Standardized Patient Examination Research Articles

Rotator cuff crepitus: could Codman really feel a cuff tear?

The objective of this study was to assess the accuracy of palpating crepitus to diagnose rotator cuff tears. Seventy consecutive consenting patients who presented with shoulder pain and no previous imaging or surgery on the affected shoulder were prospectively enrolled during a 10-month period. A standardized patient history and examination, including the crepitus test, were recorded in addition to obtaining standard radiographs. Additional imaging after initial evaluation was performed with magnetic resonance imaging and interpreted by a musculoskeletal radiologist blinded to the examination findings. Statistical analysis was used to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the crepitus test in the clinical diagnosis of a rotator cuff tear. Sixty-three patients had histories, examinations, and imaging studies available for analysis. The crepitus test had a sensitivity of 67%, specificity of 80%, PPV of 91%, and NPV of 43% for all types of rotator cuff tears. The sensitivity and specificity for full-thickness or high-grade partial tears was 82% and 73%, respectively; the PPV and NPV were 77% and 79%. Increasing age improved accuracy as the presence of crepitus in patients older than 55 years had a sensitivity of 76%, specificity of 100%, PPV of 100%, and NPV of 38%. The crepitus test has a favorable sensitivity, specificity, PPV, and NPV to assess the integrity of the rotator cuff and may be a useful examination in the clinical diagnosis of a rotator cuff tear.

The Refinement of a Cultural Standardized Patient Examination For a General Surgery Residency Program

BackgroundRecent articles have documented the importance of cultural competency in surgery. Surgical residency programs have used the Objective Structured Clinical Examinations or cultural standardized patient examinations as a training tool. Past studies evaluating cultural competency have noted the importance of including an observational (control) arm, which would allow for a more objective assessment of a resident’s competency in this area. The purpose of our article is to present the results of a follow-up study to a pilot cultural standardized patient examination for surgery residents. MethodsAll first-year surgery residents were required to participate in the videotaped cultural SP examination as part of the general surgery residency curriculum. Two measures were used to assess resident performance. On the day of the examination, the Cross-Cultural Care Survey was administered. The examination was assessed by the residents themselves, faculty observers, and standardized patients, using a written checklist that was developed to evaluate residents on all 6 Accreditation Council for Graduate Medical Education competencies. ResultsThe current study includes 20 first-year surgery residents from academic years 2011 to 2012 and 2012 to 2013. The examination of pretest differences in groups found that students born outside of the United States had significantly higher scores on attitude (t = −2.68, df = 18, p = 0.02), but no statistically significant differences were found in skillfulness or knowledge or in the overall rating scale. For the overall rating scale, change from pretest to posttest was statistically significant (t = −2.25, df = 18, p = 0.04). Further analysis revealed that students who were born in the United States demonstrated a significant increase in ratings (t = −3.08, df = 10, p = 0.01) whereas students who were not born in the United States showed little change (t = −0.35, df = 7, p = 0.74). These results show that the means in attitude scales changed little for all groups, but both white and US-born students showed greater improvement on skillfulness and knowledge. ConclusionsTraining and measurement of cross-cultural health care skills remains challenging. However, studies like these provide a good starting point from which to build.

The problem of activity in systemic scleroderma

The problem of systemic scleroderma (SSD) activity enters into the view of standardized patient examination and it is important for choosing a therapeutic complex, for determining the dose of drugs, and for monitoring therapy. Great difficulties in the determination of activity in SSD are caused by the pathogenetic and morphogenetic features of the disease. It should be emphasized that there are no clearly defined exacerbation and remission periods. It is difficult to differentiate the potentially reversible inflammatory changes determining the activity of SSD from the irreversible fibrous changes characterizing the severity of the disease. The laboratory parameters of inflammatory activity are also of little informative value. The complicated problem of activity in SSD is to be further investigated both to improve and modify existing indices and to search for a common specific marker and/or key pathogenetically and clinically relevant markers of disease activity.

AB1407 Musculoskeletal teaching and training in saudi arabia: A national survey

BackgroundMusculoskeletal (MSK) symptoms are the most common reason for patients to seek medical attention, accounting approximately 20% of both Primary care and emergency-room visits. Despite the high prevalence of musculoskeletal...

Within-Session Score Gains for Repeat Examinees on a Standardized Patient Examination

Previous studies on standardized patient (SP) exams reported score gains both across attempts when examinees failed and retook the exam and over multiple SP encounters within a single exam session. The authors analyzed the within-session score gains of examinees who repeated the United States Medical Licensing Examination Step 2 Clinical Skills to answer two questions: How much do scores increase within a session? Can the pattern of increasing first-attempt scores account for across-session score gains? Data included encounter-level scores for 2,165 U.S. and Canadian medical students and graduates who took Step 2 Clinical Skills twice between April 1, 2005 and December 31, 2010. The authors modeled examinees' score patterns using smoothing and regression techniques and applied statistical tests to determine whether the patterns were the same or different across attempts. In addition, they tested whether any across-session score gains could be explained by the first-attempt within-session score trajectory. For the first and second attempts, the authors attributed examinees' within-session score gains to a pattern of score increases over the first three to six SP encounters followed by a leveling off. Model predictions revealed that the authors could not attribute the across-session score gains to the first-attempt within-session score gains. The within-session score gains over the first three to six SP encounters of both attempts indicate that there is a temporary "warm-up" effect on performance that "resets" between attempts. Across-session gains are not due to this warm-up effect and likely reflect true improvement in performance.

NASPGHAN Guidelines for Training in Pediatric Gastroenterology

G.G.C. has received com M.C. has served on th served on the board o and Enteral Nutrition; her institution has rec collaborative and Prov pensation from Child L.A.G. has received c received compensatio employment, expert t stocks/stock options; LLC, consulted to No received or has grants Institutes of Health, th holds equity interest in has received compens Fibrosis Foundation; M Abbott Laboratories, Foundation, the Natio Diseases/National Ins ticals; E.A.R. has rece sionalism & Ethical institution has receive as the medical editor has received compen Pharmaceuticals, and Nutrition; J.T. has rec Pediatrics, Prometheu conflicts of interest. Copyright # 2012 by E Hepatology, and Nut Gastroenterology, He DOI: 10.1097/MPG.0b01

Standardized Patient Case: Evaluation of Hearing Loss

OPEN ACCESSOctober 2, 2012Standardized Patient Case: Evaluation of Hearing Loss Kate Martin, MD Kate Martin, MD University of Nevada School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9246 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractThis resource is a standardized patient case featuring Bill Thompson, an older man who has been experiencing the gradual onset of hearing loss. The case was originally designed to provide a formative tool to assess third-year medical students' skills in gathering information and writing a progress note in a timed environment. Medical students must be proficient in the domains of communication, data gathering, and documentation to succeed within the time constraints of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam. This case was implemented to help prepare our third-year medical students for a high-stakes standardized patient examination that occurs at the end of their primary care clerkships block. That examination has been modeled after the USMLE Step 2 CS exam, which is a graduation requirement at our medical school. In anonymous evaluations, students reported that the simulated test activity was helpful preparation for their examination. However, they indicated a desire for a greater amount of participation, as the original activity was largely observational. The case has since been modified to allow greater student participation on a graduated level by experience. Educational Objectives By the end of this case, first-year medical students will be able to: Observe a hypothesis-driven interview and focused physical examination (PE) involving one of the special senses in 20 minutes.Document necessary portions of a standardized patient encounter.Create an appropriate SOAP note in 15 minutes, focusing on the history of present illness (HPI) and PE. By the end of this case, second-year medical students will be able to: Perform a hypothesis-driven interview and focused PE involving one of the special senses in 20 minutes in collaboration with other students.Document necessary portions of a standardized patient encounter.Create an appropriate SOAP note in 15 minutes, including two to three most likely assessments/diagnoses. By the end of this case, third-year medical students will be able to: Perform a hypothesis-driven interview and focused PE involving one of the special senses in 15 minutes independently.Document necessary portions of a standardized patient encounter.Create an appropriate SOAP note in 10 minutes, including two to three most likely assessments/diagnoses and a prioritized plan. By the end of this case, fourth-year medical students will be able to: Perform a hypothesis-driven interview and focused PE involving one of the special senses in 20 minutes and model this behavior for a group of first-year medical students.Explain the documentation process of necessary portions of a standardized patient encounter.Evaluate a SOAP note for this encounter, focusing on the HPI and PE portions. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Bill Thompson - SOAP Note.doc Revision_Bill Thompson Rating Scale.doc Revision_Bill Thompson_Case.doc Revision_Bill Thompson_Instructor Guide.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationMartin K. Standardized Patient Case: Evaluation of Hearing Loss. MedEdPORTAL. 2012;8:9246. https://doi.org/10.15766/mep_2374-8265.9246 Copyright & Permissions© 2012 Martin. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsSpecial SensesSOAP NoteHearing LossInterviewingPhysical Examination Disclosures None to report. Funding/Support None to report. Loading ...

Examining the Diagnostic Justification Abilities of Fourth-Year Medical Students

Fostering ability to organize and use medical knowledge to guide data collection, make diagnostic decisions, and defend those decisions is at the heart of medical training. However, these abilities are not systematically examined prior to graduation. This study examined diagnostic justification (DXJ) ability of medical students shortly before graduation. All senior medical students in the Classes of 2011 (n = 67) and 2012 (n = 70) at Southern Illinois University were required to take and pass a 14-case, standardized patient examination prior to graduation. For nine cases, students were required to write a free-text response indicating how they used patient data to move from their differential to their final diagnosis. Two physicians graded each DXJ response. DXJ scores were compared with traditional standardized patient examination (SCCX) scores. The average intraclass correlation between raters' rankings of DXJ responses was 0.75 and 0.64 for the Classes of 2011 and 2012, respectively. Student DXJ scores were consistent across the nine cases. Using SCCX and DXJ scores led to the same pass-fail decision in a majority of cases. However, there were many cases where discrepancies occurred. In a majority of those cases, students would fail using the DXJ score but pass using the SCCX score. Common DXJ errors are described. Commonly used standardized patient examination component scores (history/physical examination checklist score, findings, differential diagnosis, diagnosis) are not direct, comprehensive measures of DXJ ability. Critical deficiencies in DXJ abilities may thus go undiscovered.

A Controlled Study to Determine Measurement Conditions Necessary for a Reliable and Valid Operative Performance Assessment

This study evaluated operative performance rating (OPR) characteristics and measurement conditions necessary for reliable and valid operative performance (OP) assessment. Operative performance is a signature surgical-practice characteristic that is not measured systematically and specifically during residency training. Expert surgeon raters from multiple institutions, blinded to resident characteristics, independently evaluated 8 open and laparoscopic OP recordings immediately after observation. A plurality of raters agreed on operative performance ratings (OPRs) for all performances. Using 10 judges adjusted for rater idiosyncrasies. Interrater agreement was similar for procedure-specific and general items. Higher post graduate year (PGY) residents received higher OPRs. Supervising-surgeon ratings averaged 0.51 points (1.2 standard deviations) above expert ratings for the same performances. OPRs have measurement properties (reliability, validity) similar to those of other well-developed performance assessments (Mini-CEX [clinical evaluation exercise], standardized patient examinations) when ratings occur immediately after observation. OPRs by blinded expert judges reflect the level of resident training and are practically significant differences as the average rating for PGY 4 residents corresponded to a "Good" performance whereas those for PGY 5 residents corresponded to a "Very Good" performance. Supervising surgeon ratings are higher than expert judge ratings reflecting the effect of interpersonal factors on supervising surgeon ratings. Use of local and national norms for interpretation of OPRs would adjust for these interpersonal factors. The OPR system provides a practical means for measuring operative performance, which is a signature characteristic of surgical practice.

Using Standardized Patients to Evaluate Screening, Brief Intervention, and Referral to Treatment (SBIRT) Knowledge and Skill Acquisition for Internal Medicine Residents

ABSTRACT Comprehensive clinical competency curricula for hazardous drinking and substance use disorders (SUDs) exists for medical students, residents, and practicing health care providers. Evaluations of these curricula typically focus on learner attitudes and knowledge, although changes in clinical skills are of greater interest and utility. The authors present a pre-post clinical skill evaluation of a 10-hour screening, brief intervention, and referral to treatment (SBIRT) curriculum for hazardous drinking and SUDs for primary care internal medicine residents using standardized patient examinations to better determine the impact of SBIRT training on clinical practice. Residents had large improvements in history taking, substance use screening skills, SUD assessment and diagnostic skills, and in SBIRT knowledge, including documentation, systems, and diversity issues. Residents made moderate improvements in brief intervention skills. Future SBIRT curricular evaluations would ideally include a controlled comparison with larger samples from multiple institutions.

The Development of a Cultural Standardized Patient Examination for a General Surgery Residency Program

Cultural competency and cross-cultural care issues in surgery resident education are areas of recognized need. The Accreditation Council for Graduate Medical Education (ACGME) has developed 6 core competencies addressing training to provide high quality care. Of these, cultural training is addressed under 3: patient care, professionalism, and interpersonal and communication skills. Our study sought to develop a measurable tool-a cultural standardized patient (SP) examination-that integrates cross-cultural care issues within the core competencies. All first year surgery residents (PGY-1) were required to participate in the videotaped cultural SP examination as part of the general surgery residency curriculum. Two measures were utilized to assess resident performance. On the same day, we administered a Cross-Cultural Care Survey. The SP examination was assessed by trained surgery teaching faculty using a written checklist that was developed to evaluate residents on all 6 ACGME competencies. Of the 26 eligible participants over 2 years, we were able to analyze the pre- and post-test results for 24 residents. The post-test score of the "attitude toward cross-cultural care" subscale of the Cross-Cultural Care Survey was significantly lower than the pre-test score (p = 0.012; Wilcoxon signed-ranks test). There were significant differences by ethnicity on all 3 subscales of the Cross-Cultural Care Survey (attitude = p < 0.05, knowledge = p < 0.01, skills = p < 0.05) on the pre-test. However, only the knowledge subscale scores remained significantly different between ethnicities on the post-test (p < 0.01). After additional assessment, evaluation, and refinement, our goal is to incorporate cross-cultural health care training as a permanent part of our curriculum. Our hope is that efforts to provide training in cross-cultural healthcare leads to high quality care and positive outcomes for the patient. This will not only enhance our training program, but may also become a useful tool for other surgery residency programs.

The Brief Repeatable Battery: psychometrics and normative values with age, education and gender corrections in a Serbian population

Cognitive impairment is present in up to 65 % of multiple sclerosis (MS) patients. The Brief Repeatable Battery of neuropsychological tests (BRB) is one of the most used neuropsychological tools for cognitive assessment in MS. However, relative lack of normative data limits its application in research and clinical practice. In order to obtain normative data for a Serbian population, we administered the BRB version A to 140 healthy subjects and assessed the influence of demographic factors such as gender, age, and education on the tests' scores. We also calculated corrections for these factors. Higher education was associated with better performance on all the tests. Age influenced all the tests, except the word list generation, higher age being associated with worse performance on all other tests. Women performed worse on the paced auditory serial addition test 2, no other gender differences were observed. Our data obtained for the Serbian population could further improve use of the BRB in clinical practice and for the research purposes, establishing cognitive evaluation as a part of standard neurological examination of MS patients.

Medical Students’ Attention to Multiple Risk Behaviors: A Standardized Patient Examination

Risk behaviors tend to cluster, particularly among smokers, with negative health effects. To optimize patients' health and wellbeing, health care providers ideally would assess and intervene upon the multiple risks with which patients may present. This study examined medical students' skills in assessing and treating multiple risk behaviors. Using a randomized experimental design, medical students' counseling interactions were evaluated with a standardized patient presenting with sexual health concerns and current tobacco use with varied problematic drinking status (alcohol-positive or alcohol-negative). One hundred and fifty-six third-year medical students. Student and standardized patient completed measures evaluated student knowledge, attitudes, and clinical performance. Overall, most students assessed tobacco use (85%); fewer assessed alcohol use (54%). Relative to the alcohol-negative case, students seeing the alcohol-positive case were less likely to assess sexually transmitted disease history (80% vs. 91%, p = 0.042), or patients' readiness to quit smoking (41% vs. 60%, p = 0.025), and endorsed greater attitudinal barriers to tobacco treatment (p = 0.030). Patient satisfaction was significantly lower for the alcohol-positive than the alcohol-negative case; clinical performance ratings moderated this relationship. When presented with a case of multiple risks, medical students performed less effectively and received lower patient satisfaction ratings. Findings were moderated by students' overall clinical performance. Paradigm shifts are needed in medical education that emphasize assessment of multiple risks, new models of conceptualizing behavior change as a generalized process, and treatment of the whole patient for optimizing health outcomes.

Evaluating Construct Equivalence and Criterion-Related Validity for Repeat Examinees on a Standardized Patient Examination

Prior studies report large score gains for examinees who fail and later repeat standardized patient (SP) assessments. Although research indicates that score gains on SP exams cannot be attributed to memorizing previous cases, no studies have investigated the empirical validity of scores for repeat examinees. This report compares single-take and repeat examinees in terms of both internal (construct) validity and external (criterion-related) validity. Data consisted of test scores for examinees who took the United States Medical Licensing Examination Step 2 Clinical Skills (CS) exam between July 16, 2007, and September 12, 2009. The sample included 12,090 examinees who completed Step 2 CS on one occasion and another 4,030 examinees who completed the exam on two occasions. The internal measures included four separately scored performance domains of the Step 2 CS examination, whereas the external measures consisted of scores on three written assessments of medical knowledge (Step 1, Step 2 clinical knowledge, and Step 3). The authors subjected the four Step 2 CS domains to confirmatory factor analysis and evaluated correlations between Step 2 CS scores and the three written assessments for single-take and repeat examinees. The factor structure for repeat examinees on their first attempt was markedly different from the factor structure for single-take examinees, but it became more similar to that for single-take examinees by their second attempt. Scores on the second attempt correlated more highly with all three external measures. The findings support the validity of scores for repeat examinees on their second attempt.

Measurement precision for repeat examinees on a standardized patient examination

Examinees who initially fail and later repeat an SP-based clinical skills exam typically exhibit large score gains on their second attempt, suggesting the possibility that examinees were not well measured on one of those attempts. This study evaluates score precision for examinees who repeated an SP-based clinical skills test administered as part of the US Medical Licensing Examination sequence. Generalizability theory was used as the basis for computing conditional standard errors of measurement (SEM) for individual examinees. Conditional SEMs were computed for approximately 60,000 single-take examinees and 5,000 repeat examinees who completed the Step 2 Clinical Skills Examination(®) between 2007 and 2009. The study focused exclusively on ratings of communication and interpersonal skills. Conditional SEMs for single-take and repeat examinees were nearly indistinguishable across most of the score scale. US graduates and IMGs were measured with equal levels of precision at all score levels, as were examinees with differing levels of skill speaking English. There was no evidence that examinees with the largest score changes were measured poorly on either their first or second attempt. The large score increases for repeat examinees on this SP-based exam probably cannot be attributed to unexpectedly large errors of measurement.

Pilot Evaluation of a Biopsychosocial Integrated Standardized Patient Examination in a Family Medicine Clerkship

A new biopsychosocial Integrated Standardized Patient Examination (ISPE) was implemented to assess communication skills for medical students participating in a family medicine clerkship. Mixed method, multi-level evaluation. Pilot ISPE scores were significantly higher than previous Objective Structured Clinical Examination (OSCE) (p < .01). Family Physician and Social/Behavioral Scientist rater scores were correlated (p < .001), and Cronbach's alpha statistics were acceptable (FM: alpha = .837; BH: alpha = .768). Preceptor scores on "relations with professionals" (beta = .694, p = .008) significantly predicted ISPE scores, but other clerkship assignment grades were inversely associated with ISPE. Qualitative focus group themes included lack of readiness, divergence in beliefs on scope of physician practice, and focus on grade. This pilot project describes the process and demonstrates the possibility of implementing a complex standardized patient case to assess students' management of complicated primary care patients with medical, psychological, and social issues.

The Efficacy of a Targeted Remediation Process for Students Who Fail Standardized Patient Examinations

Background: Current remediation strategies for students failing standardized patient examinations represent poorly targeted approaches since the specific nature of clinical performance weaknesses has not been defined. Purpose: The purpose is to determine the impact of a specifically targeted clinical performance course required of students who failed a clinical performance examination. Methods: A month-long clinical performance course, targeted to treat specific types of clinical performance deficiencies, was designed to remediate students failing standardized patient examinations in 2007 (n = 8) and 2008 (n = 5). Participating students were assessed on pre- and postperformance measures, including multiple-choice tests that measured diagnostic pattern recognition and clinical data interpretation and clinical performance measures using standardized clinical encounters. Comparisons between average pre- and postintervention performance scores were computed using paired sample t tests. Results were adjusted for regression toward the mean. Results: In both 2007 and 2008, the mean preintervention clinical data interpretation and standardized patient examination scores were below the criterion referenced passing standard set for the clinical competency exam. In both years the mean postintervention scores for the participants were above the passing standard for these two examinations. Pre- and postintervention differences were statistically significant in both cases. Conclusions: This study provides insight into the reasons that students fail clinical performance examinations and elucidates one method by which such students may be successfully remediated.

Development of a longitudinal integrated clerkship at an academic medical center

In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSF's traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants’ career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Introduction and Administration of the Clinical Skill Test of the Medical Licensing Examination, Republic of Korea (2009)

The first trial of the clinical skill test as part of the Korean Medical Licensing Examination was done from September 23 to December 1, 2009, in the clinical skill test center located in the National Health Personnel Licensing Examination Board (NHPLEB) building, Seoul. Korea is the first country to introduce the clinical skill test as part of the medical licensing examination in Asia. It is a report on the introduction and administration of the test. The NHPLEB launched researches on the validity of introducing the clinical skill test and on the best implementation methods in 2000. Since 2006, lists of subjects of test items for the clinical skill test has been developed. The test consisted of two types of evaluation, i.e., a clinical performance examination (CPX) with a standardized patient (SP) and objective structured clinical examination (OSCE). The proctor (medical faculty member) and SP rate the examinees' proficiency for the OSCE and CPX respectively. Out of 3,456 applicants, 3,289 examinees (95.2%) passed the test. Out of 167 examinees who failed the clinical skill test, 142 passed the written test. This means that the clinical skill test showed characteristics independent from the written test. This successful implementation of the clinical skill test is going to improve the medical graduates' performance of clinical skills.

University of Utah School of Medicine

University of Utah School of Medicine