Standardized Simulated Patients Research Articles

178 Upstream Immersion: Preparing Allied Health Students with Foundational Placement Skills through a Multi-Disciplinary Simulation Week

The COVID-19 pandemic has led to an increased demand for clinical placements for Allied Health Professional (AHP) students. Consequently, we have needed to be creative to explore other ways to ensure students complete their 1,000 hours of clinical experience across the programme. A potential option is to use simulation to replace a portion of clinical hours. Evidence confirms that up to 25% of authentic physical practice with standardized simulated patients results in comparable student competency as assessed by an educator and that a 1-week period of simulation is effective in building students’ confidence before continuing with a placement in the clinical setting Our aim was to design, develop, implement and evaluate a multi-disciplinary simulation programme to prepare students with foundational placement skills. We sought to therefore reduce the burden on NHS staff. We also sought to determine the effect of the programme on student readiness for placement, student confidence, investigate stakeholder perceptions of the programme and determine the suitability of simulation in contributing to clinical hours.Simulation-based educational (SBE) pedagogy and principles guided the programme design and included: pre-brief, simulation with regular time outs to enable rehearsal of an activity and debriefing for reflection. We employed actor role players to act as the patient, relative or carer and clinical educators to guide the students as they would on a traditional placement. We developed three generic patient case studies designed specifically to focus on the development of the key programme learning outcomes: developing patient-centred communication skills and professional behaviours. We adopted a mixed-methods approach in our research design, collecting quantitative data from student self-report pre–post questionnaires, clinical educator questionnaires and qualitative data from focus groups to address our research questions and aims.A total of 29 Allied Health Professional students (from physiotherapy, occupational therapy and podiatry) completed a 5-day intensive simulation programme. The programme included an inter-professional ‘fishbowl simulation’ followed by 3 days of profession-specific clinical scenarios with profession-specific learning outcomes ending on the final day in six simulated multi-disciplinary team meetings. The sessions were interactive with simulated patients and their relative/carers giving authentic patient feedback from a patient perspective. We observed rich transformational learning observing students improve their communication skills and becoming more patient-centred in their approach. Preliminary student feedback indicates that they found the simulation programme challenging but extremely rewarding. Formal data analysis is continuing.

Multi-source evaluation of an educational program aimed at medical students for interviewing/taking the clinical history using standardized patients.

Introduction: Simulations with standardized patients (SP) have long been used for teaching/assessing communication skills. The present study describes and evaluates an experiential training methodology aimed at medical students and based on interviews with standardized simulated patients. The training was focused on developing basic communication skills and taking medical histories. Methods: Longitudinal observational study of a cohort of third-year medical students. Three interviews with SP were carried out and videotaped. These interviews were assessed by the students, the SPs and the professors of the relevant subject areas.Results: 83 students conducted the interviews. The self-evaluations performed by the students showed an improvement between the first and third interviews, as demonstrated by the increase of 6.7% (CI 95%=3.6-10.0%) (p<0.001) in the percentage of detected items. The SPs stated an improvement of 8.5% (CI 95%=2.9-14.1) (p=0.003) from the first to the third interview regarding the percentage of students that showed a level of interest in, and ease with, the patients’ concerns. Finally, the teachers found a mean percentage of items identified in the third written clinical history of 61.4% (CI 95%=59.1-63.7) of the total available. Conclusions: This educational program, carried out with standardized simulated patients, showed positive signs of improvement from the first to the third interview, in both the student self-evaluations and the level of interest and ease perceived by the SPs. Additionally, the mean level of information recorded in the written medical histories was considered to be acceptable.

Transitioning from pre-clinical to clinical dental radiology, a pilot study: Student perceived influences on confidence.

Producing radiographic images requires the use of ionizing radiation, which has been well documented for its potentially detrimental effects on human tissues. Therefore, dental hygiene students begin their radiographic training by practicing on manikins in a pre-clinical environment. Use of manikins does not allow for patient interaction factors. No published dental studies have examined factors important in helping dental hygiene students develop confidence during the transition from manikins to working with live patients in a clinical radiology setting. The purpose of this study was to identify students' perceived influences on confidence and ultimately on performance when transitioning from a pre-clinical radiology setting to working with live patients. Specific research questions that were answered by this qualitative study were (1) What pre-clinical radiographic experiences did students feel were beneficial for transitioning from manikins to live patients? (2) What were the primary factors that students felt they struggled with when initially taking radiographs on patients? A qualitative study design was implemented in 2017. Data were obtained from students in a 2-year dental hygiene program. Survey responses, focus group feedback, and observation data were used to identify common themes. Emergent themes were reported using frequencies, emic and etic expressions. Four themes surfaced surrounding patient management, communication, appointment mechanics, and infection control. The use of standardized simulated patients may enhance clinical preparedness and confidence.

Structured clinical examinations with simulated patients during internal medicine clerkship

Practice is essential in clinical training and can be carried out with simulations. The medical school of the University of Chile performs Objective Structured Clinical Examinations (OSCE) using standardized simulated patients for interns. To report the experience with OSCE in an environment with a high number of students. Four hundred sixty-two students, participated in three OSCEs during 2016 and 2017, during their internal medicine clerkship. Each OSCE consisted of five scenarios of ambulatory care patients with prevalent medical conditions. Every student had to perform history taking, physical examination and deliver a diagnostic hypothesis, and a plan for management and counseling. Simulated patients provided feedback. To assess validity and reliability, in an argument-based model, planning and activity development were declared. The results were evaluated according to students' and organization variables, internal consistency, interobserver and theoretical concordance tests. No significant bias was found by demographic features or evaluation moment. Internal consistency was good (Cronbach 0.8). Simulated patient evaluators had a high correlation with medical evaluators (r = 0.7). There was a low correlation between OSCE results and theoretical tests. OSCE's continuously assess competences during internal medicine clerkship in an environment with a high number of students.

Evaluation of a communication skills training to facilitate addressing palliative care related topics in advanced cancer patients: study protocol of a multicenter randomized controlled trial (PALLI-KOM)

BackgroundEarly integration of palliative care concurrently to standard cancer care is associated with several benefits for patients and their caregivers. However, communication barriers on part of the caring physicians often impede a timely referral to palliative care. This study describes the protocol of the evaluation of a communication skills training aiming to strengthen the ability of physicians to address palliative care related topics adequately and early during disease trajectory.MethodsWe will implement a communication skills training and evaluate it within a prospective, multi-centered, two-armed randomized controlled trial (RCT), which will be conducted at four sites in Germany. Eligible subjects are all physicians treating patients with advanced cancer in their daily routine. An intervention group (IG) receiving a group training will be compared to a wait-list control group (CG) receiving the training after completion of data collection. At pre- and post-measurement points, participants will conduct videotaped conversations with standardized simulated patients (SP). Primary outcome will be the external rating of communication skills and consulting competencies addressing palliative care related topics. Secondary outcomes on core concepts of palliative care, basic knowledge, attitudes, confidence and self-efficacy will be assessed by standardized questionnaires and self-developed items. A further external assessment of the quality of physician-patient-interaction will be conducted by the SP. Longitudinal quantitative data will be analyzed using covariate-adjusted linear mixed-models.DiscussionIf the communication skills training proves to be effective, it will provide a feasible intervention to promote an earlier communication of palliative care related topics in the care of advanced cancer patients. This would help to further establish early integration of palliative care as it is recommended by national and international guidelines.Trial registrationGerman Clinical Trials Register DRKS00017025 (date of registration: 4 June 2019).

Intervention for Standardized Patients' Anxiety After “Receiving Bad News” Scenarios

BackgroundThis study aimed to determine the anxiety levels of standardized/simulated patients (SPs) who received bad news and to explore the effects of relaxation exercises during the de-roling/debriefing phase on the anxiety levels of the SPs. MethodA pretest/post-test pattern was used for 19 SPs who participated in the study. ResultsThe SPs were mildly anxious (mean State-Trait Anxiety Inventory [STAI] score, 38.16 ± 8.69) before delivery of the bad news. After delivery of the bad news, the SPs showed moderate anxiety levels (mean STAI score, 47.89 ± 8.95). The relaxation exercises showed a statistically significant decrease in the anxiety levels, and the SPs (p < .001) showed mild anxiety levels (STAI mean score, 25.63 ± 5.43). ConclusionRelaxation exercises during de-roling/debriefing showed promising effects to provide a psychologically safe working environment for SPs, especially after portraying difficult scenarios.

DOES CARDIAC PHYSICAL EXAM TEACHING USING A CARDIAC SIMULATOR IMPROVE MEDICAL STUDENTS’ DIAGNOSTIC SKILLS?

Challenges in clinical bedside teaching can lead to sub-optimal cardiac physical exam skills among medical trainees. To address these challenges, simulation using high-fidelity simulators may provide a realistic alternative for teaching the cardiac physical examination. The purpose of this study is to measure the ability of medical students to perform a cardiac physical exam and make the correct clinical diagnosis after a learning module using standardized Simulated Patients (SP) with real cardiac findings compared to a cardiac simulator (Harvey). After a pretest Multiple Choice Questionnaire test on Harvey, 32 first-year medical students were randomized to a one-hour teaching module on either a Standardized Patient (SP) or Harvey. Their performance and ability to make the correct diagnosis for three cardiac conditions (Aortic stenosis, Mitral regurgitation, Normal Findings) were evaluated during a videotaped posttest Objective Structured Clinical Examination (OSCE) on real patients. No difference in the mean OSCE score was observed between the two groups (SP group: M=62.2% vs. Harvey group: M =57.2%, p = 0.32). The SP group obtained a higher frequency of correct diagnoses (M = 61%) than the Harvey group (M = 21% p = 0.03). Feedback on teaching showed that Harvey offered significantly superior clinical findings. However, 34.4% of students requested a combination of either teaching modalities as opposed to Harvey alone (9.4%) or SP alone (6.2%). The medical students’ ability to perform a cardiac physical exam did not vary when taught using SP vs. Harvey. Teaching on SP did lead to better performance in correctly diagnosing cardiac conditions. Harvey, the high-fidelity simulator, was the preferred method of teaching but the combined teaching program using both SP and Harvey may be the ideal method of teaching to attain transferability to patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical utility of a blood-based protein assay to increase screening of elevated-risk patients for colorectal cancer in the primary care setting.

Colorectal cancer (CRC) screeningis effective in finding early stage CRC and dramatically improves survival rates. Despite this, the number of eligible patients who do not obtain CRC screening is unacceptably high. We conducted a longitudinal, randomized controlled trial investigating the utility of a blood-based protein assay on the quality of care delivered by practicing PCPs in the United States. We used standardized simulated patients (CPVs), presenting with symptoms suggestive of a higher likelihood of CRC, to measure how frequently these PCPs ordered diagnostic colonoscopy. 190 PCPs cared for three patients at baseline and three patients post-intervention. The PCPs were randomized into one of two study arms: control and intervention. The intervention arm consisted of educational materials about the blood-based protein assay and positive test results. Each simulated patient in the intervention arm had a positive test result that was given to the doctor. The controls were given neither intervention materials nor blood-based protein assay results. Physician responses in both groups were scored against evidence-based criteria. Data were collected at baseline and post-intervention. At baseline, we found that 71% of physicians ordered diagnostic colonoscopy. In round 2, 23% of physicians in the intervention arm adopted the new blood-based protein assay. Ordering physicians were 3.88 (95% CI 1.67-9.03) times more likely to order a diagnostic colonoscopy. In percentage terms, those who ordered the assay were more likely to order colonoscopy (92%) than either intervention physicians who did not order the assay (77%) or control physicians (66%) (p<0.001). A marginal effects estimation showed that use of the assay would increase ordering colonoscopy to nearly 95%. Over one-third of adults in the United States do not follow the recommended screening guidelines for CRC. The introduction of a blood-based protein assay significantly increased the likelihood that physicians would order diagnostic colonoscopies in elevated-risk patients compared to those without access to the assay results. The overall change in clinical utility observed here has the potential to significantly improve clinical care.

Simulated Cases in Clinical Training for Pharmacists

Clinical classes are the milestones that help pharmacy students gain clinical competency and to prepare them for their professional life. Although didactic methods provide theoretical knowledge, the retention rate of information is relatively low when compared with problem based teaching methods. Simulators such as high fidelity mannequins or standardized simulated patients are often preferred by clinical teachers in schools that teach health profession. High and low fidelity mannequins, and computerized simulators require a cost and dedicated space, which can be a disadvantage. On the other hand, standardized patients are advantageous to develop communication skills. Hence, use of simulation based methods in clinical training are useful in general, because they lead students to self-directed learning strategies, critical thinking and rational decision-making. Therefore, dissemination of simulation techniques is important to improve clinical skills.

Clinical Utility of a Comprehensive, Whole Genome CMA Testing Platform in Pediatrics: A Prospective Randomized Controlled Trial of Simulated Patients in Physician Practices.

BackgroundDevelopmental disorders (DD), including autism spectrum disorder (ASD) and intellectual disability (ID), are a common group of clinical manifestations caused by a variety of genetic abnormalities. Genetic testing, including chromosomal microarray (CMA), plays an important role in diagnosing these conditions, but CMA can be limited by incomplete coverage of genetic abnormalities and lack of guidance for conditions rarely seen by treating physicians.MethodsWe conducted a longitudinal, randomized controlled trial investigating the impact of a higher resolution 2.8 million (MM) probe-CMA test on the quality of care delivered by practicing general pediatricians and specialists. To overcome the twin problems of finding an adequate sample size of multiple rare conditions and under/incorrect diagnoses, we used standardized simulated patients known as CPVs. Physicians, randomized into control and intervention groups, cared for the CPV pediatric patients with DD/ASD/ID. Care responses were scored against evidence-based criteria. In round one, participants could order diagnostic tests including existing CMA tests. In round two, intervention physicians could order the 2.8MM probe-CMA test. Outcome measures included overall quality of care and quality of the diagnosis and treatment plan.ResultsPhysicians ordering CMA testing had 5.43% (p<0.001) higher overall quality scores than those who did not. Intervention physicians ordering the 2.8MM probe-CMA test had 7.20% (p<0.001) higher overall quality scores. Use of the 2.8MM probe-CMA test led to a 10.9% (p<0.001) improvement in the diagnosis and treatment score. Introduction of the 2.8MM probe-CMA test led to significant improvements in condition-specific interventions including an 8.3% (p = 0.04) improvement in evaluation and therapy for gross motor delays caused by Hunter syndrome, a 27.5% (p = 0.03) increase in early cognitive intervention for FOXG1-related disorder, and an 18.2% (p<0.001) improvement in referrals to child neurology for Dravet syndrome.ConclusionPhysician use of the 2.8MM probe-CMA test significantly improves overall quality as well as diagnosis and treatment quality for simulated cases of pediatric DD/ASD/ID patients, and delivers additional clinical utility over existing CMA tests.

Standardized patients versus simulated patients in medical education: are they the same or different

In order to equip medical students with all the necessary skills in dealing with patients to provide optimal treatment, the need for the use of real patients in educational settings has become prominent. But all the required skills cannot be practiced on real patients due to patients’ safety and well-being. Thus, the use of standardized patients (SPs) or simulated patients (SiPs) as a substitute for real patients signifies their importance in simulation-based medical education. One question raised in regard to using SPs or SiPs in order to enhance medical students’ tangible and intangible skills in a safe controlled environment is whether these two terminologies are the same or different? Various studies use these terms interchangeably and do not consider a difference between them. Based on our literature review, there seems to be differences between these two modalities. We also try to highlight the advantages of these modalities in clinical encounters.

Development of an instrument to measure the quality of standardized/simulated patient verbal feedback

Standardized/simulated patients (SPs) are being asked to provide formative verbal feedback to medical students. There is a need to objectively measure the quality of this feedback. This paper describes the theoretical and empirical development of the Quality of Standardized Patient Feedback form (QSF), an instrument designed to measure the quality of standardized/simulated patient verbal feedback. The QSF consists of 7 categories derived from existing literature on feedback. Interrater and internal consistency reliabilities of QSF scores were calculated through two pilot studies. In the first, 2 standardized patient educators (SPEs) analyzed 14 videos of SP verbal feedback (weighted kappa = 0.73). In the second study, 14 SPs rated 3 videos (Intraclass correlation coefficient = 0.92. Internal reliability was 0.79 (Cronbach’s alpha). Twenty-one expert SPEs were asked to rate the QSF categories as to their importance in providing feedback to learners. SPEs agreed on the importance of five of the seven categories, but were split on the importance of two categories. We found theoretical and practical support for the QSF categories. The QSF is a useful instrument for evaluating the quality of SP verbal feedback.

Implementation of “Collaborative Development of Advanced Practical Education Program to Train Pharmacists with Leadership” under the Joint Operation of Pharmaceutical Departments of Fourteen National Universities

"Collaborative Development of Advanced Practical Education Program to Train Pharmacists with Leadership" applied jointly by the pharmaceutical departments of fourteen national universities was selected to receive the special expenditure support of Ministry of Education, Culture, Sports, Science and Technology for fiscal year 2010 under "the Training of Highly Skillful Professionals and Improvement of the Quality of the Function of Professional Education". This project is to promote the collaborative development of the educational program which will make it possible to further advance and substantiate the education of pharmacists in the six year course of the pharmaceutical department for the ultimate purpose to introduce pharmacists with leadership who can play an active role and fill in a leadership position in a wide range of responsibilities into the society which, more and more, has come to expect pharmacy to take the initiative in acting against health hazards caused by infections, foods and environmental pollution as well as to meet the diversification of healthcare. To be more specific, this project is to try and evaluate the following programs repeatedly based on the plan-do-check-act (PDCA) cycle: 1) Practical medical and pharmaceutical education program; 2) Program concerning research on long term themes and advanced education; 3) Program concerning training and education of SPs (standardized patients or simulated patients) and PBL (problem-based learning) tutorial education; and 4) Program concerning the method of evaluation of education. Through this repeated trial and evaluation, this project ultimately seeks to construct a highly effective practical educational program which integrates each university's achievements and educational attempts rich in originality.

Standardized Patients Versus Simulated Patients: Is There a Difference?

The rapid development of simulation as a modality for education has created some confusion in terms, especially when applied to standardized patients and simulated patients. Some authors report them as being the same, whereas others define them in a different context, causing confusion for facilitators and researchers. The purpose of this article is to offer a discussion and definition of the roles of a standardized patient and a simulated patient and to define the differences between the two genres.

An Approach to Evaluating Competence in Assessing and Managing Violence Risk

The authors developed and evaluated a tool for assessing competency in violence risk assessment and management.The Competency Assessment Instrument for Violence Risk (CAI-V) was based on the literature on violence risk assessment, which was complemented by feedback from faculty focus groups. In an objective structured clinical examination, 31 faculty observers used the CAI-V to rate the performance of 31 learners' (26 psychiatry residents and five psychology interns) risk assessments of standardized (simulated) patients. In an interrater reliability study, six faculty members rated video-recorded risk assessments.The CAI-V had good internal consistency reliability (α=.93). Senior learners performed better on the CAI-V than junior learners, supporting the instrument's concurrent validity. Interrater reliability was good (intraclass correlation coefficient=.93). Participants reported that the CAI-V provided a helpful structure for feedback and supervision.The results supported the potential of this new approach for appraising competency in violence risk assessment and management.

An Approach to Evaluating Competence in Assessing and Managing Violence Risk

The authors developed and evaluated a tool for assessing competency in violence risk assessment and management. The Competency Assessment Instrument for Violence Risk (CAI-V) was based on the literature on violence risk assessment, which was complemented by feedback from faculty focus groups. In an objective structured clinical examination, 31 faculty observers used the CAI-V to rate the performance of 31 learners' (26 psychiatry residents and five psychology interns) risk assessments of standardized (simulated) patients. In an interrater reliability study, six faculty members rated video-recorded risk assessments. The CAI-V had good internal consistency reliability (α=.93). Senior learners performed better on the CAI-V than junior learners, supporting the instrument's concurrent validity. Interrater reliability was good (intraclass correlation coefficient=.93). Participants reported that the CAI-V provided a helpful structure for feedback and supervision. The results supported the potential of this new approach for appraising competency in violence risk assessment and management.

Breast cancer risk communication: Assessment of primary care physicians by standardized patients

PurposeTo assess primary care providers' communication about breast cancer risk. MethodsWe evaluated 86 primary care providers' communication of risk using unannounced standardized (simulated) patients. Physicians were randomly assigned to receive one of three cases: (1) moderate risk case (n = 25), presenting with a breast lump and mother with postmenopausal breast cancer; (2) high-risk (maternal side) case (n = 28), presenting with concern about breast cancer risk; and (3) high-risk (paternal side) case (n = 33), presenting with an unrelated problem. After the appointment, three qualitative parameters were assessed by standardized patients on a 3-point scale (3 = highest satisfaction, 1 = lowest): whether the physician took adequate time; acknowledged her concerns; and offered reassurance. ResultsMean satisfaction with physician communication was higher for the moderate risk case (2.92) than for the high-risk paternal case (2.25) or high-risk maternal case (2.42) (P < 0.0001). The score was not influenced by session length, medical specialty, or physician gender. ConclusionPhysicians more consistently provided a moderate risk standardized patients with reassurance and support compared with the high-risk cases. Primary care physicians may be more unprepared or uneasy addressing the issues raised by more complex scenarios and may benefit from training in the assessment and communication of breast cancer risk.

Management of patients with angina pectoris by GPs: a study with standardized (simulated) patients in actual practice.

Little is known about the management of patients with angina pectoris by GPs. The purpose of this study was to assess how a group of GPs managed a patient with angina pectoris complaints in a real-life practice setting during unbiased consultations with standardized patients. GPs were consulted during normal surgery hours by a standardized patient portraying a patient with angina pectoris. The setting was Trondheim, Norway. All 87 GPs in the city of Trondheim (Norway) were informed by letter about a study with standardized patients and invited to take part. They were asked to give consent to be visited during actual surgery hours by standardized patients. The date, number and content of the visits planned were not mentioned. They were not told that the study focused on angina pectoris. For budgetary reasons it was decided to ask 24 physicians to participate. The GPs were consulted during normal surgery hours by a standardized patient portraying a patient with angina pectoris. The patients reported on the consultations using a checklist based on guidelines for management of angina pectoris. Outcome measures were the content and number of actions undertaken from the guidelines. Twenty-eight GPs (32%) agreed to participate. Of these, 24 were selected and visited. One doctor detected the standardized patient. The results showed that the participating physicians met 76% of the guidelines used. However, the GPs ordered 31 different types of laboratory test (mean = 7.9, range = 1-18 per physician). In addition, the 23 consultations resulted in seven referrals (two for chest X-rays, four for an exercise test and one referral to a specialist in cardiology). Twenty-two of the 23 doctors made the correct diagnosis and informed the patient accordingly. When assessed in an unbiased situation in real practice, GPs performed well against a pre-set standard for management of angina pectoris patients. Much variation was found in the request for laboratory tests. These real-life practice data suggest that there is a need for discussing guidelines for effective ordering of laboratory tests in general practice.

UNDERSTANDING THE OBJECTlVE STRUCTURED CLINICAL EXAMINATION

A number of factors have contributed to the relatively rapid development and growth of the Objective Structured Clinical Examination (OSCA) as a viable and popular assessment tool. Among these was an increased need, expressed both by training institutions and certifying and licensing bodies, for valid performance-based assessment approaches. That this need became apparent at a time when concern and interest in performance-based assessment in education generally was growing, was fortuitous and contributed to the developments in medical education. In medical education important consequences were the growing interest and expertise in two distinct areas, the psychometrics of performance assessment and the use of standardized (simulated) patients in the teaching and assessment of clinical skills. Collaboration between people working in these two areas greatly facilitated the rapid development and refinement of the OSCA. Currently, there appears to be general acceptance of the legitimacy of this assessment approach. Research now seems to be directed at resolving remaining important technical problems (e.g. standard setting); the design and implementation of large scale national and regional certifying and licensing examinations are the primary current development challenges. There is a large and still growing body of related literature and many presentations about this assessment approach are given at medical education conferences.

Training and evaluating teams of simulated patients.

The purpose of this study was to train and evaluate teams of standardized (simulated) patients as part of a required course in family medicine for second-year medical students. During three hours of training, six women were trained to play the same person. These standardized teams played four roles during the 12-week course. Each simulator was interviewed by three student interviewers who were part of six groups of ten to 12 students, each group led by a physician. All sessions were audiotaped, and a coding system was developed. The completeness of response, new unscripted items, and accuracy of information provided by the simulators were measured using the audiotape sessions as sources of data. In addition, the degree of accuracy of the affect of each simulator was assessed by faculty and students in written case histories. The results of the study show that multiple simulators are an effective way of promoting active learning and of teaching basic clinical concepts and skills. Teams of standardized patients give students a consistent learning experience when there are constraints of student group size, time, and scheduling simulations within a traditional curriculum.