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2 WORKSHOP OBJECTIVES To provide background information about use of Standardized Patients for teaching and assessment To describe how standardized patients are used at the U. of Texas Health Science Center at San Antonio for training in the area of substance abuse To provide tools and resources for participants to develop programs at their own institutions

3 STANDARDIZED PATIENTS (SPS) Trained ‘actors’ who play the role of patients, families, other members of the health care team SPs were first used in 1963 by a neurologist, Dr. Howard Barrows, who recognized that students are rarely observed directly interacting with patients.

4 STANDARDIZED PATIENTS Standardized patient are used in training programs across the health care spectrum Medical students Residents Nurses Pharmacists Physician Assistants Counselors Dentists Nutritionists Journal of Psychosocial Nursing 2011; 49:35-40

5 HOW SPS ARE USED Brief (10-30 minute) scenario is developed based on curricular objectives Scenario includes setting and background information provided to the learner before the interaction(‘door information) Patient role (demographics, chief complaint, underlying issues or background, emotional state, expectations) Assessment tools are developed based on curricular objectives SP and faculty observer may have same or different assessment tools SP may be trained to give immediate feedback to learner

6 WAYS OF USING SPS Formative Feedback Learners participate in scenarios to practice and improve skills Immediate feedback for individualized learning Videos can be reviewed for additional discussion Summative Evaluation High stakes examination for grade or licensure Often conducted as an ‘OSCE’: Objective Structured Clinical Examination Series of stations evaluating different skills

7 WAYS OF USING SPS Curriculum assessment Identifying curricular strengths and deficits by analyzing aggregate performance of cohort Research Studying the effect of curricular intervention on learning, behavior

8 SPS AND OSCES FOR LICENSURE OSCEs required for licensure: Medical Council of Canada (1993) Incorporated SP assessment into licensure exam ECFMG (1994) NBME Step II Clinical Skills (2004)

9 ADVANTAGES OF USING SPS Use of SPs allows direct observation of pre- determined skills and scenarios “Challenging” and uncommon scenarios can be selected Assessment tool can be completed by the standardized patient Decreases faculty burden, increases feedback to learners Scenarios can be videotaped for review and feedback

10 DIRECT OBSERVATION VS. SPS Traditional approach: Clinical skills such as physical examination, interviewing and counseling are taught by demonstration of correct technique by faculty Learning is verified by direct observation of the learner by faculty Performance is improved by appropriate feedback to the learner QUESTION: HOW OFTEN ARE LEARNERS DIRECTLY OBSERVED BY FACULTY DURING INTERACTIONS WITH PATIENTS?

11 DIRECT OBSERVATION AND FEEDBACK How often are learners directly observed by faculty? Medical students and residents: In a study of 3 rd year medical students at U. of Va over half had never been observed performing a history or physical examination In a study of Emergency Medicine residents, <5% of their time was spent with patients under direct faculty supervision QUESTION: WHEN LEARNERS ARE OBSERVED BY FACULTY, IS THE FEEDBACK THEY ARE GIVEN ADEQUATE? Academic Medicine 2004; 39:276-80 Ann Int Med 2004; 117;757-65J

12 DIRECT OBSERVATION Is feedback adequate? In a study of videotaped new patient H&P 68% of faculty failed to note errors in history taking and PE technique A structured feedback form improved identification of errors J Gen Intern Med 2008; 23(7):1010-5 Ann Int Med 2004; 117;757-65

13 DIRECT OBSERVATION AND FEEDBACK Conclusions: Medical students and residents are rarely directly observed performing clinical skills ‘Difficult’ or unusual scenarios are even harder to observe routinely Faculty may not be adequate trained to observe and give helpful feedback to learners Time pressures, immediacy of patient care needs are barriers to direct observation of learners and provision of feedback

14 EFFECTIVENESS OF SPS Are SPs ‘real’ enough? Metaanalysis of 21 studies where SPs made unannounced visits to doctors’ offices Detection rates (identification of ‘fake’ patient) averaged 10% In some studies, 6% of real patients were identified as SPs Simulation in Healthcare 2008; 3:161-69 Medical Education 1999;33:572±578

15 SPS IN MEDICAL EDUCATION Multiple studies with medical students demonstrate using standardized patients was superior to lecture or large group demonstrations. Specifically, using SPs Improves medical student skills in interviewing and physical examination Allows for higher ratios of students: faculty Results in high ratings by students on the value of the learning experience, and the helpfulness of feedback by Standardized Patients Simulation in Health Care 2008; 3: 161-8

16 SPS IN SUBSTANCE ABUSE EDUCATION AND RESEARCH To test learners and document baseline skills To supplement teaching To measure the impact of a substance abuse training/curriculum “Other” research

17 SPS TO ASSESS OF BASELINE SKILLS In 1995 videotaped encounters with SPs were used to determine whether graduating nurses asked patients about substance abuse during a ‘comprehensive’ health history Low rates of asking about substance abuse, even when prompted Fussell et al used SPs to assess substance abuse counselors’ skills at managing a patient with methamphetamine use and partner violence Poor skills at identifying PV as comorbidity and providing appropriate counseling Journal of Substance Abuse 1995; 7: 357-36 Psychiatry 2009; 72: 382-92

18 SPS IN SUBSTANCE ABUSE EDUCATION Fourth year medical students were trained in the assessment and management of alcohol-related problems by one of three methods: Watching and discussing a videotaped interview with an actor playing the patient Group interview with a real patient with alcohol-related problems Live interview with actor: one student interviewed the actor while the rest of the group observed The actor came ‘out of role’ to give feedback at the end Results No different in scores on knowledge and attitude Students rated live SP as better with regard to acquisition of interviewing skills Medical Teacher 2001; 23: 490-93

19 SPS TO ASSESS IMPACT OF CURRICULUM Motivational Interviewing is a ‘client-centered style of counseling …to help people resolve ambivalence and prepare for change’ Controlled trials have shown the use of MI improves client retention and reduces post treatment substance abuse Training is offered through 2 day workshops ( How to verify that the skills have been adequately learned?

20 SPS IN MOTIVATIONAL INTERVIEWING Baer et al compared 3 methods of assessing MI skills at baseline, immediately after training, and 2 months later Audiotapes of actual clinical encounters “Helpful Response Questionnaire” : a paper and pencil questionnaire that presents hypothetical patient statements and asks for the clinicians response SPs (psychology grad students) with ETOH and marijuana use Video and audiotapes were coded using the Motivational Interviewing Coding System (MISC) Drug and Alcohol Dependence 2004; 73: 99-106

21 RESULTS Only 3/22 clinicians provided audiotapes at all three time points Low numbers of new clients, working with groups, need for consent were all cited as barriers to audiotaping 19/22 completed the case-prompted questionnaire (HRQ) and all three SP encounters The HRQ showed improvement in MI skills immediately post training and 2 months after training The SP interviews showed improvement in MI skills immediately post training, but much of the improvement was not sustained at 2 months post training 2/19 were ‘proficient’ at MI prior to the training, and 8 were ‘proficient’ at 2 months post training Drug and Alcohol Dependence 2004; 73: 99-106

22 SPS AND MOTIVATIONAL INTERVIEWING Conclusions: It is easier to tape clinicians interacting with a SP than it is to get actual audiotapes of real patient encounters “The use of SPs appears to be a feasible and reliable method for skill assessment” Further work: Use of video taped SPs to generate written response by the clinician (VASE-R: Video Assessment of Simulation Encounters-Revised) Drug Alcohol Depend. 2008 September 1; 97(1-2): 130–138

23 SP AND SUBSTANCE ABUSE RESEARCH SP was trained to portray a patient dependent on prescription opioids enrolling in a clinical trial The SP ‘walked through’ the steps to enroll in the clinical trial, from the initial phone call to the prescreening, consent form, intake, physician and counselor assessment The SP made many suggestions to improve the process and identified areas where the staff needed more training This experience was rated very highly by the research team as it helped them prepare for ‘real’ trial participants Fussell HE. Journal of Substance Abuse Treatment 2008; 35: 470-75

24 CONCLUSIONS: SPS FOR CLINICAL SKILLS Direct observation and feedback of students and residents by faculty preceptors may be inadequate Standardized patients provide feedback to medical students that is comparable to or superior to faculty feedback Medical students trained with SPs in basic clinical skills perform better in testing situations than MS trained in the ‘usual’ way SPs in GME Well received, highly rated by learners Educational programs incorporating SPs improve performance in testing situations

25 CONCLUSIONS Standardized Patients are already an integral component of training for medical students in the US In the field of substance abuse education and research, SPs Have been used to establish baseline knowledge, enhance teaching, assess curricular effectiveness, and improve processes in a research study THERE IS NO DATA ON THE HOW USE OF STANDARDIZED PATIENTS TO TRAIN STUDENTS OR CLINICIANS ACTUALLY AFFECTS CLINICAL PERFORMANCE OR PATIENT OUTCOMES

26 CHALLENGES OF USING SPS Need to recruit, train and pay ‘actors’ Need to develop realistic scenarios Need to develop valid assessment tools Management of results: Formative feedback: time and resources to help learners improve Summative feedback: deciding what to do if a learner ‘fails’ Time/Logistics of scheduling SP interactions Time spent interacting with SPs may take away from other learning activities including direct patient care

27 THE UTHSCSA EXPERIENCE Michelle V. Conde, MD Clinical Associate Professor Division of General Medicine UTHSCSA South Texas Veterans HealthCare System Audie L. Murphy Division

28 UTHSCSA EXPERIENCE: HOW WE USE SPS (PART I) Objective Structured Clinical Evaluation (OSCE): Formative evaluation Summative evaluation Curriculum assessment

29 ALCOHOL SCREENING STATION You are about to see a new patient. You note that the nurse has indicated he is a retired general with a chief complaint of insomnia. Mr. Bradley is 78 yo, retired from the Army and recently moved to San Antonio to be closer to his daughter’s family. He has been very healthy all his life, though he does have HTN and takes HCTZ. For the past several months, he has had difficulty sleeping. He wakes up often in the night and cannot get back to sleep. He feels tired most of the day. Your goal in this exercise is to focus on the patient’s insomnia and identify any contributing/exacerbating factors. Instructions: Please enter the room and talk to the patient. You have ten (10) minutes.

30 OSCE RESULTS 2007 PGY-2S The general who couldn’t sleep A standardized patient (SP) played a retired General with insomnia. 26 residents were asked to take a history and identify contributing factors. 71% of residents screened for depression but only 38% assessed alcohol use. % residents who screened

31 GAPS IN CLINICAL CARE Unhealthy alcohol drinking Common Often undetected in primary care visits Screening for unhealthy drinking in presence of co morbidities is not routinely performed Example: depressive disorders Only 23% PCPs assess ETOH use Hepner KA, et al. Ann Int Med. 2007;147

32 CURRICULAR OBJECTIVES FOR ACADEMIC YEAR 2008- 2009 To develop, pilot, and integrate a standardized patient-based curriculum in improving screening for unhealthy drinking To improve residents’ ability to screen for unhealthy alcohol use by eliciting number of drinks/day while interviewing an SP To enhance residents’ ability to further evaluate impact of alcohol use on health when given the positive history of alcohol consumption

33 We implemented changes in our medical interviewing curriculum (taught in PGY- 1 year during mandatory Primary Care Block Rotation) Previously: “live” patient/resident encounters videotaped in VA Acute Care Clinic (patients presented with acute problems and also exacerbations of chronic illnesses) Topics covered were variable Faculty reviewed tapes with residents in a small group setting Standardized curriculum lacking METHODS- 1

34 New curricular changes (monthly intern rotation): *Alcohol screening in patient presenting with depression *Tobacco cessation counseling Setting medical agenda Disclosing unintended medical outcomes Didactic materials on course website Use SP encounters (guided formative feedback) HOW WE USE SPS (PART 2)

35 Guided practice with Videotaped SP encounters: Provided opportunity to practice and improve skills At each station SPs complete checklists identifying important communication skills Immediate verbal SP feedback for individualized learning Written SP feedback Videotape excerpts reviewed by faculty member in small group setting HOW WE USE SPS (PART 2)

36 SAMPLE SCENARIO You are about to see a 50 yo new patient who was evaluated in the ER 1 month ago after a ‘fender bender’ and noted to have facial abrasions and high blood pressure. He was told to follow-up after his emergency room visit to get his BP rechecked. Conduct a new patient history. Then discuss the most significant issues you identify with the patient. Assume the physical examination is normal except for a blood pressure of 150/96.


38 LEARNER SURVEY (N=33) SP scenario and interaction realistic 82% SP feedback helpful 85% Likert scale 1-5; 4= Very good; 5= Excellent


40 7/08- 12/08 3 SP encounters: Topic 1: Setting medical agenda Topic 2: Counseling Topic 3: Breaking bad news All videotaped/received SP and faculty feedback 1/09- 6/09 4 SP encounters Topics 1-3: same Topic 4: ETOH screen in setting of insomnia and depression 9/09 OSCE with station similar to Topic 4 Timeline of SP cases for 24 Interns on month- long Outpatient Rotation *SP- standardized patient

41 7/08- 12/08 3 SP encounters: Topic 1: Setting medical agenda Topic 2: Counseling Topic 3: Breaking bad news All videotaped/received SP and faculty feedback 1/09- 6/09 4 SP encounters Topics 1-3: same Topic 4: ETOH screen in setting of insomnia and depression 9/09 OSCE with station similar to Topic 4 Timeline of arrangement of SP encounters for the 24 PGY1s on mandatory month- long PCBR *SP- standardized patient

42 7/08- 12/08 3 SP encounters: Topic 1: Setting medical agenda Topic 2: Counseling Topic 3: Breaking bad news All videotaped/received SP and faculty feedback 1/09- 6/09 4 SP encounters Topics 1-3: same Topic 4 : ETOH screen in setting of insomnia and depression 9/09 OSCE with station similar to Topic 4 Timeline of arrangement of SP encounters for the 24 PGY1s on mandatory month- long PCBR *SP- standardized patient

43 ASSESSING OUR CURRICULAR CHANGES We compared 2009 OSCE performance on a different SP encounter but with similar background of unhealthy alcohol use between residents who did and did not do the 4 th SP encounter during their PGY-1 year. Faculty completed checklist that included screening AUDIT and CAGE questions. Approved by IRB in exempt category.

44 RESULTS 2009 OSCE Completed ETOH- screening SP encounter (n= 14) Did not complete ETOH screening SP encounter (n= 10) Asked drinks/day 13/14 (93%)8/10 (80%) Asked additional f/u question 7/14 (50%)4/10 (40%)

45 CONCLUSIONS AND KEY LESSONS LEARNED Teaching intervention using SPs and review and feedback of videotapes may improve alcohol screening. Few residents have a standardized approach to screen for unhealthy ETOH use in depressed patients. OSCE results can be helpful in evaluating curriculum.

46 Looking to the Future: Assessment tool- Did Learner: State conclusion/recommendation clearly Relate drinking to concerns and medical findings Assess readiness to change Respond to ambivalence Identify barriers Identify specific steps to decrease drinking (if ready) Identify how drinking will be tracked Discuss who might be “helper” Arrange follow up?


48 Availability of a Simulation Center Recruitment Training Scenario Development Resources for identifying Scenarios OBJECTIVES

49 Simulation Centers Medical Schools Nursing Schools Association of Standardized Patient Educators Association (ASPE) ACCESS TO STANDARDIZED PATIENTS

50 RECRUITMENT A Standardized Patient (SP) that can fit the description of the patient in the case SP recruitment requirement/description decided by case author Description based on criteria for instance of age, height, weight, gender, physical condition, etc SP Experience

51 Send the scenario approximately 2 weeks before a training sessio to SP Conduct a training session(s) Case writer/clerkship director attend training Consult with case writer/course director with any questions that came out during training Immediate feedback at time of exam TRAINING SPS

52 Interpersonal Communication Skills Training Verbal Feedback Training ADDITIONAL TRAINING

53 Case Template (hand out example?) Door scenario (examples?) SCENARIO DEVELOPMENT




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