Standardized Patient Interviews Research Articles

An innovative model for teaching complex clinical procedures: Integration of standardised patients into ward round training for final year students

Objectives: Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. However, although the need for ward round training is emphasized in the published literature, there are currently no reports of ward round training in a simulated setting with standardized patients.Methods: 45 final year students participated in a ward round training session lasting two hours with three standardized patient scenarios and role-plays. Final year students assumed the role of either doctor, nurse or final year student with role-specific instructions and provided each other with peer-feedback during the training session. Training was assessed using final year student focus groups and semi-structured interviews of standardized patients. Written protocols of the focus group as well as the interviews of standardized patients were content analysed.Results: In the course of five focus groups, 204 individual statements were gathered from participating final year students. Ward round training proved to be a feasible tool, well accepted by final year students. It was seen to offer a valuable opportunity for reflection on the processes of ward rounds, important relevant feedback from standardized patients, peer group and tutors. Semi-structured standardized patient interviews yielded 17 central comments indicating that ward rounds are a novel and exciting experience for standardized patients.Conclusion: Ward round training with standardized patients is greatly appreciated by final year students and is viewed as an important part of their education, easing the transition from observing ward rounds to conducting them on their own.

Implementation and Evaluation of a Training Program for the Management of Sexual Assault in the Emergency Department

Sexual assault nurse examiner (SANE) programs have improved the quality of care for sexual assault victims. An adverse effect of these programs is reduced resident clinical exposure to victims of sexual assault. The objectives of this project are to determine the baseline level of resident competence in knowledge and management of sexual assault and to demonstrate the effectiveness of training in developing resident competence. The study included 27 emergency medicine residents at an urban academic center with an active SANE program. The design included pretest, intervention, and retest at 6 months. The intervention included 8 hours of lecture, role play, and skills laboratories. Objectives were based on SANE standards. The 4 assessments were a written knowledge test, evidence collection on mannequin, standardized patient interviews, and a written emergency department note. Data were compared with paired t tests. Twenty-three (85%) residents completed the study. Preintervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note. Residents showed significant postintervention improvements in written knowledge (improvement 24%; 95% confidence interval [CI] 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Performance on standardized patient-based communication skills did not change after the intervention. Resident posttest scores were similar to those of SANE providers. Emergency medicine residents training in an urban center with an active SANE program had limited knowledge and skills in the treatment of victims of sexual assault. Our multimodal educational intervention increased residents' knowledge and evidence collection skills to levels equivalent to that of experienced providers in a SANE program.

Performance and customization of 4 prognostic models for postoperative onset of nausea and vomiting in ear, nose, and throat surgery

Objective To evaluate the performance of 4 published prognostic models for postoperative onset of nausea and vomiting (PONV) by means of discrimination and calibration and the possible impact of customization on these models. Design Prospective, observational study. Setting Tertiary care university hospital. Patients 748 adult patients (>18 years old) enrolled in this study. Severe obesity (weight > 150 kg or body mass index > 40 kg/m) was an exclusion criterion. Interventions All perioperative data were recorded with an anesthesia information management system. A standardized patient interview was performed on the postoperative morning and afternoon. Measurements Individual PONV risk was calculated using 4 original regression equations by Koivuranta et al, Apfel et al, Sinclair et al, and Junger et al Discrimination was assessed using receiver operating characteristic (ROC) curves. Calibration was tested using Hosmer-Lemeshow goodness-of-fit statistics. New predictive equations for the 4 models were derived by means of logistic regression (customization). The prognostic performance of the customized models was validated using the “leaving-one-out” technique. Main Results Postoperative onset of nausea and vomiting was observed in 11.2% of the specialized patient population. Discrimination could be demonstrated as shown by areas under the receiver operating characteristic curve of 0.62 for the Koivuranta et al model, 0.63 for the Apfel et al model, 0.70 for the Sinclair et al model, and 0.70 for the Junger et al model. Calibration was poor for all 4 original models, indicated by a P value lower than 0.01 in the C and H statistics. Customization improved the accuracy of the prediction for all 4 models. However, the simplified risk scores of the Koivuranta et al model and the Apfel et al model did not show the same efficiency as those of the Sinclair et al model and the Junger et al model. This is possibly a result of having relatively few patients at high risk for PONV in combination with an information loss caused by too few dichotomous variables in the simplified scores. Conclusions The original models were not well validated in our study. An antiemetic therapy based on the results of these scores seems therefore unsatisfactory. Customization improved the accuracy of the prediction in our specialized patient population, more so for the Sinclair et al model and the Junger et al model than for the Koivuranta et al model and the Apfel et al model.

Clerkship enhancement of interpersonal skills

Background The purpose of this research was to determine if students improve interpersonal skills as the third year progresses despite the lack of any specific curriculum or teaching methods. Methods Third-year students completed 1 of 3 16-week sequential clerkship blocks. Each student completed a clinical performance examination before and after clerkship consisting of a videotaped standardized patient interview and physical examination. Videotapes were randomly assigned to communication faculty for evaluation. Results Although the majority (73%) of students improved during their block, 17% showed no improvement, and 12% had deficient interpersonal skills after their clerkship. Conclusions Despite the lack of skill-directed curriculum, most medical students showed improved interpersonal skill performance after a 16-week clerkship. Developing an interpersonal curriculum for all third-year students may not be necessary. Because faculty are being asked to do more with less, we believe efforts focused on individual students during the third year will be more productive.

A randomized trial of teaching bioethics to surgical residents

Background Bioethics education has been recommended as a formal component of surgical residency training. The best method for teaching bioethics to residents is unclear. We compared the effectiveness of a standardized patient (SP)-based seminar to a traditional seminar format for teaching bioethics to surgical residents. Methods We randomized 31 first- and second-year surgical residents to either a SP-based seminar or a traditional seminar on informed consent. Immediately after the seminars, we evaluated resident performance in patient encounters on informed consent by using an objective structured clinical examination. Their knowledge of informed consent was also evaluated by using a 20-question short-answer written examination immediately after the seminars and then 3 weeks later. Results Twenty-nine residents completed the study; two withdrew because of an emergency. The SP seminar group had lower SP interview scores on the 22 item checklist compared with the traditional seminar group (57% versus 66%; difference −9%; 95% confidence interval [CI], −17% to −1%, P = .03). The SP seminar group also had lower knowledge scores on the questionnaire immediately after the seminar (60% versus 73%; difference −13%; 95% CI, −21% to −4%, P = .003). The difference in knowledge scores persisted at 3 weeks (41% for the SP group, 59% for the traditional seminar group; difference −18%; 95% CI, −29% to −7%; P = .002). Conclusions A traditional seminar was superior to an SP-based seminar for teaching informed consent to surgical residents.

STUDENTJAMA. Medical school curricula in spirituality and medicine.

A GROWING NUMBER OF MEDICAL SCHOOLS ARE OFFERING courses in spirituality in medicine. In 1994, only 17 of the 126 accredited US medical schools offered courses on spirituality in medicine. By 1998, this number had increased to 39, and by 2004, to 84 schools. To characterize the curricula, we conducted a search of PubMed, PsychINFO, the Educational Resources Information Clearinghouse (ERIC), and the Social Science Citation Index (details are available from the authors). We then determined whether the articles reported on curriculum development, curricular goals and objectives, topical content, educational strategies, evaluation methods, or evaluation of outcomes. Ten reports met these inclusion criteria. Three programs had been developed for first-year students, 2 for firstand second-year students, 2 for second-year students, and 2 for third-year students. Four of these 10 curricula specifically focused on spirituality and medicine, while 2 other courses included additional components on cultural competency and end-of-life care. Three curricula taught students in the context of a medical humanities course that included spirituality as a component topic. Although authors generally described the content of their courses, most did not report the key steps of the curriculum development process. Only one described a needs assessment, though only for the local community and not for the medical students. Four included objectives, the most common of which were to understand how patients’ spiritual beliefs impact health; to understand how medical students’ own belief systems can affect the care they provide; and to develop skills to take a spiritual history. Most curricula used several educational methods, such as lectures, small group discussion, standardized patient interviews, and readings. One included a 6-hour on-call experience with a hospital chaplain. The majority of reports in the reviewed literature failed to specify what particular aspects of spirituality and medicine the courses covered. For example, several articles stated that students attended lectures on “spirituality and medicine” without providing additional details. Other articles mentioned the assignment of “selected readings” but did not list any of the assigned references. Most schools evaluated their programs’ effectiveness with student surveys of satisfaction or self-reported changes in attitude or knowledge. However, to evaluate the effectiveness of psychiatry clerkship problem-based case studies concerning spiritual issues at one school, Musick et al randomized students to either a case that involved spiritual issues or cases that made no mention of spirituality. At the end of the course they interviewed a standardized patient with spiritual issues and were assigned to write the patient’s spiritual history. Only the students who worked with the spiritual case study had a statistically significant increase in self-reported knowledge about taking a spiritual history. Students in the intervention and control groups obtained statistically equivalent scores on the standardized patient interview. Unfortunately,most curricula were not presented in enough detail to replicate and few assessed outcomes on effectiveness. The lack of detail in these published reports is not unique; recent reviews of resident research and evidence-based medicine curricula note similar deficiencies. Our review has several limitations. First, we included only published reports; and though unpublished curricula could be just as useful to educators they are difficult to access. Second, our search strategy, though thorough according to accepted standards of literature review, may still have missed some of the published curricula. Indeed, spirituality may be taught in several venues, including courses on holistic medicine and complementary and alternative medicine (CAM). Brokaw et al surveyed CAM course directors at 53 medical schools and found that 64% included teaching about spirituality, faith, and/or prayer.

Teaching patient-centered tobacco intervention to first-year medical students.

The University of Wisconsin's Tobacco Intervention Basic Skills curriculum (TIBS) was inaugurated to begin training 147 first-year medical students in skills for promoting health behavior change. Learning activities included lecture, demonstration, reading, quiz, role-play exercises, and standardized patient interviews. After TIBS, the 69 students who provided pre- and postintervention data exhibited more therapeutic attitudes and increased knowledge and self-confidence in applying TIBS skills. Two months later, 52% of the 109 posttest respondents had applied TIBS in clinical settings, often for behaviors other than tobacco use. We conclude that medical students can gain from early training on promoting behavior change.

Implementation and Assessment of a Spiritual History Taking Curriculum in the First Year of Medical School

Background: The Association of American Medical Colleges has recommended addressing spirituality in the medical curriculum. Description: To evaluate the impact of a spiritual history-taking curriculum on the skills, knowledge, and attitudes of 1st year medical students. The study implemented a spiritual history-taking curriculum in the 1st year of medical school that included reading assignments, practice history taking, and standardized patient (SP) scenarios with spiritual content. It assessed students' performance in three ways: (a) using a videotaped SP interview, (b) a survey of students' attitudes regarding incorporating patients' religious and cultural views into medical decision making, and (c) a written test question on their first examination. Evaluation: Students (146) took part in the medical school's spirituality curriculum, which included participation in videotaped interviews; 98% completed the initial survey, and 75% completed the follow-up survey. On the final videotaped SP interview, 65% of students were able to recognize the patient's spiritual concern according to trained faculty observers. On the attitude survey, there was an increased desire to accommodate patients' beliefs, although the magnitude of the increase was generally quite small. Ninety-four percent of students answered the test question correctly. Conclusion: Spiritual history taking can be integrated effectively into the existing history-taking curriculum in 1st year medical training.

An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians

We evaluated a 2-day training workshop on motivational interviewing (MI) for addiction and mental health clinicians ( n=22). Clinicians completed the helpful responses questionnaire (HRQ) and taped interactions with a standardized patient (SP). Independent, blinded coders rated the tapes using the motivational interviewing skills code (MISC). Post-training assessment showed significant increase on the HRQ and two of four MISC summary scores for SP interviews. At 2-month follow-up, means of the HRQ and two MISC summary scores remained higher than baseline, but declined from post-training. Some MI skills improved to a greater degree than others, and a subset of clinicians (>40%) showed continued improvement at follow-up. Results were consistent across interviews with different SPs, supporting the use of this assessment method. Findings highlight the need for additional research on the use of standardized patients, alternative assessment techniques, and effective methods of technology transfer for MI skill acquisition and retention.

Web-based learning: sound educational method or hype? A review of the evaluation literature.

The first reports of Web-based medical education appear in 1992, building on 30 years of computer-assisted instruction. Proponents claimed computer-assisted instruction is superior to text-based, lecture, and traditional educational methods for reasons that include control by the learner over content, time, and place of learning; enhancement of learning, reasoning, and efficiency; and cost savings. Many studies that reported advantages contained methodologic flaws and reported advantages unrelated to computer-specific features. Web-based learning (WBL) represents a further evolution of computer-assisted instruction. Technical advantages of WBL include universal accessibility, ease in updating content, and hyperlink functions that permit cross-referencing to other resources. These technical advances, specifically hyperlink and searching capabilities, fit the constructivist learning theory, where learners search out and create their own knowledge bases. However, as was evident with computer-assisted instruction, potential advantages may not translate into significant improvements in educational outcomes. With the widespread adoption of WBL, it is critical that medical educators have evidence regarding its performance as a learning medium. This paper reviews the medical, dental, and nursing WBL evaluation literature to: (1) identify which facets of WBL have been evaluated, (2) describe the evaluation strategies used, (3) synthesize the findings, and (4) discuss educational implications and future research directions.

The challenge of creating new OSCE measures to capture the characteristics of expertise.

Although expert clinicians approach interviewing in a different manner than novices, OSCE measures have not traditionally been designed to take into account levels of expertise. Creating better OSCE measures requires an understanding of how the interviewing style of experts differs objectively from novices. Fourteen clinical clerks, 14 family practice residents and 14 family physicians were videotaped during 2 15-minute standardized patient interviews. Videotapes were reviewed and every utterance coded by type including questions, empathic comments, giving information, summary statements and articulated transitions. Utterances were plotted over time and examined for characteristic patterns related to level of expertise. The mean number of utterances exceeded one every 10 s for all groups. The largest proportion was questions, ranging from 76% of utterances for clerks to 67% for experts. One third of total utterances consisted of a group of 'low frequency' types, including empathic comments, information giving and summary statements. The topic was changed often by all groups. While utterance type over time appeared to show characteristic patterns reflective of expertise, the differences were not robust. Only the pattern of use of summary statements was statistically different between groups (P < 0.05). Measures that are sensitive to the nature of expertise, including the sequence and organisation of questions, should be used to supplement OSCE checklists that simply count questions. Specifically, information giving, empathic comments and summary statements that occupy a third of expert interviews should be credited. However, while there appear to be patterns of utterances that characterise levels of expertise, in this study these patterns were subtle and not amenable to counting and classification.

Donor site morbidity after microvascular fibula transfer

The free microvascular fibula and soft tissue transfer has become a widely used method to reconstruct the head and neck region. Only few reports focus on the donor site morbidity of purely mandibular reconstructions. On the basis of the hospital charts, a standardized patient interview and a standardized physical examination, the present study evaluates the early and late donor site morbidity in 42 mostly oncologic patients after an average follow-up interval of 34 months. Of these, 16 patients (38.1%) exhibited complicated wound healing that did not correlate with the patient's age, sex, type of transplant, use of a skin graft, result of preoperative angiography, rate of postoperative mobilization or the incidence of late donor site morbidity. At the time of follow-up examination, about one-fourth of the patients reported discomfort, pain or swelling. Objective findings included sensory deficits in 76.3%, motor deficits in 39.5% and reduced strength in 44.7% of the patients. Even though objectively measured morbidity exceeded subjectively perceived morbidity, it can be concluded that there is significant early and late donor site morbidity, which should be considered when opting for a fibula graft. Patients should be informed accordingly.

Preoperative risk factors for postoperative delirium

The objective of this article was to estimate the incidence of delirium in a sample of patients undergoing elective surgery and to identify the preoperative factors most closely associated with developing this complication. Consecutive patients ( n=500) underwent a full preoperative medical evaluation including assessment of cognitive and functional status. Daily evaluation on postoperative days 1 through 4 included medical record review and direct standardized patient interviews. Logistic regression was used to explore the associations between preoperative factors and postoperative delirium. Delirium was detected in 57 (11.4%) patients. Univariate factors associated with delirium included age≥70 years (RR=3.1 [1.75,5.55]), preexisting cognitive impairment (RR=3.1 [1.73, 5.43]), greater preoperative functional limitations (RR=1.57 [1.27, 1.94]), and a history of prior delirium (RR 4.1 [1.98 to 8.27]. Adjusting for other factors, previous delirium (OR=4.08 [1.85, 9.0]), age≥70 years (OR=3.2 [1.6, 6.0], and preexisting cognitive impairment (OR=2.16 [1.15, 4.0] remained predictive of delirium. Patients’ perceptions that alcohol had affected their health (OR=6.53 [1.58 to 28.1]) and use of narcotic analgesics just prior to admission (OR=2.7 [1.37 to 5.3]) were also significantly associated with delirium postoperatively. Several easily obtained preoperative clinical factors can be used to identify patients at risk for postoperative delirium. This approach, when combined with specialized delirium teams using established guidelines, may be more effective in targeting patients at risk, thus reducing the number of episodes and days of delirium.

Effect of student ethnicity on interpersonal skills and objective standardized clinical examination scores

Objective: To determine whether standardized patients’ perceptions of medical students’ ethnicity influenced ratings on the interpersonal skills subsection of the objective standardized clinical examination (OSCE) and performance overall on the OSCE. Methods: The OSCE is used to evaluate medical students’ performances in the obstetrics and gynecology basic clerkship at the Johns Hopkins University School of Medicine. It is based on a series of standardized patient interviews conducted by medical students and incorporates ratings by standardized patients on each student’s interpersonal skills. Medical students ( n = 353) enrolled in the obstetrics and gynecology basic clerkship from 1995–1998 were classified according to ethnicity. Overall OSCE scores according to ethnicity were analyzed using one-way analysis of variance. Total interpersonal skills scores and scores on the individual components of the interpersonal skills section of the OSCE were analyzed according to students’ ethnicity using the Kruskal-Wallis test for nonparametric analysis of variance. Results: There were no statistically significant differences among ethnic groups in overall OSCE scores, total interpersonal skills scores, or scores on the individual components of the interpersonal skills section of the OSCE. Conclusion: No bias attributable to perceived medical student ethnicity that affects performance on the OSCE exists.

Relation between phase of menstrual cycle and emergency department visits for acute asthma.

Hormonal fluctuations during the menstrual cycle are hypothesized to influence the course of asthma among women. A recent study found that almost 50% of emergency department (ED) visits occur during the perimenstrual phase. Our prospective cohort study in 64 EDs examined the relation between phase of menstrual cycle and visits for acute asthma. A total of 288 women with acute asthma were evaluated with a standardized patient interview and medical record review after excluding subjects who were pregnant, on hormonal therapy, postmenopausal, status post hysterectomy, had incomplete reproductive data, or whose ED visit fell more than 28 d after their last menstrual period. Only 13% reported reproductive factors as a personal asthma trigger. For all subjects, ED asthma visits were classified by menstrual phase: 33% were preovulatory (Days 5 to 11), 26% were periovulatory (Days 12 to 18), 20% were postovulatory (Days 19 to 25), and 21% were perimenstrual (Days 26 to 4), p = 0.008. There was no significant association between phase of menstrual cycle and asthma severity. Our data indicate that ED visits for acute asthma among women are more frequent during the preovulatory phase in contrast to other studies reporting more visits in the perimenstrual phase.

What do Psychiatry Residents Think of an Objective Structured Clinical Examination?

Although interest is increasing in the use of Objective Structured Clinical Examinations (OSCEs) for the assessment of psychiatry residents, there are very few reports of the experiences and attitudes of residents to this form of evaluation. Eighteen residents in psychiatry participated in an OSCE consisting of eight 12-minute standardized patient interviews. Of the 15 who completed a postexamination survey, 93% rated the scenarios as very realistic and 80% considered the scenarios reflective of clinical situations they had experienced. The residents were very confident that such an examination could discriminate between incompetent and competent medical students, but the residents were less certain of the OSCE’s power to do so between competent and incompetent residents. While residents rejected the idea of such an OSCE for board certification, many felt they would like the experience to be a formative part of their training.

Reinvigorating PBL by integrating standardized-patient interviews.

Reinvigorating PBL by integrating standardized-patient interviews.

Standardized patients in the assessment of general practice consulting skills (694).

This paper describes the use of standardized patient interviews as a means of assessing the consulting skills of fifth year medical students studying general practice. Interviews are restricted to a duration of 9 minutes and focus on either diagnostic or management tasks. Volunteers are trained to play standardized roles depicting common general practice presentations. A detailed marksheet has been developed to increase inter-examiner reliability, discourage global marking and incorporate a patient assessment of the student. Issues of reliability, validity and security in this form of assessment are discussed.

Late outcome of percutaneous dilatational tracheostomy in intensive care patients.

Percutaneous dilatational tracheostomy is increasingly practiced in intensive care units and has a low incidence of early complications. The late effects of this procedure are still poorly known and were the focus of this study. Prospective descriptive clinical study. Interdisciplinary intensive care unit in a 300-bed teaching hospital. A consecutive group of critically ill patients who underwent percutaneous tracheostomy between Nov. 90 and March 93, surviving at least 2 months after decannulation. There were 17 patients fulfilling the inclusion criteria and 16 of them were seen and examined. The follow-up protocol required a formal standardized patient interview, a physical examination of the stoma site and a fiberoptic laryngotracheoscopy. Results of these sub-tests and overall outcome rating were standardized and expressed as good, moderate or poor. Subjective rating was good in all patients. All denied suffering from any side effects of their tracheostomy. Clinical examination revealed neither stridor nor hoarseness in any of the patients. Most of the scars were whitish and less than 1 cm in length, a few were sunken in, none had adhesions. In 15 patients the clinical result was good and in one, moderate (whitish, sunken-in scar, longer than 2 cm). Ten patients underwent tracheoscopy, while 6 did not. There were no signs of significant stenosis or tracheomalacia. In 8 patients with minor findings results were scored as good, while 2 were classified as moderate (combination of swelling and scar formation of a string-like membrane). The overall rating was good in 13 patients (81%) and moderate in 3 patients (19%). There were no poor outcomes. Late outcome of percutaneous dilatational tracheostomy in critically ill patients is mostly good. Pending further studies, the use of this technique in intensive care units appears justified.

Evaluation strategies selected by residents: The roles of self‐assessment, training level, and sex

Thirty internal medicine residents, 10 from each of 3 years, participated in standardized patient interviews. They selected from 17 strategies the way they would like to receive evaluation/feedback about their performances. Eighty percent selected as their primary choice a highly diagnostic strategy—a trend more likely in women. Women also were more likely to select multiple strategies using themselves as evaluators. There was no association of choice with year, initial self‐rating, or desire for ranking versus objective score rating performance. The results support the idea that residents, regardless of level of confidence in their abilities, seek informative feedback even when it could be avoided.