Lights, Camera, Action…The Effective Use of Standardized Patients

in Health Professions Education

Maria Wamsley, MDSharon Youmans, Pharm.D., MPH

Creative Commons LicenseAttribution-NonCommercial-Share Alike 3.0 Unported

You are free:• to Share — to copy, distribute and transmit the work • to Remix — to adapt the work Under the following conditions:• Attribution. You must give the original authors credit (but not in any way that

suggests that they endorse you or your use of the work).• Noncommercial. You may not use this work for commercial purposes. • Share Alike. If you alter, transform, or build upon this work, you may distribute the

resulting work only under a license identical to this one.

See http://creativecommons.org/licenses/by-nc-sa/3.0/ for full license.

Workshop Objectives

By the end of the workshop…• Discuss the rationale for the use of standardized

patients (SPs) in health professions education.• Describe the use of (SPs) in health professions

education for learner skill assessment.• Explain the process for developing an standardized

patient (SP) case.• Create an outline for a SP case for formative (teaching)

or summative (assessment) purposes.

Workshop Agenda

• Introductions• Overview of SP use• Process of writing SP case• Developing case outline (breakout)• Next steps• Wrap-up

Workshop Agenda

• Introductions• Overview of SP use• Process of writing SP case• Developing case outline (breakout)• Next steps• Wrap-up

Millers Pyramid of Assessment

Does

Shows

Knows How

Knows

Direct observation, unannounced standardized patients

Simulation, Standardized patients

MCQs

Case presentations, essays

Miller G. Acad Med 1990

OSCE• Series of timed stations• Each station focused on a

different task• 8-10 stations to achieve

reliability• Checklist of specific behaviors• Ex: U.S. Medical Licensing

Exam, Canadian Pharmacy Licensing Exam

Reznick RK Acad Med 1993

Reliability Estimate of OSCE

1 hour 2 hours 3 hours 4 hours0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

van der Vleuten CPM and Schuwirth L. Med Educ 2005.

SP Assessments

• 80% of all medical schools use SPs to assess learners

• 30% of all pharmacy schools • ACGME recommends SPs to

assess resident competencies– Interviewing– Communication skills– Counseling

Brownell Teach Learn Med 1994Sturpe, AJPE 2010

Using SPs for Teaching Purposes

• Practicing communication skills– Breaking bad news– Handling challenging patient

interaction– Addressing unprofessional

behavior of colleagues• Interprofessional

standardized patient exercise• Global health simulation

Global Health Simulation

Goal: Prepare trainees to face the ethical challenges of global health fieldwork

Format: Simulation based curriculum comprising 5 scenarios that focus on ethically challenging scenarios in resource-poor settings.

Scenario

You are assisting an HIV outreach team in rural Malawi. The team visits remote villages to do rapid HIV tests on pregnant women. It is known that the majority of pregnant women in these areas do not receive prenatal care or HIV treatment. Women who test positive are offered treatment for free, but the patient must go to the nearest clinic (5 hours walk) monthly to get check ups and their HIV medications. Women are assured that test results and treatment will be kept confidential. You arrive to discuss positive HIV test results with Blessings, who is in her third-trimester of her pregnancy.

Hybrid (Patient-Focused) Simulations

• Combines SPs with inanimate models

• Used in procedural or surgical skills teaching

• Adds the patient perspective to the simulation

Ex: SP plays a pregnant woman but a plastic pelvis/mannequin simulates the actual birthing processNestel D and Kneebone R. Acad Med 2010.

Multiple Mini Interviews (MMI)

• Interview format to assess applicant skills– Ethics– Communication– Professionalism– Interpersonal relationships– Ability to collaborate

• Series of short stations

Beyond Standardized Patients

• Standardized caregivers• Standardized colleagues• Standardized students

Workshop Agenda

• Introductions• Overview of SP use• Process of writing SP case• Developing case outline (breakout)• Next steps• Wrap-up

What makes a case?

TEST RESULTS

INTERSTATION EXERCISE

STUDENT INSTRUCTIONS

FEEDBACK INSTRUCTIONS

GUIDE TO THE CHECKLIST

CHECKLIST

TRAINING MATERIALS

SP DEMOGRAPHICS

CASE OBJECTIVES

17

Elements of a SP Case

• Decide if case for teaching (formative) or assessment (summative).

• Choose the objectives of the case.

• What is the level of the learner? (e.g. 1st year, 4th year, resident)

• What is the context? (e.g. circumstances, background, setting)

Elements of a SP Case

• Develop checklist– Checklist: YES or No answers– Checklist: Global ratings– Number of checklist items–Which one is better?

Cunnington, Adv Health Sci Edu, 1997Ostergarrd, Med Teach, 2003

UCSF SOP MMI

Scenario:You are a volunteer at a local free health clinic for people who cannot otherwise afford healthcare. Pat is new to the clinic and has been asked to fill out a basic information sheet to keep on file at the clinic. You have been asked by the staff to greet Pat and review this basic information. (Pat is waiting inside the room.)

Vera Lyons case• Assess medical students’ skill in

communicating with an interprofessional colleague (nurse)

• Assess medical students’ ability to evaluate and manage a hospitalized patient with an acute complaint

Vera Lyons

• A 55 year old woman hospitalized with cellulitis who develops new chest pain

• Nurse is unable to reach Vera’s physicians; student on the team enters the room and is charged with evaluating the chest pain, coming up with a diagnostic and treatment plan, communicating with patient and nurse

Elements of a SP Case

• Who completes the checklist?– Faculty?– SP?

• How do learners receive feedback?

Workshop Agenda

• Introductions• Overview of SP use• Process of writing SP case• Developing case outline (breakout)• Next steps• Wrap-up

• Essential to good inter-rater reliability• Allows multiple actors to understand

your criteria for them to… Reveal or withhold specific information Give the learner credit for an item when

there are multiple ways to ask the patient for the information

Guide to the Checklist

25

Example:Do you smoke?

• YES: Student must ask: IF you smoke, HOW MUCH you smoke and HOW LONG have you smoked to get credit for this answer

• Your response: “Yes.” “Two packs a day.” “30 years.”

Guide to the Checklist

26

• Assess clinical reasoning• Assess ability to integrate history and PE findings

• Can use: SOAP note Questions related to the case Simulations Heart sounds Lung x-ray

Inter-station exercise

27

Next steps…Case

review by experts

Revisions

SP training

Revisions

Pilot case

Revisions

The Future?

Additional Resources

Hodges B, Hanson M, McNaughton BA, Regehr G. Creating, Monitoring, and Improving a Psychiatry OSCE. A Guide for Faculty, Academic Psychiatry, 26:3, Fall 2002

Coaching standardized patients : for use in the assessment of clinical competence (sample training materials, Checklist Guide, Feedback Instructions)Peggy Wallace, Ph.D., (UCSD) Imprint New York : Springer Pub., c2007 UCSF Call # RT71 .W35 2007

Association of Standardized Patient Educatorsaspe@aspeducators.org

MedEdPortal https://www.mededportal.org/

30