Using Standardized Patients

PRESENTERS:DR PATRICIA WATHENDR. MICHELLE CONDE

AUDREY ORTEGA

USING STANDARDIZED PATIENTS

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

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.

STANDARDIZED PATIENTS

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

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

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

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)

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

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?

DIRECT OBSERVATION AND FEEDBACK

• How often are learners directly observed by faculty? • Medical students and residents: • In a study of 3rd 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

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):1010-5Ann Int Med 2004; 117;757-65

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

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; 3:161-69Medical Education 1999;33:572±578

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

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

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: 357-36Psychiatry 2009; 72: 382-92

SPS IN SUBSTANCE ABUSE EDUCATION

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

(http://www.motivationalinterview.org)• How to verify that the skills have been

adequately learned?

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

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

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

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

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

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

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

THE UTHSCSA EXPERIENCE

Michelle V. Conde, MDClinical Associate ProfessorDivision of General Medicine

UTHSCSASouth Texas Veterans HealthCare

SystemAudie L. Murphy Division

UTHSCSA EXPERIENCE:HOW WE USE SPS (PART I)

•Objective Structured Clinical Evaluation (OSCE):• Formative evaluation•Summative evaluation•Curriculum assessment

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.

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

depression screening

drinks/day% r

esi

dents

who s

creened

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

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

• 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)

• 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)

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.

LEARNER SURVEY (N=33)

SP scenario and

interaction realistic

82%

SP feedback helpful

85%

Likert scale 1-5;4= Very good; 5= Excellent

ASSESSING OUR CURRICULAR CHANGES

7/08- 12/08

3 SP encounters:Topic 1: Setting medical agendaTopic 2: CounselingTopic 3: Breaking bad newsAll videotaped/received SP and faculty feedback

1/09- 6/09

4 SP encountersTopics 1-3: sameTopic 4: ETOH screen in setting of insomnia and depression

9/09

OSCE with station similar to Topic 4

Timeline of SPcases for 24 Interns on

month- long Outpatient Rotation

*SP- standardized patient

7/08- 12/08

3 SP encounters:Topic 1: Setting medical agendaTopic 2: CounselingTopic 3: Breaking bad newsAll videotaped/received SP and faculty feedback

1/09- 6/09

4 SP encountersTopics 1-3: sameTopic 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

7/08- 12/08

3 SP encounters:Topic 1: Setting medical agendaTopic 2: CounselingTopic 3: Breaking bad newsAll videotaped/received SP and faculty feedback

1/09- 6/09

4 SP encountersTopics 1-3: sameTopic 4: ETOH screen in setting of insomnia and depression

9/09

OSCE with station similar to Topic 4

Timeline of arrangement of SPencounters for the 24 PGY1s on mandatory month- long PCBR

*SP- standardized patient

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%)

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.

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?

RECRUITING AND TRAINING STANDARDIZED PATIENTS

(SP) UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER SAN ANTONIO

H-E-B CLINICAL SKILLS CENTERSCHOOL OF MEDICINE

NOV 3, 2011PRESENTED BY AUDREY ORTEGA

STANDARDIZED PATIENT EDUCATOR

• Availability of a Simulation Center

• Recruitment

• Training

• Scenario Development

• Resources for identifying Scenarios

OBJECTIVES

• Simulation Centers

• Medical Schools

• Nursing Schools

• Association of Standardized Patient Educators Association (ASPE)

ACCESS TO STANDARDIZED PATIENTS

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

• 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

• Interpersonal Communication Skills Training

• Verbal Feedback Training

ADDITIONAL TRAINING

• Case Template (hand out example?)

• Door scenario (examples?)

SCENARIO DEVELOPMENT

• ASPE

• MedEdPortal

• SP List Serv

RESOURCES FOR IDENTIFYING SCENARIOS

QUESTIONS