1. Fourth Year Student “patients” for First Year Doctoring Course Robin Schroeder, MD Steven E. Keller, PhD Chantal Brazeau, MD UMDNJ-New Jersey Medical School Newark, NJ

2. Educational Goals and Objectives Provide an effective method to teach first year students about medical mistake disclosure Provide an effective method to teach first year students about medical mistake disclosure Provide teaching and feedback opportunity for fourth year students Provide teaching and feedback opportunity for fourth year students

3. Our Goals Improve the realism of a doctor- patient encounter for first year students Improve the realism of a doctor- patient encounter for first year students Revealing a medical mistake Revealing a medical mistake Avoid the cost of standardized patients Avoid the cost of standardized patients

4. Background First year doctoring course First year doctoring course Humanism and professionalism module of “Doctoring” course Humanism and professionalism module of “Doctoring” course Medical mistake made in treating thyroid disease Medical mistake made in treating thyroid disease One “rogue” faculty facilitator provided an “SP” for his small group One “rogue” faculty facilitator provided an “SP” for his small group Anecdotally, his students felt that they had a more realistic experience Anecdotally, his students felt that they had a more realistic experience

5. Educational Background Since early 1970’s, increased interest in medical students as teachers Since early 1970’s, increased interest in medical students as teachers Many programs now aimed at teaching medical students how to teach (primarily fourth year students) Many programs now aimed at teaching medical students how to teach (primarily fourth year students) Scant reporting on how the students are taught to teach Scant reporting on how the students are taught to teach Limited evaluation of the teaching skills of students Limited evaluation of the teaching skills of students

6. Ideal Method Teaching Medical Students How to Teach Integrated, longitudinal curriculum designed for each level of training Integrated, longitudinal curriculum designed for each level of training Include learning theory Include learning theory Content specific for different venues (bedside, small group, lecture) Content specific for different venues (bedside, small group, lecture) This type of program not described in the literature This type of program not described in the literature

7. Reality Teaching Medical Students How to Teach Budgetary constraints Budgetary constraints Overextended teaching faculty Overextended teaching faculty Students listen to other students Students listen to other students So, we Created an informal, low cost program requiring minimal faculty time/effort Created an informal, low cost program requiring minimal faculty time/effort Obtained IRB exempt approval Obtained IRB exempt approval

8. Process Sent an e-mail to all fourth year students Sent an e-mail to all fourth year students “Now that interviews are winding down, we have a wonderful opportunity for you to display your acting skills as a simulated patient for PCI-history only, no physical exam involved!...Students have told us that it is difficult to role play with member of their own group…fourth year students will be more realistic” We ended up with 10 4th year student volunteers We ended up with 10 4th year student volunteers

9. Training the Students Provided lunch! Provided lunch! Reviewed the scenario Reviewed the scenario Students suggested possible “patient” reactions that they could portray Students suggested possible “patient” reactions that they could portray Vary the “patient” reaction Vary the “patient” reaction Reviewed “Giving Feedback”, so fourth year student “patients” could give feedback to first year student “doctors” Reviewed “Giving Feedback”, so fourth year student “patients” could give feedback to first year student “doctors”

10. Preparing the Facilitators Many had never worked with an SP Many had never worked with an SP Different styles, backgrounds Different styles, backgrounds All we did was to provide “Suggested Use of Simulated Patient” pointers All we did was to provide “Suggested Use of Simulated Patient” pointers Sent via e-mail Sent via e-mail

11. Suggested Use of Simulated Patients Prepare class by reviewing the scenario from the week before and briefly go over the new facts— that a mistake was made by the attending and that the mistake now needs to be addressed Prepare class by reviewing the scenario from the week before and briefly go over the new facts— that a mistake was made by the attending and that the mistake now needs to be addressed Inform the class that a “patient” will come in and that it is their task as the physician to address the mistake with the patient Inform the class that a “patient” will come in and that it is their task as the physician to address the mistake with the patient Pick a student to begin and have the “patient” knock on the door, enter and then begin the encounter Pick a student to begin and have the “patient” knock on the door, enter and then begin the encounter

12. Suggested Use of Simulated Patients Realize that the particulars of each patient’s case may be different and do not get hung up on differences between the printed scenario and what is transpiring in your group-try to remain silent, only interrupting if the students is at a loss or if the scene is getting out of control. Let the student proceed until there is a natural stopping place such as the student doctor is blocked, there is an impasse, or several minutes have passed. In any of these cases, interrupt the scenario and ask the student patient to step out for 2 minutes. Realize that the particulars of each patient’s case may be different and do not get hung up on differences between the printed scenario and what is transpiring in your group-try to remain silent, only interrupting if the students is at a loss or if the scene is getting out of control. Let the student proceed until there is a natural stopping place such as the student doctor is blocked, there is an impasse, or several minutes have passed. In any of these cases, interrupt the scenario and ask the student patient to step out for 2 minutes.

13. Suggested Use of Simulated Patients Ask the student doctor to tell how he/she felt it went, ask the small group what went well and what could be done differently (2 minute discussion) Ask the student doctor to tell how he/she felt it went, ask the small group what went well and what could be done differently (2 minute discussion) A student who makes a good suggestion can be selected as the next doctor A student who makes a good suggestion can be selected as the next doctor Have the “patient” provide feedback to the “doctor” Have the “patient” provide feedback to the “doctor”

14. Suggested Use of Simulated Patients Have another student start from the beginning of the encounter Have another student start from the beginning of the encounter Allow as many students to be the “doctor” as possible or until it becomes redundant Allow as many students to be the “doctor” as possible or until it becomes redundant

15. Evaluation of the “SP” Experience Four questions, Likert scale responses, two open-ended qualitative questions Four questions, Likert scale responses, two open-ended qualitative questions Completed by: First year students First year students Fourth year students Fourth year students Faculty facilitators Faculty facilitators

18. Results-1 st year students n = 187 n = 187 Unbiased sample, all students completed the evaluation Unbiased sample, all students completed the evaluation

19. Results-1 st year students 1. To what degree did this SP experience help you understand the process of explaining medical mistakes to patients? 93% responded moderate to very high degree (3, 4, 5 on Likert scale)

20. Results-1 st year students 2. Compared to having members of your PBL group role playing scenarios, how did the use of the SP compare? 85% responded moderate to very high degree (3, 4, 5 on Likert scale)

21. Results-1 st year students 3. Considering the SP as an educational resource, how well was this resource used in your PBL group? 99% responded moderate to very high degree (3, 4, 5 on Likert scale)

22. Results-1 st year students 4. How well did the use of the SP help in achieving the educational goals of the session? (See attached goals) 95% responded moderate to very high degree (3, 4, 5 on Likert scale)

23. Goals and Objectives At the end of this case, the students should be able to: Demonstrate the following ability related to the patient as a person: Demonstrate the following ability related to the patient as a person: Formulate an apology to a patient in the event of making a mistake Formulate an apology to a patient in the event of making a mistake Discuss the following issues related to awareness of self as humanistic professionals in relation to patients and within the healthcare system: Discuss the following issues related to awareness of self as humanistic professionals in relation to patients and within the healthcare system: Describe 2 examples of medical mistakes Describe 2 examples of medical mistakes Describe at least 5 “techniques” that physicians can use to prevent burnout Describe at least 5 “techniques” that physicians can use to prevent burnout Appreciate self-care as an integral aspect of professionalism Appreciate self-care as an integral aspect of professionalism

24. Goals and Objectives At the end of this case, the students should be able to demonstrate the following abilities related to being a competent practitioner with professional duty to lifelong learning: Develop the ability to ask relevant and logical questions using existing knowledge as it applies… Develop the ability to ask relevant and logical questions using existing knowledge as it applies… Develop learning issues appropriate to knowledge base… Develop learning issues appropriate to knowledge base… Utilize different sources of evidence when researching… Utilize different sources of evidence when researching…

25. Results-1 st year students Please list 3 positives of having an SP in your PBL group: (limitation/weakness-we assumed that the responses were in rank order) More realistic doctor-patient experience More realistic doctor-patient experience Overall better PBL experience Overall better PBL experience Specific feedback given by “patient” Specific feedback given by “patient”

26. Results-1 st year students Please list 3 negatives of having an SP in your PBL group: 32% of students did not list any negatives 60% came up with one negative The few “negatives” raised included “repetitiveness” of the exercise and the “time” that it took

27. Conclusions Significant positive educational impact can be made by using fourth year students as “patients” for first year student doctor- patient encounters Significant positive educational impact can be made by using fourth year students as “patients” for first year student doctor- patient encounters Minimal time and expense needed for implementation Minimal time and expense needed for implementation This pilot project can easily be adapted to fit a similar course in any school This pilot project can easily be adapted to fit a similar course in any school

28. Questions?