USING STANDARDIZED
PATIENTS
PRESENTERS:
DR PATRICIA WATHEN
DR. MICHELLE CONDE
AUDREY ORTEGA
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
• 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
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 predetermined 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):1010-5
Ann 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; 3:161-69
Medical 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: 357-36
Psychiatry 2009; 72: 382-92
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
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, MD
Clinical Associate Professor
Division of General Medicine
UTHSCSA
South Texas Veterans HealthCare
System
Audie 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
% residents who screened
• 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.
The general who couldn’t
sleep
80%
70%
60%
50%
40%
30%
20%
10%
0%
depression
screening
drinks/day
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
HOW WE USE SPS (PART 2)
• 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
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
SP feedback
helpful
82%
85%
Likert scale 1-5;
4= Very good;
5= Excellent
ASSESSING OUR
CURRICULAR CHANGES
Timeline of SP
cases for 24 Interns on
month- long Outpatient Rotation
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
9/09
4 SP encounters
Topics 1-3: same
Topic 4: ETOH screen in
setting of insomnia and
depression
OSCE with
station similar
to Topic 4
*SP- standardized patient
Timeline of arrangement of SP
encounters for the 24 PGY1s
on mandatory month- long PCBR
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
9/09
1/09- 6/09
4 SP encounters
Topics 1-3: same
Topic 4: ETOH screen in
setting of insomnia and
depression
OSCE with
station similar
to Topic 4
*SP- standardized patient
Timeline of arrangement of SP
encounters for the 24 PGY1s on
mandatory month- long PCBR
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
9/09
4 SP encounters
Topics 1-3: same
Topic 4: ETOH screen in
setting of insomnia and
depression
OSCE with
station similar
to Topic 4
*SP- standardized patient
RESULTS
2009 OSCE
Asked
drinks/day
Asked
additional f/u
question
Completed
ETOHscreening SP
encounter
(n= 14)
13/14 (93%)
Did not
complete
ETOH
screening SP
encounter
(n= 10)
8/10 (80%)
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 CENTER
SCHOOL OF MEDICINE
NOV 3, 2011
PRESENTED BY AUDREY ORTEGA
STANDARDIZED PATIENT EDUCATOR
OBJECTIVES
• Availability of a Simulation Center
• Recruitment
• Training
• Scenario Development
• Resources for identifying Scenarios
ACCESS TO STANDARDIZED PATIENTS
• Simulation Centers
• Medical Schools
• Nursing Schools
• Association of Standardized Patient Educators
Association (ASPE)
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
TRAINING SPS
• 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
ADDITIONAL TRAINING
• Interpersonal Communication Skills Training
• Verbal Feedback Training
SCENARIO DEVELOPMENT
• Case Template (hand out example?)
• Door scenario (examples?)
RESOURCES FOR IDENTIFYING
SCENARIOS
• ASPE
• MedEdPortal
• SP List Serv
QUESTIONS