purpose of this study was to identify the correlations between medical students’ communication skills and patient-physician interaction of clinical performance examination. A total of 36 fourth-year medical students were enrolled in this study and were surveyed concerning communication skills during clinical performance examination. The survey included 20 items in 4major areas: pre-interview (greeting, verifying patient’s name, introducing self, expressing interest, and confirming major symptoms), data collection (asking open-ended questions, reflecting, facilitation, clarifying information, and mid-point summarizing), data provision and patient education (finding out what the patient is thinking, responding to the patient’s emotions, explaining in a manner easy to understand, checking for the patient’s comprehension, taking additional questions), and non-verbal communication (professional appearance, active and respectful listening, appropriate eye contact, appropriate nodding, appropriate silence). 20 items of communication skills were reclassified to 5 patient-physician interaction items, and compared with patient-physician interaction scores of clinical performance examination. There were no correlations between communication skills and patient-physician interaction scores in two examination items (breast pain and acute abdominal pain). This study demonstrated that medical education of communication skills could not be transferred to improvement of patient-physician interaction in clinical skills assessment.

Correlations between Self-Assessment of Communication Skills and Patient-Physician Interaction in Medical Students

The purpose of this study was to identify the correlations between medical students’ self-assessment of communicationskills and patient-physician interaction. A total of 36 fourth-year medical students were enrolled in this study and weresurveyed concerning communication skills during clinical performance examination. The survey included 20 items in fourcategories: beginning an interview (greeting, identification, introduction, attention, and chief complaint), gathering information(open question, reflection, facilitation, clarification, and summarizing), giving information (discovering the patient’sunderstanding, empathy, easy terms, checking of understanding, and giving opportunities), and non-verbal communication(neat features, listening, eye contact, nodding, and silence). 20 items of communication skills were modulated to five patientphysicianinteraction items, and compared with patient-physician interaction scores by self-assessment. There were nocorrelations between communication skills and patient-physician interaction scores except one item, making an efforts tounderstand patient’s situation. This study demonstrated that medical education of communication skills could not betransferred to improvement of patient-physician interaction in clinical skills assessment.

Dental Student Attitudes Towards Communication Skills Instruction and Clinical Application

This study investigated dental students' attitudes towards communication skills instruction and clinical application and explored the impact of a one-semester course and year in school on students' attitudes, measured by the Communication Skills Attitude Scale. Demographic characteristics and self-assessment of communication skills were also analyzed. The study employed a pretest-posttest survey design combined with cross-sectional data. Participants were first- and fourth-year students at a U.S. dental school. Out of a possible 120 students, 106 (fifty-seven D1 and forty-nine D4) participated in the pretest, an 88 percent response rate; out of a possible 121 students, 115 (fifty-seven D1 and fifty-eight D4) participated in the posttest, a 95 percent response rate. In the results, D4 students consistently demonstrated less positive attitudes towards communication skills instruction and more negative attitudes regarding the importance of interpersonal skills in clinical encounters than did their D1 counterparts. A single communications course had no discernible effect on attitudes or self-assessments for either cohort. Females reported more positive attitudes towards clinical application of interpersonal skills than did males. Gender significantly interacted with two demographic variables: primary language and parent as health care professional. Female children of health care professionals reported poorer attitudes towards clinical communication skills training and application than did their male counterparts. Generally, parental occupation in health care moderated the decrease in positive attitudes over time towards clinical usefulness of communication skills. The D4 students rated their communication skills higher than did the D1 students. Students who demonstrated more positive attitudes towards communication skills training and application were more likely to say their own skills needed improvement.

Medical Student's Communication Ability during the Medical Interview – Perceptions of Self, Patients and Faculty

Background: Research indicates that students struggle to transfer class room taught communication skills into the reality of clinical practice. Students have previously been shown to be poor at self assessment of communication skills with over or under estimation of ability. Patients have previously shown little correlation with faculty. Methods: This study sought to investigate medical student's actual communication skills at the bedside, during a medical from the perspectives of faculty (behavioral scientists) patients and self assessment. A validated Calgary Cambridge observation tool was utilized. Results: Patients and faculty reported clear evidence of classroom taught skills being utilized clinically. The median scores achieved were similar with faculty reporting 64.5 %, (Q1, 59.5: Q3, 70.75), Patients 64% (Q1, 56.25: Q3, 71) and students' selfassessment at 63% (Q1, 56: Q3 68), (Range 0-100%). Students underestimated their skills in initiation of interview, gathering information and building structure. Students over estimated their abilities in understanding the patients perspective, building a relationship and closing Original Research Article British Journal of Education, Society & Behavioural Science, 4(3): 362-374, 2014 363 the interview. A medium correlation of 0.584 was determined between faculty and patients with a pvalue of 0.00069. There was no correlation between students self assessments and faculty nor between students and patient assessments Conclusion: Medical students can transfer some classroom taught communication skills to the clinical setting, during the medical to the satisfaction of faculty and patients. Students in the early years of training appear poor at self assessment of their actual ability in some aspects of communication skills. This concurs with previous findings. However, patients had good agreement with faculty this has been seen previously with standardized patients but not with actual hospital in-patients.