HPS in Medical Education 1
EFFECTS ON LEARNING USING HUMAN PATIENT SIMULATION
IN MEDICAL EDUCATION
_____________________________________________
A Dissertation Proposal
Presented to
The Faculty of the Curry School of Education
University of Virginia
_____________________________________________
In Partial Fulfillment
of the Requirements for the Degree
Doctor of Philosophy
_____________________________________________
by
Sue Oliver Kell
July, 2006
HPS in Medical Education 2
CHAPTER I
INTRODUCTION
Patient safety is of utmost concern to anyone currently seeking or providing
health care services. “First, do no harm,” or a similar oath, is taken by all physicians
when obtaining a license to practice medicine. In the last decade, the prevalence of
health care provider mistakes and their effect on patient safety has led to changes in
medical education, including the use of human patient simulation. Human patient
simulators are computer-driven, life-sized mannequins, programmed to respond to
medical situations and procedures, giving students a chance to perform and learn in closeto-real-life scenarios. Simulators provide a risk-free environment that can be standardized
and reviewed. Many medical teaching institutions are purchasing human patient
simulators (HPS) to enhance the clinical and emergency response skills of health care
students.
Because of the many perceived advantages associated with HPS, the number of
educational centers using HPS worldwide has grown exponentially since the mid-1990’s.
In 1994, there were 9 simulation centers worldwide. In 2005, there were 557 simulation
centers worldwide, with 356 being in the United States (Worldwide simulation sites,
2005).
The expense of HPS is a significant factor when looking at the cost-to-benefit
ratio of this educational format. Each high-fidelity mannequin costs an average of
$200,000 and it takes approximately one million dollars to open a simulation center (Jha,
Duncan, & Bates, 2001). A simulation center is a facility containing the simulation
HPS in Medical Education 3
equipment, instructors, and support personnel needed to conduct training of healthcare
students and workers.
Simulation in High Risk Occupations
Many high risk occupations use forms of simulation for training purposes in
hopes of increasing safety (Jha et al., 2001). The aviation industry was the first to widely
employ simulation for educational purposes. Flying skills and management of flight
emergencies are two areas where simulation education has been developed. Since the
late 1920’s, flight simulators have been shown to be so effective for pilot training that
certification for pilots can occur by demonstrating competence on a flight simulator.
Studies from the 1980’s found that safety has been linked to the crew’s ability to manage
resources effectively. In response, aviation education experts use activities, such as fullmission simulations and debriefings, termed Crew Resource Management (CRM), which
is required training used to improve crew performance (Gaba, Howard, Fish, Smith, &
Sowb, 2001).
Anesthesia was the first of the medical fields to find parallels to aviation’s
educational needs. As a high risk occupation where 80% of all adverse anesthesia
incidents are due to human error (Jha et al., 2001), it has been thought that simulation
experiences might improve patient outcomes. The first anesthesia simulator was
developed in 1969, but it was not until the mid-1980’s that educators began routinely
utilizing simulation in anesthesia training (Gaba et al., 2001).
Many other medical disciplines, including emergency medicine, cardiology,
radiology and pharmacology are now beginning to incorporate simulation in the
education of health care professionals (Gaba et al., 2001). Pharmacology, the science of
HPS in Medical Education 4
drugs and their effects on the human body, is an area ripe for simulation development.
Management of medication interactions, overdoses, and side effects are common
requirements for patients in emergency medicine settings. Similar to anesthesiology,
pharmacology scenarios using a human patient simulator are relatively user-friendly to
program. A broad range of HPS pharmacology scenarios could provide experiences for
medical students and residents who may not otherwise encounter these challenges in
early practice.
Patient Safety
Patient safety is one of the driving forces behind the use of human patient
simulation. In 1999, the Institute of Medicine (IOM) investigated the incidence and
reasons for the startling number of medical errors leading to death and disability, and
made recommendations for solutions, including the use of simulators in healthcare
training (Kohn, 1999). The latest IOM report on medication mistakes claims an average
of one error per hospitalized patient per day, costing $3.5 billion to treat the related
patient injuries due to error {{59 Aspden, P. 2006; }}. Simulators inspire hope for
patient safety gains because students can see the simulated patient response to their
clinical decisions and actions at no risk to a real patient. A study by Peignet found that
doctors trained with a simulator performed retinal photocoagulation as well as those
trained with patients (Peugnet, Dubois, Rouland, 1998). Despite this study and others,
there is no solid evidence that simulation-based training improves patient outcomes.
Cohort studies examining outcomes would be difficult to perform because of the sheer
number of patients and physicians that would be required and a host of confounding
factors to be considered (Jha et al., 2001).
HPS in Medical Education 5
HPS Replaces Dog Laboratories
The discontinuation of dog laboratories in medical universities is becoming a
reality in the United States. As of 2003, of the 125 schools, 100 have replaced their dog
labs with other methods of teaching anatomy, including human patient simulation.
Arguments concerning the ethical treatment of animals in medical institutions have been
a hot issue for students, faculty and animal activists, for years. As HPS has become more
sophisticated, their ability to teach students is highly regarded by groups such as the
Physicians Committee for Responsible Medicine. Medical advisor for the group, John
Pippin, a Dallas cardiologist says,
“Human simulators can be programmed by an instructor to show a variety
of responses. You can program it to be critically ill or stable. To show an
allergic response versus a normal response. They can be programmed to
respond to 55 different drugs.” (March 12, 2006 editions of the
Milwaukee Journal Sentinel)
Pippin feels the real advantage of HPS is the ability to repeat procedures, which is
not possible in the dog laboratory.
"You can't do that with a dog," Pippin said. "Medical students learn at
different rates. Of the five students working on that dog, some will get it
and some won't. And those who don't are going to have to do it over and
over again. The live dog lab doesn't give them that opportunity." (March
12, 2006 editions of the Milwaukee Journal Sentinel)
Medical Students
Becoming a medical student is a highly selective process. Students are chosen
based on performance in academics, Medical College Admissions Test (MCAT) scores,
motivation and commitment to medicine, and personal characteristics linked to physician
success. Students must complete 90 undergraduate credit hours which include Biology,
General Chemistry, Organic Chemistry and Physics {{58 Anonymous 2006; }}.
HPS in Medical Education 6
At the University of Virginia, approximately 500 interviews are granted every
year out of approximately 3,500 applicants. Only 141 students are selected from the total
pool of interviewees each year {{58 Anonymous 2006; }}.
Medical School Curriculum
Medical students at the University of Virginia are enrolled in a four year program
of medical training where learning in the presence of patients is one of the valued
components of the school’s educational philosophy. Knowledge, management and
understanding are also components of the education philosophy and are combined in a
curriculum termed the ‘practice and science of medicine.’ First year medical students
engage in the basic knowledge acquisition of physiology, histology, genetics,
biochemistry, anatomy, and neuroscience. This first year of knowledge building is a
critical step in knowledge construction upon which all future layers of learning are
applied. This scientific knowledge is used to discuss clinical applications in small groups
with faculty, called the Practice of Medicine (POM). In the first year of medical school
at UVA, students learn to obtain patient histories through patient interviews, and conduct
physical exams on patients. Two of the five sections of Pharmacology, General
Principals and Endocrinology, are taught at the end of the first year of medical school
{{51 Anonymous 2005; }}.
Pharmacology and pathology are the primary foci for second year medical
students. This coursework is dovetailed with clinical observations and the furthering of
patient examination skills though a curriculum organized by organ systems--pulmonary,
gastrointestinal, cardiovascular, renal, neurological, infectious disease, endocrinology.
HPS in Medical Education 7
Second year medical students receive preceptorship assignments, where students work in
a community medical practice with a physician for one week {{51 Anonymous 2005; }}.
Third year medical students devote much of their time to clinical training.
Clerkship assignments occur at UVA and surrounding hospitals and are arranged by
medical department, such as internal medicine, surgery, pediatrics, and the like, and
involve direct patient contact. Students learn during patient rounds with practicing
physicians, and in seminars with faculty {{51 Anonymous 2005; }}.
Fourth year students select electives to further their education in their own areas
of interest, by selecting clinical rotations under their advisors’ guidance. Students also
participate in an intensive study of neurology {{51 Anonymous 2005; }}.
After completion of the four years of medical school, graduates apply for
admission to a three year accredited Residency program in their chosen specialty area.
The majority of applicants are selected by one of their three program institution choices.
In the first year, these graduates are called interns, and thereafter first and second year
residents. Progression through the three years of residency leads to greater independence
in treating patients. Interns and first and second year residents focus on their chosen
specialty area, but are also required to rotate through most, if not all, of the clinical
specialties.
Pharmacology Curriculum
Pharmacology principles are taught primarily by lecture, using PowerPoint slides,
and by observation in clinical settings. There is a website of practice exam questions
available to students as well as small discussion groups with faculty and a Pharmacology
HPS in Medical Education 8
Course Newsgroup website for course information, resources and the posting of
pharmacology questions.
“The three goals of the course are, in the order of importance, to learn the
basic mechanisms of action of the major drug classes, to learn the fundamentals of
their therapeutic use, and to memorize the major representative drugs of each
class.” {{57 Cruetz, C. E. 2006; }}
Five sections of Pharmacology are covered in medical school, including General
Principles, Endocrinology, Pharmacology, Autonomic and GI Drugs, and Introduction to
Central Nervous System Drugs (CNS), CNS and Cardivascular Drugs, and Antimicrobial
and Antineoplastic Drugs {{57 Cruetz, C. E. 2006; }}.
Simulation in Pharmacology
Limited reference to the use of human patient simulation is found in the literature
regarding the application of this technology in pharmacology. However, information
about use of HPS in anesthesiology is more readily available and does have parallels with
pharmacology in that administration of medications is a key function within the
discipline. The National University of Singapore describes the application of human
patient simulation in Anesthesiology training as follows:
“Specifically, simulator training will be very useful in:
1. Teaching basic skills to medical students.
2. Training trainee doctors in basic anaesthesia skills before they
administer anaesthesia to real patients.
3. Crisis management for experienced doctors, nurses and
paramedics, particularly those who work in intensive care,
emergency departments and operating theatres.
4. Demonstration of new drug and new equipment by pharmaceutical
and medical equipment companies.
Teaching and training with a patient simulator will render current
medical school teaching more complete, realistic and systematic. All
students can be trained to a required practical standard in a controlled, safe
and even enjoyable environment.” {{49 Anonymous Undated; }}
HPS in Medical Education 9
Experts think that HSP is particularly important in learning medical practice in
this domain, because administration of medications on real patients for training purposes
is considered to be ethically unacceptable due to inherent patient safety risks. With HPS,
students can either participate in hands-on activities with HPS, or observe how
experienced clinicians manage predetermined scenarios involving pharmacology.
More than ever, schools of medicine and nursing are expected to produce
clinicians who have a comprehensive knowledge base and skill set. During their training,
students may experience treating only a limited number of patient conditions. This
occurs because students depend on learning from the live patients who present at their
medical universities. Not every student on a toxicology rotation will treat a patient who
has ingested jimson seeds, or seen fasciculations from a rattlesnake bite. Simulation can
fill in the ‘gaps’ by providing a broad range of patient conditions. HPS scenarios can be
standardized, evaluated and reviewed as needed (Gaba, 2000).
I plan to take advantage of fourth year medical students’ and interns’ limited skill
set in this dissertation study. Treatment of venomous snakebites is a topic not typically
covered during medical school or internship. At the University of Virginia, treatment of
venomous snakebites only occurs if the fourth year student or resident chooses the
Toxicology Rotation through the Division of Medical Toxicology or if they happen to be
present when a patient presents with a snakebite in the emergency room.
The UVA Department of Emergency Medicine treats approximately two dozen
venomous snakebite victims each year, usually in the warmer months. Bites most
commonly occur from Copperhead snakes, and at most one or two Timber Rattlesnake
bite victims are treated per year. Since Timber Rattlesnake bite victims are a rarity, most
HPS in Medical Education 10
of my participants will not have any experience treating this condition. I plan to use
treatment of Timber Rattlesnake patients as the educational topic for my study and
control groups.
Research Questions
Research demonstrating the educational benefits of using HPS over traditional
teaching methods is lacking. There is limited research showing the effectiveness of HPS
in any educational modality including knowledge, application, retention or performance.
This dissertation will describe two pilot studies and a final study, which all
evaluate the effectiveness of HPS as a teaching tool. The underlying question in these
studies is, “What is the role of HPS in improving learning in pharmacology?”
My dissertation research will investigate the use of HPS in a specific learning
situation, the treatment of a Timber Rattlesnake victim. The question for this research
follows: “How does a learning experience with HPS effect medical resident treatment
and evaluation of a standardized patient who is the victim of a snakebite?”
Important Definitions:
human patient simulation- a form of multimedia learning which replicates patient
conditions with sufficient realism to practice diagnosis and treatment
standardized patient- someone trained to perform like a patient with a certain medical
condition
multimedia learning- building mental representations with words and pictures
knowledge- presence of factual information
application- use of knowledge to interpret a given circumstance
retention- ability to recall knowledge and application after two weeks have lapsed.
HPS in Medical Education 11
performance- interventions in patient care to improve patient condition
In summary, the effectiveness of using human patient simulation in medical
education safety needs to be analyzed. Many educators think HPS has the potential to
improve patient care and safety by giving students a more hands-on approach to learning
about a wide variety of patient conditions in a safe environment. Little is known about
the true educational benefits of using human patient simulation. So, I will ask what
benefits occur using HPS in the educational modalities of knowledge acquisition,
application and retention of knowledge, and performance.
HPS in Medical Education 12
CHAPTER II
REVIEW OF LITERATURE
A review of the literature found many relevant topics concerning medical
education as it relates to learning theory, human patient simulation, pharmacology, and
multimedia. This evidence provides an important foundation upon which I build my case
to study the role of human patient simulation in teaching medical residents pharmacology
principles. In order to defend the instructional design used in this experiment, I will
present information on learning theory for use in this application. I will explain the
practice of medical education as it currently exists, including the different types of
learning that must take place, characteristics of the medical school curriculum, and the
learning challenges involved. Last, I will provide a discussion of the research outcomes
relative to this line of inquiry.
Learning Theory
Learning implies change, demonstrated change leads to theory generation, and
theory informs practice. In the last sixty years educational theorists have described three
basic philosophies of learning: behaviorism, cognitivism and constructivism. Simply
stated, behaviorism is based on changing behavior patterns through repetitive learning
tasks involving memory, cognitivism is based on the thought processes leading to and
measured by behavior changes resulting from mental models, and constructivism is
making sense of the world, in an individual way, by using past learning experiences to
create a set of rules or mental models to explain how things are understood. Learning is a
search for meaning which builds upon previously formed attitudes and beliefs which are
used to solve problems in new situations. Examples of each, in order, might include,
HPS in Medical Education 13
Pavlov’s classical conditioning with stimulus and response thereby creating memory,
imitation of behavior in social contexts which creates new behavior patterns, and learning
through experience to react accurately in novel situations. It is difficult to completely
separate each approach in education because many educational teaching strategies
incorporate aspects of all three approaches (Jonassen & McAleese, Undated).
We see this blending of learning theory in medical education where medical
students are challenged to make learning gains in scientific knowledge, demonstration of
skills, and through expressing empathy and problem-solving. These learning domains
represent a wide range of expected ability in practitioners, from the objective to
subjective areas of activity.
David Jonassen, a professor in Instructional Systems at Pennsylvania State
University, states that constructivist learning strategies are “most effective for an
advanced knowledge acquisition stage of learning” and are practiced universally on the
undergraduate and graduate levels. Constructivist learning requires a more open-ended
approach, is learner controlled, and is more difficult to measure. Constructivist learning
strategies provide learners with a representation of reality, authentic tasks, case-based
learning environments, reflective practice, context- and content-dependent knowledge
construction, and collaborative construction of knowledge (Jonassen & McAleese,
Undated).
Jonassen describes a continuum of learning, from introductory, to advanced and
finally expert, with each level requiring different approaches to learning. Introductory
knowledge acquisition might be best transferred by traditional methods, such as lecture,
with predetermined learning outcomes, sequenced instruction and criterion-referenced
HPS in Medical Education 14
evaluation. The advanced and expert levels of knowledge acquisition are more suited to
constructivist environments, where learner discovery occurs in real contexts (Jonassen &
McAleese, Undated).
Computer access and other forms of technology and multi-media access are some
of the ways constructivist learning has been promoted in today’s world (Jonassen &
McAleese, Undated). With information so readily available, people have more control
over their own learning domain than ever before. Medical schools have taken advantage
of this fact by providing medical students with numerous on-line resources, such as casebased learning scenarios, notes pages, tutorials and more. Human patient simulation is a
prime example of how technology can promote constructivist learning environments by
providing a sense of reality in case-based scenarios that can be acted upon in
collaboration with others.
Learning Objectives in Medical Education
Medical education incorporates a blend of the three learning approaches, but in
recent years has moved towards more constructivist strategies. This shift is due in part to
the development of core competencies set by the Accreditation Council of Graduate
Medical Education (ACGME). Since 1999, the Residency Review and Institutional
Review Committees of ACGME require the incorporation of these general competencies
into their Requirements. In addition to medical knowledge and patient care, the
competencies include practice-based learning and improvement and interpersonal and
communication skills, professionalism, and systems-based practice. It has been
suggested that human patient simulation may play an important role in the transition of
medical education curriculums. (Outcome project, 2006)
HPS in Medical Education 15
Medical schools, such as the one located at the University of Virginia, have
incorporated the ACGME standards into their curriculum. The UVA Medical Education
Website lists twelve competencies as learning objectives for physicians. Below is a
reproduction of the competencies:
1. “The development and practice of a set of personal and professional
attributes that enable the independent performance of the
responsibilities of a physician and the ability to adapt to the evolving
practice of medicine. These include an attitude of:
a. Humanism, compassion and empathy
b. Collegiality and interdisciplinary collaboration
c. Continuing and lifelong self education
d. Awareness of a personal response to one's personal and
profession limits
e. Community and social service
f. Ethical personal and professional conduct
g. Legal standards and conduct
h. Economic awareness in clinical practice
2. Competence in the human sciences:
a. in the understanding of current clinically relevant medical
science
b. in scientific principles as they apply to the analysis and further
expansion of medical knowledge
3. The ability to engage and involve any patient in a relationship for the
purpose of clinical problem solving and care throughout the duration
of the relationship
4. Eliciting a clinical history
5. Performing a physical examination
6. Generating and refining a prioritized differential diagnosis for a
clinical finding or set of findings
7. Developing and refining a plan of care for both the prevention and
treatment of illness and the relief of symptoms and suffering
8. Developing a prognosis for an individual, family or population based
upon health risk or diagnosis, with and without intervention, and
planning appropriate follow-up
9. Selecting and interpreting clinical tests for the purpose of health
screening and prevention, diagnosis, prognosis or intervention
10. Organizing, recording, presenting, researching, critiquing and
managing clinical information
11. Selecting and performing procedural skills related to physical
examination, clinical testing and therapeutic intervention.
HPS in Medical Education 16
12. Knowledge of the social, cultural, economic, ethical, legal and
historical context within which medicine is practiced” ((Van
Merriënboer, J. J. G., Kirschner, & Kester, 2003)
These twelve competencies demonstrate the wide range of learning domains
required of medical students, as discussed earlier. From objective to more subjective
realms, medical education needs a blend of teaching strategies based on our three
basic learning philosophies.
These twelve learning objectives can be classified into the types of intellectual
behaviors described by Benjamin S. Bloom in his earliest work on cognitive domains.
Dr. Bloom was an educational pioneer, a behaviorist, who developed a system of
specifications or taxonomy to describe instruction and learning objectives so that they
might be planned and measured properly. Dr. Bloom’s goal was to improve “the
effectiveness of developing 'mastery' instead of simply transferring facts for mindless
recall” (http://www.businessballs.com/bloomstaxonomyoflearningdomains.htm).
Bloom reports six major cognitive competencies in educational settings starting with
knowledge (information recall), comprehension (understanding information),
application (using information), analysis (explain information), synthesis (generalize
information) and evaluation (assess information) (Chapman, 2005).
I have placed Bloom’s competencies in the chart below showing their relationship
to many of the twelve physician learning competencies as they apply to
pharmacology. What follows next in the third column of the chart are the teaching
strategies which are used or might be used to impart these competencies in
pharmacology. (Learning skills program,2005)
HPS in Medical Education 17
Table 1
Competence
Educational Objective
Knowledge
 Knowledge of the
science of pharmacology
 Knowledge of the socioeconomic, cultural,
ethical, legal and
historical context of
pharmacology
 Understanding drug
effects
 Obtaining patient history
Comprehension
Teaching
Strategy/Activities
 Lecture
 Reading
 Practice questions
 Drills
 Observation of
physician/patient
interaction
 Discussion groups
Application
 Make pharmacotherapeutic
recommendations
 Performing a patient
examination
 Present problem based
scenarios
 Practice examination
skills
 Shadow experienced
clinician
Analysis
 Evaluating patient’s
response to
pharmacologic agents
 Recommending drug
therapy in reference to
patient diagnosis
 Revise pharmacology
action plan as needed
 Determine plan to
evaluate effectiveness of
drug therapy to patient
condition
 Prognosis of patient
condition
 Interpret drug analysis
results
 Partner with experienced
clinician
Synthesis
Evaluation
 Participate in
pharmacology research
 Generating reports
 Group discussion
 Critique
Bloom’s work extended later to include the affective domain or development of
attitudes and beliefs in education. The steps within the affective domain include receive
HPS in Medical Education 18
(listening), respond (reacting and participating), value (develop opinion), organize
(develop a value system), internalize (adopt a value system). Bloom’s description of
learning within the affective domain relates to the first learning objective of physician
competencies, described above, which involves the development of personal and
professional attributes that promote independence in learning, compassion, collaboration,
awareness of personal limitations, service to others, ethics, legality and economic
awareness. This first learning objective is applicable to the study of pharmacology and is
an obvious best fit in Bloom’s description of the affective domain (Chapman, 2005).
The psychomotor domain was an extension of Bloom’s work by other educational
experts, and includes learning strategies, such as imitation (copy actions), manipulation
(remember actions), precision (accuracy of actions), articulation (adapt actions) and
naturalization (automatic actions) (Chapman, 2005). The psychomotor domain is
relevant to my study because residents need a host of psychomotor skills related to
pharmacology, such as drug preparation and administration for oral, injected and
intravenous medications.
Learning Theory Informing Pharmacology Instruction of Medical Students
Human patient simulators seem especially well suited in providing the conditions
needed for adult learners, such as medical residents. We know from theories and
principles of adult learning that learning is more effective when it relates to real life
situations (Kaufman, 2003). Learners should be given opportunities to practice
knowledge and then to reflect on their performance and hear constructive feedback from
instructors. Modeling desired actions and behaviors has an important impact on adult
learners as well (Kaufman, 2003). Well-planned instruction with HPS naturally
HPS in Medical Education 19
incorporates these principles by giving students a close to real life tool, it allows students
to observe procedures and to practice skills, and scenarios can be started and stopped as
needed to promote learning.
One risk of complex learning is that learners can be overwhelmed by the
complexity of tasks. Managing cognitive load is an important consideration. Assuring
that learning is scaffolded so that tasks move from simple to complex or that appropriate
background knowledge has been achieved is needed. (Van Merriënboer, J. J. G. et al.,
2003) I believe it is important for medical students to have a sufficient knowledge base
of medicine before learning with HPS. Because it resembles real patient practice in many
ways, HPS provides a complexity of learning that would be difficult at the novice level.
For example, students would need to have prior knowledge of how to take patient
histories, administer IV medications, monitor vital signs and diagnose before learning
with HPS to avoid cognitive overload.
Multimedia Learning Theory
In human patient simulation learning environments, students are engaged visually
and through listening. In active simulations, students also have tactile input as they
perform medical procedures on the mannequin. In this inquiry, I am defining HPS as a
form of multimedia.
Multimedia, simply put, uses pictures and words to convey its messages.
The
multimedia principle states that people learn more from pictures and words than words
alone because of dual-coding. Dual coding refers to the 2 channels within the brain,
visual and verbal, which receive information when multimedia formats are employed.
Spoken and written words are received by the verbal channel; pictures, video and
HPS in Medical Education 20
simulations are received by the visual channel. When words and pictures are integrated,
more learning improves, otherwise known as the split-attention principle (Pavio, 1986;
Sweller, van Merrienboer, J. G., & Paas, G. G. W. C., 1998).
Educational researchers have found that new knowledge is constructed upon prior
knowledge, hence the prior knowledge principle (Mayer, 2005). The prior knowledge
principle will be particularly relevant to the three studies described in this dissertation
because participants have been chosen who have very similar backgrounds of knowledge:
fourth year undergraduate, first-year medical students and first-year residents (also called
interns, first year of residency after medical school). Participants were chosen in this
manner because of they have taken the same courses in their healthcare curriculums.
Also relevant are other multimedia theories, such as the modality principle, which
maintains that learning increases with the combination of graphics and narration more
than the combination of narration and printed words. In our HPS studies, we would need
to employ 'guided' simulation with an instructor explaining the subject material and
demonstrating HPS based on the modality principle. The personalization and voice
principles involve gains when presenting multimedia messages with conversational or
nonformal styles, rather than formal styles. This style has been employed by the
instructor in our HPS studies in light of this information. The guided discovery principle
states that in multimedia instruction learners make improvements more readily when
guidance is provided along with the multimedia technology. And last, the collaborative
principle shows that working together in a group is better than working alone in online
learning programs (Mayer, 2005).
HPS in Medical Education 21
Instructional Design for Media
The Four-Component Instructional Design Model (4C/ID-model) for multimedia
learning promoted by Jeroen J. G. van Merrienboer consists of four components:
learning tasks, supportive information, procedural information and part-task practice.
“Such complex learning explicitly aims at the integration of knowledge, skills
and attitudes: the ability to coordinate qualitatively different skills; and the transfer of
what is learned to daily life or work settings.” (Mayer, page 72)
The 4C/ID-model aims to prepare learners for real life mastery of learning
through these four components, which are supported by the fourteen principles of
multimedia learning.
My dissertation study would need to follow in a similar way the principles
described in the first component involving learning tasks of the 4C/ID-Model by teaching
students in an environment which is close to real life situation by using HPS. Students
would make observations, measure vital signs, administer medications and record
information in a patient medical record. They would have an instructor facilitator who
would present a patient scenario involving snakebites that has a predetermined course of
symptoms to be observed and treated. The instructor would guide students through the
recommended procedures in treating such a patient, so that students would be assisted in
each step of treating this particular snakebite victim. My study would follow the fidelity,
training-wheels and completion strategy principles listed in Table 2 described in the first
component of the 4C/ID model, learning tasks and learning in simulated task
environments.
The second component of the 4C/ID model involves supportive information. In
my study students would not have the opportunity to self-pace their learning experience.
HPS in Medical Education 22
Instead they would receive the information in an instructor-led HPS format, following the
redundancy principle of limiting instruction to only one format. In my study learners
would be encouraged to ask questions and offer explanations as the snakebite scenario
proceeds.
The procedural principles described in the third component of the 4C/ID model
would also be incorporated in my study. Students would receive information through
verbal and visual channels through instructor explanations and observations of the
simulation mannequin.
Part-task activities would also be an integral part of the study when students
observe, measure, record and develop an action plan for the snakebite victim, following
the component-fluency principle in the fourth component of the 4C/ID model. Students
would practice their learning using the human patient simulator.
Table 2- 4C/ID-Model
Learning Tasks and Learning in Simulated Task Environments
Sequencing principle- present learning tasks from simple to complex
Fidelity principle- learning based on real life
Variability principle- constructing different learning tasks for knowledge
transfer
Individualization principle- proceeding to next level of learning based on
individual performance and effort
Training-wheels principle- providing learning that guides and supports
students
Completion-strategy principle- learning from worked out examples
Supportive information and Learning from Hypermedia
Redundancy principle- presenting the same information in different ways
is detrimental to learners
Self-explanation principle- learners explain solutions in worked out
examples
Self-pacing principle- learners control pace of instruction
Procedural Information and Electronic performance Support Systems
HPS in Medical Education 23
Temporal split-attention principle- simultaneous timing when presenting
visual and verbal information
Spatial split-attention principle- keeping visual and verbal information
together in space
Signaling principle- making critical learning obvious
Modality principle- using visual and verbal channels to expand working
memory
Part-Task Practice and Drill and Practice CBT Programs
Component-fluency principle- practicing learning strengthens learning
van Merrienboer and Kester use the work in medical simulation by Maran and
Glavin to describe a learning continuum that incorporates some of the 4C/ID-model
concepts. Maran and Glavin describe low fidelity to high fidelity learning, i.e., learning
from situations that have very little resemblance to real life to those that attempt to
imitate real life as a means to sequence learning. For example, a possible strategy
proposed to teach patient diagnosis might be to provide medical students with learning
activities that first involve written medical patient scenarios, secondly students might
engage in computer simulation or role-play by peers, then on to standardized patient
actors and finally diagnose real patients.
Patient Safety
It appears that HPS was identified early on as a means to solve one of the most
challenging aspects of medical education today—patient safety. Identification of the
magnitude of morbidity and mortality associated with medical errors has made patient
safety of utmost importance to everyone.
The 1999 Institute of Medicine Report, To Err Is Human: Building a Safer
Health System was instrumental in turning national attention towards patient safety. The
magnitude of the patient safety issue is described in the report in the following statement:
HPS in Medical Education 24
“More people die in a given year as a result of medical errors than from motor vehicle
accidents (43,458), breast cancer (42,297), or AIDS (16,516). The report discusses the
impact of human error and the role simulation training might provide in patient safety.
The authors state, “The Committee believes that health care organizations should
establish team training programs for personnel in critical care areas (e.g., the emergency
department, ICU, and OR) using proven methods such as crew resource management
techniques employed in aviation, including simulation” (Kohn, Corrigan, Donaldson,
1999).
My study will not determine whether or not the use of HPS improves patient
safety. That determination would take years to research as practitioners proceed to
practice over time after their formal medical education ends. Many confounding factors
obscure changes in patient safety as well, including varying rates of learning effect decay,
obtaining a comparable study sample of patients with unique levels of health and
wellness, retrieval of medical records to determine patient outcomes, and more.
Standardized Patients
Before HPS, many medical residents were given experiences with standardized or
simulated live patients to assess performance. Standardized patients are live patient
actors who have been coached to portray real medical conditions. Standardized patients
have been used to train and evaluate clinicians for over forty years. The use of
standardized patients assists medical educators in assessing the clinician’s “interpersonal
and communication skills as well as his or her professional and technical performance.”
(Vu & Barrows, 1994)
HPS in Medical Education 25
In an article summarizing recent developments in the use of standardized patients
in medical education, authors Nu Viet Nu and Howard S. Barrows found that student
performance assessments can be standardized and scored objectively and that tests
demonstrate validity and feasibility. However, costs of associated with standardized
patient assessment are high and no cost-to-benefit information is available (Vu &
Barrows, 1994).
In my study of HPS, participants will learn and demonstrate the treatment of
venomous snakebite victims by practicing on the simulation mannequin. Invasive
procedures, such as placing an IV and administering antivenin, will be performed in
small groups. Obviously, this type of activity is not possible with a standardized live
patient. However, I will incorporate the use of standardized live patients to evaluate
participants individually after the education treatment. This strategy insures that neither
the lecture nor the HPS group will have an advantage of using the same technology when
I test for the difference in teaching strategies.
Evaluation of health care providers using standardized patient encounters have
been conducted by analyzing recorded information from providers on patient charts and
from standardized patients themselves. In a study of internal medicine residents and
faculty physicians at two Veterans Affairs Medical Centers, researchers found that patient
chart abstraction often “underestimates the quality of care for common outpatient general
medical conditions when compared with standardized-patient reports.” In this research,
SP’s were unannounced and interspersed with real clinic patients. It was found that
patient charts commonly did not contain a complete record and SP’s were better able to
recount events during the patient visit. {{54 Luck, J. 2000; }}
HPS in Medical Education 26
In my study, I developed research tools to capture not only observations of a
trained evaluator, but patient chart information and SP recall of events.
Human Patient Simulation in Medical Education
At the University of Virginia Health System’s Department of Emergency
Medicine, the Human Patient Simulation Laboratory is located in a converted patient
room in Hospital West. The human patient simulator, Stan, an adult male mannequin,
lies in a hospital bed and is surrounded by the medical equipment commonly found in an
intensive healthcare setting, including a heart monitor and medical supplies. “The ultra
sophisticated and highly versatile HPS blinks, speaks and breathes, has a heartbeat and a
pulse, and accurately mirrors human responses to such procedures as CPR, intravenous
medication, intubation, ventilation, and catheterization.” (Human patient simulator.2004)
The mannequin has “a profound array of intricately programmed systems –
cardiovascular, pulmonary, pharmacological, metabolic, genitourinary (male and female),
and neurological.” (Human patient simulato,.2004). There are 70 preset HPS scenarios
or instructors can create custom scenarios themselves (Human patient simulator.2004).
The mannequin’s responses are controlled electronically through the Instructor’s
workstation, a dual processor computer with wireless remote control, and software
includes HPS Version 6 with a Mac OS X interface which has preset and programmable
medical scenarios and patient profiles. Instructors have the ability to ‘bookmark’
learning activities with HPS so that students can repeat a procedure for practice or stop
for debriefing and restart as ready. A drug recognition system is an integral part of the
HPS system. Medications to be administered are scanned with a bar code reader, so that
HPS in Medical Education 27
form, dose and route can be tracked. A ‘library’ of fifty-five drugs are available in the
system (Human patient simulator, 2004).
Student actions are recorded in a data ‘diary’ so that review of responses is easily
available for analysis. This continuous and time-based record can be saved and printed
for later review (Human patient simulator, 2004). For example, the student diary might
contain observed responses to drug therapy by recording vital signs at given time
intervals.
Advantages of Human Patient Simulation
Evidence contained within the literature supports the educational advantage of
using HPS in medical training, especially where patient safety is the focus (Ziv, Small,
Wolpe, 2000). Students can take risks and practice without the consequences of making
errors on live patients. Students can openly communicate with their facilitator in real
time about the procedure being performed instead of talking later, in consideration of the
patient. Students can also experience the clinical manifestations of specific disease or
trauma scenarios at any time, without having to wait for patients who demonstrate those
conditions. The HPS scenarios can be standardized and repeated and stopped and
restarted as needed. Worldwide, 85% of all simulator centers use their technology for
teaching (Wong, 2004). And the ethical issues concerning the use of animal laboratories
in medical education is addressed by replacing procedures on animals with procedures
using human patient simulation.
Qualitative Studies of HPS
In one qualitative survey, students responded that “…HPS was a better teaching
tool (94.5%) and raised more questions (76.5%) than lectures. They wanted more topics
HPS in Medical Education 28
taught this way (96%), as they could apply and re-enforce textbook knowledge, and
visualize real-time changes” (Tan, 2002). In a debriefing session after HPS learning at a
Harvard preclinical experiment “students were uniformly enthusiastic about the
immediacy and realism of the experience. Some felt that every medical student should
have the opportunity to practice in this way several times during all four years of medical
school” (Gordon, 2001).
I feel there is value in promoting student satisfaction in education. Students who
are excited about learning may be more likely to continue their education to conclusion.
Students may be more likely to talk about what they are learning with others and
internalize the joy of learning, motivating them towards life-long learning. My
qualitative pilot study confirms that students engaged in HPS educational formats find its
value worthwhile.
Quantitative Studies of HPS
Given its perceived advantages, the number of HPS training centers is increasing
in record numbers, from 9 to 557 in 11 years . The number of simulation centers
worldwide continues to grow without regard to educational effectiveness or benefit-tocost analysis. There is little research to demonstrate teaching effectiveness of HPS over
traditional teaching methods. Published studies show little if any increase in student’s
learning (Wong, 2004) giving credibility to the issues concerning the weaknesses of
media comparison research described by Surry and Ensminger in Table 1, page 36.
Knowledge-based research on HPS
A 2002 study at the University of Toronto found there was no difference in
students’ knowledge after using simulator and video formats in teaching three medical
HPS in Medical Education 29
scenarios involving anesthesia (Morgan, Cleave-Hogg, McIlroy, Devitt, 2002). The
study included 144 fourth year medical students who were oriented to the simulation
center and given a 5-minute performance-based pretest using HPS. The students were
then randomly selected into two groups, HPS and video. Each group received a 90minute educational session with content based on the same course curriculum objectives,
(1) preoperative assessment, (2) preparation of equipment, (3) induction of anesthesia, (4)
critical event 1, and (5) critical event 2. Then students attended a 90-minute educational
session on a different topic learning content by the alternate method, video or simulator,
from the first session. Students all received the same posttest (identical to the pretest),
which required the student to provide a statement of the problem, a differential diagnosis,
management plan and cause identification. Students were graded on a checklist by the
faculty observer. Six weeks later a final 10 question short-answer examination was given
to participants (Morgan, 2002).
A repeated-measures, mixed-model analysis of variance was preformed on test
results. Included in the analysis were the between-subjects factor (teaching modality)
and the within-subjects factor (pre and posttest) scores. The short answer exam results
were evaluated by univariate ANOVA analysis (Morgan, 2002).
Results of the study showed no statistical difference in posttest scores in simulator
and video groups. There was also no difference in the first and second learning sessions
by teaching modality. As expected, a statistically significant difference was found in pre
to posttest scores, showing that learning did take place using either teaching method.
Finally, results of the short answer test showed no significant difference by method,
HPS in Medical Education 30
video or simulator. The researchers of this study note that lack of a control group was a
limitation of the study (Morgan, 2002).
A study performed at the National University of Singapore suggests that
knowledge increased by 27% after 210 first-year anaesthesia students were given a 20minute HPS session. In this study, students who were scheduled to take a class in
“physiology in action” were divided into 10 groups ranging from 19-25 participants.
First participants received a 20-minute lecture of concepts regarding the physiological
responses to hypotension and shock. Following the lecture all received a 20-question
true/false pretest of knowledge. Groups were then given a second lecture on the
physiological responses to hypotension and shock using HPS-based teaching in an
operating theatre. “The HPS laboratory was set up to simulate an operating theatre,
complete with an anaesthesia machine (Narkomed 4, North American Drager, Telford
PA) and anaesthesia monitor (Hewlett Packard, Boise ID) with a six-channel display…”
This lecture was performed by observation of physiological changes on the mannequin
during blood pressure shifts and then groups observed three clinical scenarios for which
hypotension was a common theme (Tan, 2002).
At the conclusion of the HPS demonstration, participants were given a 20question knowledge true/false post-test exam to evaluate gains in knowledge following
the HPS training. The post-test also included open-ended survey questions to evaluate
students learning preferences. Results on the individual pre to post test scores were
compared using a paired sample T-test and the level of statistical significance was
measured at p<0.05. Students’ retest demonstrated a 27% improvement in knowledge as
compared to the pretest (Tan, 2002). .
HPS in Medical Education 31
The authors suggested that the greatest limitation of their study might have been
the reinforcement of concepts using HPS and thus improvement of test scores. There was
also no measurement of baseline knowledge before the two treatments, lecture and HPS
based learning, and no control group to strengthen the study conclusions (Tan, 2002).
Above are two examples of research studies comparing knowledge after education
programs using simulation. The simulation education program in the first study was
compared to a video-based program, and in the second study, knowledge gains from a
simulation observation were compared to gains observed in the pre-lecture. Both studies
contain research flaws, the greatest being the lack of a control group and baseline
knowledge. Good research design will be important to my study of simulation to obtain
valid results. I plan to compare control groups receiving the traditional lecture-based
program material with groups that are taught the same material in a simulator lab and
examine a range of learning modalities, including retention and performance. I will
include pretest and posttest measures.
Application-based research of HPS
A California study showed that fourth year medical students taught acute patient
management skills using a simulator performed better than students in problem based
learning (PBL) groups when managing dyspnea scenarios. Thirty-one fourth year
medical students in an acute-care course were randomly selected into two groups, HPS or
PBL to participate. All participants attended a simulator orientation session. Baseline
patient Critical care management (CCM) skills were measured by a blinded investigator
and verified by a second investigator. The measurement tool consisted of a standardized
checklist recording the observations of student skills by the investigators during the
HPS in Medical Education 32
management of a unique patient scenario. The PBL group was taught about dyspnea
(DYS) in a PBL format and the HPS group learned by HPS. The groups were then
switched, in order to “equalize” time spent in each learning format, by learning about
acute abdominal pain. Median CCM and DYS scores between the groups were compared
using a Wilcoxon Rank-Sum test. Means were compared using t-test and statistical
significance was measured at P<0.05. Results of the study show equivalent baseline
CCM scores before the treatments by PBL and HPS. Post treatment measurements of
CCM resulted in better scores on HPS than PBL on DYS scenarios.(Coates, Steadman,
Huang, Matevosioan, McCullough, Larmon, Ariel, 2003). Scores for the second module
on acute abdominal pain were not calculated.
As with many of the studies regarding HPS, sample size in this study is small. It
is almost impossible to perform a randomized experimental study using medical students
for a number of reasons. Researchers are limited to quasi-experimental studies with
convenience samples because of the limited number of study participants available in the
typical university setting. My study will also have this limitation. At the University of
Virginia, each of the four medical school class years has approximately 140 students.
Gaining consent is difficult for students with full and demanding schedules. I plan to
observe students in an existing toxicology rotation who experience simulation training in
topics as part of their rotation.
Retention-based research of HPS
A study of twenty-six inexperienced medical students trained with an endoscopic
sinus surgery simulator (ES3) retained skills for 2 months at the Otolaryngology Surgical
Simulation Center in New York. Students were trained in three levels (novice,
HPS in Medical Education 33
intermediate, and advanced) of difficulty and obtained learning curves within 80% of
experienced sinus surgeons (Uribe, Ralph, Glaser, Fried, 2004). Researchers were able to
build upon a simulation device created by defense contractor, Lockheed Martin, who
developed the ESS (Fried, Satava, Weghorst, Gallagher, Sasaki, Ross, Sinanan, Uribe,
Eltsan, Arora, Cuellar, 2004). A comprehensive curriculum incorporating endosocpic
sinus surgery and simulation was developed by a team of multidisciplinary experts.
“Using both visual and haptic (force) feedback to create a virtual reality environment, the
ES3 was developed to teach core ESS procedures to otolaryngology residents.” Students
were able to operate on a virtual patient with simulated handheld instruments, which
replicated the typical surgical interface. The instruments relayed information on
“mistakes, errors, and misses” and recorded “overall and task specific scores for each
student’s performance,” including the time to and accuracy of skills relative to optimal
performance. Metrics development was constructed by team of expert practitioners in the
field.
Retention of skills is an important hope for simulation-based training. This study
does not compare retention to a control but does show that skills taught through
simulation were retained at least for 2 months.
Performance-based research of HPS
Two small studies of performance among anesthetists found positive results.
Thirty-one first year residents who received training on a computer screen-based
simulator which was followed by individualized debriefing, performed better in critical
events using a mannequin-based simulator than those who received standard training
(Schwid, Rooke, Michalowski, & Ross, 2001) A second study of 28 found the
HPS in Medical Education 34
performance of participants trained on a simulator significantly better in simulated
critical situations involving anesthesia (Chopra et al., 1994).
A few studies in radiology, surgery, gastroenterology and cardiology also show
good use of simulation. House staff radiologists trained by either a lecture or a
videotape-based intervention on a computer were evaluated with a simulator and found a
significant difference comparing the effectiveness between learning formats (Sica,
Barron, Blum, Frenna, & Raemer, 1999). In a randomized study, Derossis found that
surgeons “tested on the simulator had greater proficiency in suturing, transferring, and
mesh placement, when tested on the simulator, than did the control group.” (Derossis,
Bothwell, Sigman, & Fried, 1998)Gastroenterology residents trained on a simulator to
perform flexible sigmoidoscopy made fewer subsequent errors (Tuggy, 1998). And
medical students could better recognize pathologic heart sounds after practice with a
heart sound simulator (Champagne, Harrell, & Friedman, 1989).
The results of these briefly described studies above show promise for HPS as a
teaching tool. Well designed research is needed to validate results. Few studies measure
statistical significance, or show test measurements of reliability, validity or other
psychometric criteria (Wong 2004).
Multimedia in Education
As new technologies in education, like HPS have been developed, high hopes
have been placed on their potential contributions to learning. Schools of the past have
primarily used the spoken word to transmit learning. Newer multimedia formats present
verbal and visual representations to enhance learning. Traditionally, motion pictures,
radio, television and computers have been considered multimedia devices, but now
HPS in Medical Education 35
simulations, microworlds, virtual reality and games are also considered to be multimedia
formats. Multimedia all have similar histories in that,
“First, they began with grand promises about how the technology would
revolutionize education. Second, there was an initial rush to implement the cutting–edge
technology in schools. Third, from the perspective of a few decades later it became clear
that the hopes and expectations were largely unmet.” (Mayer, 2005)
Richard Mayer explains history repeating itself largely because educators took a
technology-centered approach. A technology-centered approach forces learners to adapt
to technology rather than fitting the technology to suit the needs of the learners. More
appropriate are learner-centered approaches towards technology, where educators attempt
to find ways to enhance learning by adapting technology (Mayer, 2005).
“I began with the expectation that media were a significant element in any
educational reform which sought achievement gains. The problem was that as I reviewed
the evidence it seemed clear that it did not support my expectations or my intuition”
(Clark, 1991).
Since the early 1980’s, Richard E. Clark, a Professor in the Department of
Educational Psychology and Technology at the University of Southern California has
been a well-known critic of the concept that learning benefits can be attributed to the use
of media in education. In his analysis of educational research studies concerning media,
he has concluded that there is no benefit of using media to enhance learning. He states,
media are “mere vehicles that deliver instruction but do not influence student
achievement any more than the truck that delivers our groceries causes changes in our
nutrition” (Clark, 1983). Clark proposes that rival hypotheses may exist, including the
novelty effects and unintentional differences in learning content when using media
formats, which impact research conclusions. He also has found that “same teacher”
control was not employed in most of the media comparison studies, which further
HPS in Medical Education 36
confounds results (Clark, 1991). He explains that although various media formats can
deliver instruction, they may not contribute any more than existing learning methods
(Clark, 1984).
Does Clark consider the type of learninig that certain media might best
compliment? Knowledge-building, application, performance are different learning
attributes. We know from Bloom’s work that as students move towards performance of
learned skills, that more realistic environments are appropriate, meaning technologies that
provide more realistic learning environments might be more conducive to learning gains.
My study will compare two teaching strategies, while incorporating same teacher control
and identical learning goals and objectives.
Multimedia Research
HPS is a form of multimedia instruction and is led by an instructor, who uses
words to guide students as they see procedures, responses, and symptoms. Because little
research and theory have been performed on the learning gains from HPS, work
regarding other forms of multimedia will be relevant to this discussion. Research and
theory regarding the multimedia formats of virtual learning environments, games and
simulations, can help us better understand the issues regarding HPS learning formats
(Mayer, 2005).
Virtual Learning Environments (VLEs) are three dimensional, computerized
places or situations that a learner can engage in to promote learning. Users can sit at a
computer screen or wear a device in which to look through. The military, space, aviation
and medical industries have employed VLEs for training purposes.
HPS in Medical Education 37
“Medical and rehabilitation applications have generally been developed within
projects aimed at supporting learning of specific activity or skill. Evaluation of
application success is based on evidence of cognitive or motor co-ordination training for
individuals.” (Rizzo, 2000, 2001)
VLEs are highly versatile and have been used in learning to promote exploration,
creating or modifying, and role play. Successful learning gains are not completely
known because the abstract concepts that are featured are not easily measured by
traditional evaluation tools. While student and instructor attitudes are favorable towards
VLEs, it is hard to determine whether attitudes are due to a novelty effect of the
technology or perceived learning benefits (Cobb, Fraser, MHB).
Games, simulations and microworlds are interactive technologies that place the
emphasis of learner experience over instructor explanations. Instructors are used for
support, encouragement and resources. The impact of video games has had a staggering
effect, socially and economically. Electronic game sales topped seven billion dollars in
2005, doubling from 1996 sales. This translates into two games purchased for every
household in America ((Entertainment software association.2006). It is not known what
percent of these games are considered educational, though it can be argued that even
entertainment video games provide a certain measure of learning. Educational electronic
games are relatively new to our human learning experience and there is no one best
design to promote the highest level of learning. Research regarding games, simulations
and microworlds is largely inconclusive. Quantitative measures usually show little if any
significant learning differences and may not even use accurate measures to capture
learning gains. Qualitative measures can help analyze learning attitudes but don’t answer
the fundamental questions concerning statistical difference (Reiber, MMH).
HPS in Medical Education 38
The history and use of multimedia formats is relevant to my study of HPS because
it reveals that the challenges in program design and development and research is not
unique to HPS. The verdict is still out showing proof of learning effectiveness.
Value of Media Comparison Studies
An online poll performed by the Instructional Technology Forum (ITFORUM)
was conducted in 2001 to examine the value of media comparison studies. The
researchers, Surry and Ensminger, analyzing the poll results write, “One of the most
interesting and surprising results of the poll was the wide range of opinions that people
had about media comparison studies.” Out of almost 150 respondents, ranking the value
of media comparison studies on a scale of 0-10, responses were evenly distributed,
meaning that value was felt to be equally weak or strong. The researchers were surprised
that respondents, who are professionals in the field of instructional technology, felt so
strongly about the value of media comparison studies(Surry & Ensminger, 2001).
They expressed that one reason might be the ‘changing nature of technology.’ As
new technologies emerge, proof of educational value and cost effectiveness become
issues in promoting the use of that technology. Surry and Ensminger describe the ‘No
Significance Difference Phenomenon,’ the results many media comparison studies
eventually conclude. They state, “The reason so many media comparison studies have
found ‘no significant difference’ is, of course, that it is the instructional method, not the
delivery medium, that is the primary cause of changes in achievement.” A second reason
is the difficulty in designing comparison studies that address unique media attributes. Do
media have attributes, such as learner control or interactivity, that cause them to be more
HPS in Medical Education 39
effective? The authors suggest that media research would be more research-worthy if
they explored such attributes(Surry & Ensminger, 2001).
The following table is a reprint of errors Surry and Ensminger ( ) believe to be the
weaknesses of many media comparison studies:
Table 1- Weaknesses of Media Comparison Studies
Category
Specification Error
Lack of Linkage to Robust Theory
Inadequate Treatment Implementation
Inadequate Literature Review
Measurement Flaws
Inconsequential Outcome Measures
Inadequate Sample Sizes
Inappropriate Statistical Analysis
Meaningless Discussion of Results
Description
Vague definitions of the primary
independent variables
Little more than nominal attention to the
underlying learning and instructional
theories that are relevant to the
investigation
Infrequent (usually single) treatment
implementation often averaging less than
30 minutes
Cursory literature review focused on the
results of closely related studies with little
or no consideration of alternative findings
Precise measurement of easy-to-measure
variables (e.g., time); insufficient effort to
establish the reliability and validity of
measures of other variables
A lack of intentionality in the learning
context, usually represented by outcome
measures that have little or no relevance for
the subjects in the study
Small samples of convenience, e.g. the
ubiquitous undergraduate teacher education
or psychology majors
Use of obscure statistical procedures in an
effort to tease statistically significant
findings out of the data
Rambling, often incoherent, rationales for
failing to find statistically significant
findings
My proposed research study, a comparison of media formats, lecture using
PowerPoint slides and HPS, will attempt to address these identified areas of weakness by
HPS in Medical Education 40
using clear identified independent variables linking to educational theory with adequate
literature review, appropriate treatment implementation, with a reliable and valid
evaluation tool, relevant outcome measures, significant power of sample size, sound
statistical analysis and appropriate interpretation of results.
Literature Review Summary
My study of the learning effects of human patient simulation is relevant to a
primary concern in current medical practice--patient safety. The highest levels of the
medical community, the Institute of Medicine and the Accreditation Council for Graduate
Medical Education have suggested that use of human patient simulation in medical
education shows promise. My study will contribute to the body of research evaluating
the effectiveness of human patient simulation in medical education.
Human patient simulation meshes well with the core competencies medical
students must demonstrate, especially contributing to learning involving patient care,
medical knowledge, practice-based learning and improvement, interpersonal and
communication skills. My study will attempt to answer whether or not human patient
simulation improves patient assessment and treatment recommendations leading to
improved patient outcomes.
Human patient simulation has the potential to be a more effective educational tool
over the use of standardized patients, because more invasive procedures can be
performed with out human risk. This notion is so strongly believed to be true that our
most highly regarded institutions of learning have acquired human patient simulators in
record numbers.
HPS in Medical Education 41
Research by learning modality is incomplete with many studies measuring
learning gains through knowledge tools. Our evaluation of learning with human patient
simulators needs to be re-examined to see which learning modalities it best addresses and
develop appropriate measures to capture gains. My study and the two pilot studies
already conducted have examined learning preferences of students, knowledge gains,
retention, application and performance of knowledge.
Educational theory tells us that the greatest learning comes from material that is
relevant to every day life. Human patient simulation provides learning in a close to real
life setting, thereby addressing theory that is known to be of value. HPS is a form of
multimedia, a new learning format with much research coming to identify best practices
in programs.
This study is relevant and needed to contribute to the improvement of medical
education, which currently is in a state of transition.
My research will be guided by two research questions which were developed in
response to the needs identified in this review of literature: “What is the role of HPS in
improving learning in pharmacology?” and “How does a learning experience with HPS
effect medical resident treatment and evaluation of a standardized patient who is the
victim of a snakebite?”
Bridge from Literature to Proposed Study
A constructivist process of learning is involved in a physician’s learning process
through medical school and residency. Knowledge is constructed as a foundation, and
applied to it are layers of comprehension, application, performance, analysis, synthesis
and evaluation. Construction of learning goes on to include affective and psychomotor
HPS in Medical Education 42
domains. Human patient simulators provide realistic learning environments where
doctors will need this foundation of skills in order to perform unfamiliar clinical
procedures for training purposes.
Past research regarding the use of HPS has been conducted largely with
experiments that explore the relationship of learning with HPS and knowledge. Few
research efforts have explored more complex learning modalities such as performance,
where HPS may show real promise in training physicians.
It is this reason that I have chosen 4th year medical students and residents, who
have a foundation of knowledge and experience, as participants in this dissertation study.
I have chosen a topic that will be relatively unfamiliar with this population, and have
controlled for instructor effect by using the same instructor for each group. Analysis will
consist of mixed measures evaluation tools to better identify the role of HPS in learning.
HPS in Medical Education 43
CHAPTER III
METHODOLOGY
My research inquiry on the use of human patient simulation in medical education
began in the Spring of 2004 with a qualitative study that will be recounted in the
proceeding section, Pilot Study I. The study was impressive to me because I was able to
witness and measure the extent to which undergraduate pre-medical students regarded the
technology as a superior learning tool. It was the appeal of the technology among the
students and myself that led me to continue my research in this venue.
The next Spring, in 2005, I conducted a quantitative study measuring knowledge
gains in basic pharmacology principles after first year medical students participated in
either lecture or HPS education formats. I was able to secure 44 study participants, who
were divided in to two groups, study and control, and then evaluated on knowledge and
application of knowledge through repeated measures, pre-, post-, and retention. Students
learning did show gains in both education formats but significant difference in gains
between the two groups was not found. Further research of the literature showed me why
the ‘no significant difference’ phenomenon is prevelant in media comparison studies.
This study will be detailed in the section, Pilot Study II.
In the final section of this Chapter III Methodology, I will describe my proposed
dissertation study involving mixed measures, qualitative and quantitative, to hopefully
tease out the learning variances that result from teaching strategies involving human
patient simulation. I hope to obtain participants who are in their fourth year of medical
school or interns just beginning their supervised medical practice, because of their
foundation of medical knowledge. I hope to show that HPS has a role in medical
HPS in Medical Education 44
training, which can improve physician skills with patients and diagnosis and treatment of
their medical conditions.
Pilot Study I
The design research process for this dissertation inquiry began in the Spring of
2004 with a mixed methods exercise that was conducted to assess the effectiveness of
using human patient simulation as a teaching tool for pharmacology principles. Fourteen
students in an undergraduate class, INST 203 Clinical Emergency Medicine Research 1,
volunteered to participate in a supplementary class exercise involving simulation. This
study was classified as exempt from the University of Virginia Investigational Review
Board of the Behavioral Sciences (Appendix B). Students were randomized into two
groups by selecting an odd or even number from a hat. Students selecting odd numbers
were placed in the lecture group and students selecting even numbers were placed in the
HPS group.
Lesson plans for understanding basic pharmacologic principles were developed
for lecture and HPS formats (Appendix E). Each group received a 20-minute program
addressing identical learning objectives and covering the same material content on basic
pharmacologic principles. Students who received the lecture format were introduced to
the HPS after the lecture ended. The instructor for the HPS group was Dr. Mark Kirk,
Director, Medical Toxicology Fellowship and Steering Committee member of UVA’s
HPS Laboratory. Dr. David Eldridge, first year Toxicology Fellow was the instructor for
the lecture group.
Students in both groups were given a written 10-item interview (Appendix A)
examining participant perception of attention level, learning, retention, clinical readiness
HPS in Medical Education 45
and educational format preferences. Participants were also asked their recommendations
regarding HPS and lecture learning formats after their education sessions (Appendix A).
Each questionnaire was labeled with the number, even or odd, that the participant had
drawn for group selection. Presence of these numbers allowed us to track responses for
analysis. Students were given 20 minutes to write their answers and were asked to
expand on answers to previous questions if they finished early in order to use the full
time allotment. It was felt that using the equal time limits for each participant would
improve the quality and completeness of responses and make them more uniformly
comparable. Answers were compared for similar themes.
Both groups wrote open-ended answers comparing lecture and HPS educational
formats. The HPS participants were asked to recall previous experiences with lectures in
school, since they did not receive a lecture as part of this study. Participants in the
lecture group were given a brief exposure to HPS learning at the conclusion of their
pharmacology lecture. Their answers were based on this HPS exposure and the lecture
they had received as part of this study.
Completed interview questionnaires were collected from each study participant at
the end of the twenty-minute time allotment. Responses were scanned for themes and
general agreement or denial of the question’s premise concerning education traits (Table
3). For example, in question 1, participants addressed attention level. Participants wrote
about their feelings and thoughts concerning attention level and how the trait was
improved or decreased by teaching format.
Seven questionnaires from the HPS group and five questionnaires from the lecture
group were collected at the end of the interview session. Cross case analysis found that
HPS in Medical Education 46
response interpretations could be made concerning improvement of five educational
traits: attention level, learning, retention, clinical readiness, and learning format
preference. Table 1 shows a matrix diagram showing improvement in traits by learning
format.
Table 2- Reported improvements in Educational Traits
HPS
Group
Reported Improvements in Educational Traits
Attention
Subject #
level
Learning
Retention
Readiness
Preference
HPS Lecture HPS
Lecture HPS
Lecture HPS
Lecture HPS
Lecture
22 X
X
X
X
X
2 X
X
X
X
X
X
X
14 X
X
X
X
X
12 X
X
X
X
X
X
10 X
X
X
X
X
16
X
X
X
X
8 X
X
X
X
X
Lecture
Group
Attention
level
Learning
Retention
Readiness
Preference
HPS Lecture HPS
Lecture HPS
Lecture HPS
Lecture HPS
Lecture
3 X
X
X
X
X
7 X
X
X
X
X
9 X
X
X
X
X
11
X
X
X
1 X
X
X
X
X
Subject #
Content analysis of the responses of both groups found the presence of recurring
themes, including: HPS active learning, HPS visual learning, lecture benefits of
presenting factual material, HPS application of knowledge, and the benefits of combining
learning formats. Graph1 shows the total mentions of these themes in the transcribed text
from both groups.
HPS in Medical Education 47
Graph 1
Learning Benefit Them es
35
30
25
20
15
10
5
0
HPS Act ive learning
HPS Observat ion
Lect ure learning f act ual
HPS applicat ion of
Combined learning
cont ent
knowledge
approaches
N um be r of M e nt i ons
Participants overwhelmingly agreed that HPS improved the results of the
educational traits we identified: attention level, learning, retention, clinical readiness.
Students entering the simulation lab exhibited a greater level of interest and
engagement than those receiving the lecture. Ten of the twelve respondents
acknowledged a greater attention level in the HPS format (Table 1). This is evidenced in
the written text of the interviews. One student stated, “I felt more attentive in the
simulator-based learning because I was standing and actively participating.” Another
expressed, “In lectures, I am less inclined to be interested or learn and retain as much
because it is more of a passive learning experience for me.”
HPS participants also felt that the program addressed additional learning styles as
well as auditory. A student expressed, “Simulator based learning was great because of
hands on involvement and it was closer to what one would see in real life. You can’t
read in any book what the chest rising and falling or inhalation looks like or what
HPS in Medical Education 48
happens to the body when you combine two drugs. To visualize it is very educational.”
Comments such as these led us to conclude that HPS learning stimulates more senses,
such as vision and touch, allowing a greater level of information acquisition for
participants.
In terms of anticipated retention and clinical readiness of the subject material, one
participant stated, “…the simulator-based teaching method helped b/c I could remember
myself or others specifically doing something & observing the response.” Memory of the
specific events in the simulator lab creates a strong connection to the subject material and
we propose leads to a better retention of information and readiness to react and perform
in a similar situation in real life. Sixty-six percent of the participants responded that HPS
would allow for greater retention, while 17% of the participants responded that lecture
would benefit retention to a greater degree. Two participants did not respond.
Participants mentioned HPS frequently in terms of the identified themes in active
learning, observational learning and application of knowledge. Participants also
mentioned the value of lecture formats in obtaining background facts and definitions
needed to grasp the subject matter.
Participants of both groups overwhelmingly recommended a combined approach
of HPS and lecture formats to learn pharmacologic basic principles. Eleven of the twelve
participants who completed the written interview recommended a combination of
formats, with only one recommending that HPS be used alone to teach this subject.
I interpret these responses to mean that most of our participants find HPS to be a
valuable and successful way to learn. HPS presents a real-life situation which students
value in their learning. However, most participants did appreciate learning terms and
HPS in Medical Education 49
facts through lecture and would recommend a lecture and HPS to be used in combination
to achieve the greatest learning benefit.
Pilot Study Design 2
A second pilot study was developed which recruited a larger group of participants
to for a quantitative methods study of human patient simulation. This prospective,
between-group, quasi-experimental study employed convenience sampling and repeated
measures to evaluate the effectiveness of HPS as a teaching tool. We taught basic
pharmacology principles either by HPS or lecture format. Both formats used identical
goals, and objectives, and subject content in order to limit bias. This study was approved
by the Institutional Review Board for the Social and Behavioral Sciences at the
University of Virginia (see Appendix D).
First Year Medical Students (FYMS) were selected as the target population for
this study because of their limited knowledge of pharmacology principles. These
students represent similar education backgrounds, abilities and ages, and included male
and female students 21 years or older. We secured 44 FYMS who were randomized into
two groups: HPS and lecture. Each FYMS volunteer received a coded envelope with
study materials, including the consent form, pretest and posttest.
A bank of test items were constructed by an Associate Professor in Pharmacology
and reviewed by a panel of experts, including two certified Toxicologists and two
Toxicology Fellows. Pilot testing of items was performed by medical student rotators
during a rotation in the UVA Division of Toxicology. Question items were matched for
subject content and difficulty pre- to posttest The retention test contained ten items
selected from the pretest (odd-numbered questions) and 10 items from the post-test
HPS in Medical Education 50
(even-numbered items). The pre, post and retention tests each contained 13 knowledge
questions and 7 application questions. The ratio of knowledge to application questions
was not purposeful.
After completion of the consent form and the pretest, students were divided into
their respective groups and received an education program on basic pharmacology
principles either by HPS or lecture format. The same instructor was utilized for both the
HPS and the lecture groups in an attempt to reduce bias. The instructor facilitated the
HPS group through discussion and demonstration. HPS instruction consisted of a
combination of hands-on and observational learning experiences. No more than eight
students received the HPS education at a time due to space limitations and more effective
use of the HPS. Students accepted hands on responsibilities during the instruction
including, drug administration, timer, observer, recorder. As the instructor explained
each of two scenarios, students administered increasing amounts of drug and observed
the HPS symptomatic reaction. The HPS was connected to an EKG and other monitoring
devices, which varied in measurement as the drug in question was administered.
Students observed changes in cardiac function, blood pressure, breathing rates, pupil size
reactions and more.
The participants in the lecture group received a 20-minute PowerPoint
presentation on pharmacology principles. Students in the lecture group reviewed the
same two scenarios presented in the HPS sessions. The PowerPoint slides contained
print, photographs and graphs to relay information. Each learning format, HPS and
lecture, addressed identical learning objectives and subject content on basic
pharmacology principles.
HPS in Medical Education 51
Table 3- Learning Objectives
Learning objectives
 The student will understand routes of exposure
 The student will understand the life of a drug: absorption, distribution, target
organ effect, metabolism and elimination.
 The student will be familiar with dose response
 The student will be familiar with drug interactions
A 20-question post-test was administered at the conclusion of each program to
measure gained knowledge and application of knowledge. At that time, students placed
their consent, pre and posttests in their coded envelopes to be collected.
Table 4
Study Flowchart
SCHEDULE OF ACTIVITIES FOR HPS PILOT
STUDY
recruitment
overview
assign group
consent form
pre-test
Lecture program
HPS program
post-test
post-test
retention test
retention test
Scores on pre, post and retention tests were analyzed by group using SPSS
software to perform repeated measures analyses of variance. Assistance from the UVA
Center for Research was obtained to conduct statistical analyses.
Results of the statistical analysis showed no significant difference in knowledge,
application and retention between the lecture and HPS groups.
The analysis performed
was a 2 way repeated measures using the with-in factor of time (3)-pre, post, ret
HPS in Medical Education 52
and the with-in factor of evaluation measure (2) application, knowledge and the between
group of Lecture or HPS. A one-way ANOVA was performed at each level with the
greatest difference being within the post-application between the two groups at a
significance level of .159.
Table 5
Statistical Analysis
HPS
Total
Mean
N
Std. Deviation
Mean
64.923
22
20.0586
65.252
63.977
22
15.9724
62.402
44
44
20.0450
17.3976
N
Std. Deviation
75.300
22
14.0817
71.412
43
18.4373
75.500
22
8.4471
76.377
44
11.8995
78.830
20
13.4084
79.907
41
12.2728
Graph 2
100
90
80
Lecture
70
HPS
60
50
40
Pre-Test
Application
Score
Pre-Test
Knowledge
Score
Post-Test
Application
Score
Post-Test
Kowledge
Score
Retention
Application
Score
Retention
Knowledge
Score
HPS in Medical Education 53
Graph 3
Application Only: Bar
85
80.93
78.83
80
75.30
75
Lecture Application
HPS Application
70
67.34
65.58 64.92
65
60
Pre-Test Application
Score
Post-Test Application
Score
Retention Application
Score
Graph 4
Application Only: Trend
85
80.93
80
78.83
75.30
75
Lecture Application
HPS Application
70
67.34
65
65.58
64.92
60
Pre-Test Application
Score
Post-Test Application
Score
Retention Application
Score
HPS in Medical Education 54
Graph 5
Knowledge Only: Bar
85
80
77.25
75.50
75
76.52
74.34
Lecture Knowledge
HPS Knowledge
70
63.98
65
60.83
60
Pre-Test Knowledge
Score
Post-Test Kowledge
Score
Retention Knowledge
Score
Graph 5
Knowledge Only: Trend
85
80
77.25
75.50
75
76.52
74.34
Lecture Knowledge
HPS Knowledge
70
65
60
63.98
60.83
Pre-Test Knowledge
Score
Post-Test Kowledge
Score
Retention Knowledge
Score
HPS in Medical Education 55
Proposed Study Design 3
This prospective, nonrandomized mixed methods study compared two groups,
study and control fourth year medical students and resident participants after contact with
a standardized patient (SP) actor who experienced a bite from a Timber Rattlesnake. The
study group received a prior human patient simulation education program on venomous
snakebites and the control group received the traditional PowerPoint lecture on the same
topic. The study examined how the two teaching methods affect learning gains and
performance in participants.
Groups were surveyed for prior experience with snakebite treatment (APPENDIX
L). My study quantitatively evaluated pre and post knowledge with a multiple-choice test
tool (APPENDIX M). Participants were also evaluated on the presence of critical
elements in medical charting documentation (APPENDIX H) on the standardized patient
snakebite victim by a trained standardized patient evaluator (APPENDIX K). The study
qualitatively evaluated the responses of fourth year medical students’ and residents’
responses to open ended questions regarding their learning experiences (APPENDIX O),
from a checklist completed by the standardized patient themselves (APPENDIX P), and
from my own research observations of video footage of physician/patient contact
(APPENDIX Q).
Participants
Fourth year medical students and interns routinely choose to rotate through the
Division of Medical Toxicology service as a part of their training at the University of
Virginia Health System. Six to eight fourth year medical students and residents spend up
to 4 weeks during their rotation and meet 5 days per week learning about various aspects
HPS in Medical Education 56
of medical toxicology. Subject areas include human exposure to medications, bites and
stings, plants and herbals, chemicals and workplace exposures. Fourth year medical
students and residents normally receive toxicology training through lecture, discussion,
human patient simulation, and live patient contact during the Toxicology Rotation.
Fourth year medical students and residents are graded on a pass/fail basis for their
performance during this course of study.
Background
Venomous snakebite treatment is a topic covered during a rotation through the
UVA Division of Medical Toxicology. Student rotators, consisting of fourth year
medical students and residents, usually receive training on venomous snakebites by
attending a lecture by a clinical toxicologist accompanied by PowerPoint slides.
Contact with live patients may occur during the month-long rotation, as rotaters
participate in hospital rounds involving actual snakebite victims. Snakebite victims are
most likely to present at the hospital during the warmer months. Most of the snakebite
victims at UVA are bitten by Copperhead snakes. Only 1-2 patients per year are bitten
by a Timber Rattlesnake.
To avoid contamination of prior knowledge in my study, I chose the treatment of
a Timber Rattlesnake victim as the evaluation topic of interest because of its relatively
rare occurrence.
In my study, a simulated patient, who has been given a predetermined scenario
and profile involving exposure to a Timber Rattlesnake bite, was utilized for participant
evaluation measures. The study did not impact fourth year medical students and intern
success or failure during their rotation,
HPS in Medical Education 57
Human patient simulation is presently used to demonstrate pharmacology
principles and exposures to bioterrorism agents in the toxicology rotation. Development
of the use of simulation for snakebites was a new application for the human patient
simulator and will continue to be used for future rotations of students.
Methods
In July 2006, the group of UVA Toxicology rotaters was assigned to the control
group by coin toss. The following month’s rotaters were assigned in alternate, study or
control, and assignment continued in alternate until the study’s conclusion.
Study participants completed a survey identifying prior classroom or treatment
experience of venomous snakebite patients. Prior experience needed to be identified to
determine if research results were affected when prior experience was present. The Prior
Experience Tool may be viewed in APPENDIX L.
A multiple choice knowledge tool on venomous snakebite treatment was
developed to capture prior knowledge and then post education knowledge gains after the
education programs. Questions were created by a Certified Clinical Toxicologist and
have been piloted to assess validity and reliability. The Venomous Snakebite Treatment
Knowledge Tool can be viewed in APPENDIX M.
One group of fourth year medical students and residents participants were given
the standard lecture on venomous snakes using PowerPoint. The second group received
the same information using a human patient simulation format that covered identical
goals and objectives as the lecture. Both educational sessions incorporated a patient
scenario involving a venomous snakebite. Group assignment involved intact rotations,
meaning there was no separation of study and control participants within a rotation. One
HPS in Medical Education 58
month all of the fourth year medical students and residents in the rotation received
training on venomous snakes by lecture and the next month’s rotation of fourth year
medical students and interns received the training using the human patient simulation.
Both lecture and HPS training for venomous snakes covered an overview of
crotalid snakes, copperhead, rattle and cottonmouth snakes. Included was information on
identification, usual habitats, and the mechanisms of action of crotalid venom. Education
incorporated typical snakebite patient profiles, symptoms, treatment and possible
complications. Particular attention was given to teaching proper observation of swelling
as it progresses adjacent to the bite site, deciding when to administer antivenin,
administering antivenin, and analyzing laboratory assays. Training also reviewed
essential resources available to clinicians, including speciality consultants, such as
poison center experts, dermatologists, neurologists, and hematologists, and ways to
access more information through the literature (Appendix G).
Lecture Group
The lecture group attended a PowerPoint presentation that included photographs of the
material being discussed along with the accompanying lecture. A scenario (Appendix F)
was described, along with images of an actual snakebite victim, showing bite wounds and
subsequent symptomatology and treatment administration was included. This is the
typical teaching method and content presented during past Toxicology Rotations. Both
groups received instruction led by Dr. Mark Kirk, which improves consistency in
achieving similar learning goals and objectives and subject content.
HPS Group
HPS in Medical Education 59
The HPS group entered a simulated emergency department patient exam room
which contained the simulator mannequin. The facilitator, Dr. Kirk, stood to the side of
the mannequin and a computer technician manning a laptop computer, which controls the
mannequin’s actions and reactions sat in the back corner of the room. Patient monitoring
equipment was present along with an air compressor, all part of the peripheral equipment
needed to operate and utilize the simulator. Students stood around the ‘patient bed’ and
were assigned tasks by Dr. Kirk, including recording measurements and symptoms,
obtaining measurements, administering medication, timing responses, and the like.
Dr. Kirk introduced participants to the treatment of venomous snakes, as
described above. He presented the patient, a victim of a venomous snakebite, as
described in Appendix F, and the computer technician operated the programmed
sequence of controls for our scenario. The mannequin simulated changes in vital signs,
localized bite symptomatology and neuromuscular abnormalities. Students participated
actively in patient treatment during this guided example.
Both groups completed a post-test multiple-choice knowledge test at the
conclusion of their educational program (APPENDIX M).
Standardized Patient Experience
Medical resident participants from each group, control and study, made
appointments for a standardized patient encounter at UVA’s Department of Medical
Education, Clinical Skills Training and Assessment Program (CSTAP). CSTAP is an
instruction and assessment facility for students, residents and health care providers and is
located in UVA’s Hospital West. CSTAP provides patient exam rooms where students
practice their role as physician and a trained standardized patient portrays someone with a
HPS in Medical Education 60
given medical condition. Each exam room is equipped with two cameras so that the
physician/patient interaction can be observed and recorded. Interactions were observed
by trained evaluators in the CSTAP control room.
In my study, the fourth year medical students and residents were evaluated after
their education program on venomous snakes at CSTAP. Each participant had an
opportunity to treat a standardized patient portraying a victim of a Timber Rattlesnake
bite.
Training for the first two standardized patient actors took place over a 2 hour
period in the Clinical Skills Training and Assessment Program office. CSTAP staff and
poison center staff led the SP actors through a trainer (APPENDIX R) which included
background information, potential script options, and several mandatory statements to be
covered in the patient exam contact with participants. SP’s were advised to stay in
character throughout the encounter and not to volunteer any additional information about
which they were not specifically asked. Hiking clothing, moulage for the snakebite
wound, and appropriate pain reactions were discussed and practiced. One of the two
experienced SP’s participated in a demonstration encounter with our Toxicology Fellow
physician, which assisted us in modeling appropriate SP actions. The SP’s were also
trained to access the WebSP software in order to record their survey answers on the
Standardized Patient Checklist of Physician Skills (APPENDIX P).
The standardized patients occupied an ‘emergency department patient room’
where the resident made first contact with the patient upon ‘entry to the medical center.’
The resident performed the history and physical exam of the patient and created a
treatment plan as is usual practice of any patient entering emergency care at the hospital.
HPS in Medical Education 61
The patient presented as someone who was hiking when they were bitten on the left index
finger by a snake after they tried to pick it up. The patient complained of severe pain at
the site and came to the Emergency Department for treatment (Appendix F). Participant
physicians interact with the standardized patient and then recorded the history and
physical and treatment plans electronically. The standardized patient scenario was
scripted so that the patient experienced extensive swelling at and beyond the bite site.
Physician participants could choose to perform circumference measurements of the
affected limb and record results on the patient record. Participants could also choose to
track and record the leading edge of the swelling. Participant physicians could decide on
the need for antivenin and administer the appropriate dose.
Evaluation
Evaluation measures were completed by the participant, standardized patient,
evaluator and researcher.
The evaluator in my study was a Toxicology Fellow at the Blue Ridge Poison
Center. At the UVA Health System, Toxicology Fellows are licensed physicians who are
accepted into our certified fellowship program, in the Division of Medical Toxicology in
the UVA Department of Emergency Medicine, and learn to provide patient consults on
calls to the emergency poison hotline and on patients within the hospital. The
Fellowships in Toxicology is a two-year program which prepares physicians to sit for the
toxicology certification board.
The responsibilities of the evaluator were two-fold: 1) to observe the
participant/SP encounter and complete an observation survey (APPENDIX K), and 2) to
review the participant’s electronic patient note and rank (1-5) the note for the presence of
HPS in Medical Education 62
critical elements using a scoring rubric (APPENDIX N). During the SP encounters with
participants, the evaluator sat in the CSTAP observation room to watch video feed from
the patient room. The evaluator also had computer access to the electronic record each
participant composed at the conclusion of their SP encounter.
The standardized patient measured of the participant’s performance in the
physician role on the Standardized Patient Checklist of Physician Skills. This survey
captured Likert scale information on the standardized patient’s perceptions of the
physician participants’ interaction, examination and treatment skills. The checklist can
be viewed in APPENDIX N.
The researcher evaluation consisted of my observations in the observation room,
along with the trained evaluator. I developed an observational protocol (APPENDIX Q)
which follows the six competency areas identified by ACGME. My observations were
typed into the protocol form for each individual participant. Observations were written to
include descriptive and reflective information.
A final qualitative measure incorporated open ended questions for each
participant. The questions explored themes concerned the quality of the learning
experience provided by Dr. Kirk, the standardized patient experience, and readiness to
manage patients after their learning experience. Questions can be viewed in APPENDIX
O.
Analysis
The data for analysis in this study will be captured quantitatively and qualitatively
for each participant.
Quantitative measures include:
HPS in Medical Education 63
Survey of Prior Knowledge (APPENDIX L)
Venomous Snakebite Treatment Knowledge Tool (APPENDIX M)
Snakebite Standardized Patient Measurement of Applied Skills
(APPENDIX K)
Qualitative measures include:
Standardized Patient Checklist of Physician Skills (APPENDIX P)
Researcher Observation Protocol (APPENDIX Q)
Focus Group Themes APPENDIX O
The responses to the Survey of Prior Knowledge will be recorded in an Excel
spreadsheet for presence or absence of prior experience. A within group analysis of
lecture and simulation participants will be performed to identify individuals with prior
experience. This determination may show prior experience to have a significant effect on
participants treating the standardized patient. I will look for differences on the qualitative
and quantitative measures and will control for the differences if present at a significant
level.
Results of the multiple choice knowledge pre and post test, the Venomous
Snakebite Treatment Knowledge Tool, will be analyzed by group using SPSS to calculate
repeated measures of variance by group using a within factor pre to post.
The information recorded on the patient chart for the standardized snakebite
patient will be evaluated for the presence and accuracy of critical elements. Critical
elements include items in the history, physical exam, diagnostics, assessment and action,
that relate specifically to the treatment of Rattlesnake bites. Critical elements will be
evaluated by a trained evaluator for accuracy according to the Snakebite Standardized
HPS in Medical Education 64
Patient Assessment Tool (APPENDIX K). One point will be awarded for the presence of
the critical element. The grading of the critical elements will be reported as a percentage
of the actual points as compared to the total points possible for each participant.
Percentages will be compared between the lecture and simulation groups using an
analysis of variance (two sample t test) to measure the main effect of group assignment at
the p= or < .05 level of significance.
Likert scale responses to the Standardized Patient Checklist of Physician Skills
(APPENDIX P) will be analyzed by mode, the number, 1-5, marked most often by the
standardized patient in response to the individual physician participants’ skills.
Variations in the mode by group, lecture or simulation will be explored.
Text data on the Researcher Observation Protocol (APPENDIX Q)
will be recorded electronically into a Word file and scanned for themes, comparisons and
contrasts. Observations will be recorded in descriptive and reflective formats in response
to the six competency areas identified by the ACGME.
A final qualitative measure will incorporate focus group discussion of each group
of fourth year students and residents in my study. Intact study groups, lecture or
simulation, will be scheduled to participate in a focus group discussion within a week of
the standardized patient experience. The focus group session will explore themes
concerning the standardized patient experience and readiness to manage patients after
their learning experience. Themes to be introduced for discussion are listed in the Focus
Group Themes in APPENDIX O. Discussion content will be recorded in written notes,
using a marker written on a flip chart tablet. Discussion themes will be summarized and
presented in the results of my study.
HPS in Medical Education 65
REFERENCES
Human patient simulation. (Undated). Retrieved 5/31/2006, 2006 from
http://medicine.nus.edu.sg/anaeweb/hps.htm
Clinical skills training and assessment program. (2006). Retrieved 5/31, 2006 from
http://www.healthsystem.virginia.edu/internet/cstap/
Entertainment software association. (2006). Retrieved
4/17/2006http://www.theesa.com/facts/top_10_facts.php
Outcome project. (2006). Retrieved February 17, 2006 from
http://www.acgme.org/outcome/comp/compFull.asp
Requirements for admission. (2006). Retrieved 5/31, 2006 from
http://www.healthsystem.virginia.edu/internet/admissions/requirements.cfm
How common are medical mistakes? (2005). Retrieved January 25, 2006 from
http://www.wrongdiagnosis.com/mistakes/common.htm
Learning skills program. (2005). Retrieved 5/21, 2006 from
http://www.coun.uvic.ca/learn/program/hndouts/bloom.html
School of medicine curriculum. (2005). Retrieved 5/31/2006, 2006 from
http://www.healthsystem.virginia.edu/internet/som-curriculum/
Worldwide simulation sites. (2005). Retrieved January 25, 2006 from
http://www.bris.ac.uk/Depts/BMSC/
Human patient simulator. (2004). Retrieved February 19, 2006 from
http://www.meti.com/
Bloom, B. S. (Ed.). (1956). Taxonomy of educational objectives; the classification of
educational goalsLongmans, Green.
Bond, W. F., Deitrick, L. M., Eberhardt, M., Barr, G. C., Kane, B. G., & Worrilow, C. C.
et al. (2005). Cognitive versus technical debriefing after simulation training. Journal
of American Emergency Medicine, 10(13), 276-277, 278, 279, 230, 231, 232, 233,
234, 235, 236, 237, 238.
Brady, M. S., ed. (2004). Focus on simulation & technology. Journal of Nursing
Education, 43(4), 147-189.
HPS in Medical Education 66
Champagne, M. T., Harrell, J. S., & Friedman, B. J. (1989). Use of heart sound simulator
in teaching cardiac auscultation. Focus on Critical Care, 16, 448-449. 450, 451. 452.
453. 454. 455. 456.
Chapman, A. (2005). Bloom's taxonomy - learning domains. Retrieved 5/21, 2006 from
http://www.businessballs.com/bloomstaxonomyoflearningdomains.htm
Chopra, V., Gesink, B. J., de Johg, J., Bovill, J. G., Spierdijk, J., & Brand, R. (1994).
Does training on an anaesthesia simulator lead to improvement in performance?
British Journal of Anaesthesia, 73, 293-294, 295, 296, 297.
Clark, R. E. (1984). Paper presented at the Annual Meeting of the American Educational
Research Association, New Orleans, LA.from American Educational Research
Association database.
Clark, R. E. (1983). Reconsidering research on learning from media. Review of
Educational Research, 53(4), 445-449.
Coates, W. C., Steadman, R. H., Huang, Y., Matevosian, R., McCullough, L. B., &
Larmon, B. et al. (2003). Full-scale high fidelity human patient simulation vs.
problem based learning: Comparing two interactive educational modalities. Acad
Emerg Med, 10(5), 489.
Cruetz, C. E. (2006). Introduction to medical pharmacology - 2006 - 2007. Retrieved
5/31, 2006 from http://www.meded.virginia.edu/public/CourseSitesDocs/Pharmacology/coursedocs/unrestricted/pdf/
CourseIntroductionwocover.pdf
Derossis, A. M., Bothwell, J., Sigman, H. H., & Fried, G. M. (1998). The effect of
practice on performance in a laparoscopic simulator. Surgical Endoscopy, 12, 11171118, 1119, 1200.
Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional
competence. Journal of the American Medical Association, 287(2), 226-227, 228,
229, 230, 231, 232, 233, 234, 235.
Fried, M. P., Satava, R., Weghorst, S., Gallagher, A. G., Sasaki, C., & Ross, D. et al.
(2004). Identifying and reducing errors with surgical simulation. Qual Saf Health
Care, 13(Suppl 1), i19-i26.
Gaba, D. M. (2000). Anaesthesiology as a model for patient safety in health care. British
Medical Journal, 320(7237), 785-788.
HPS in Medical Education 67
Gaba, D. M., Howard, S. K., Fish, K. J., Smith, B. E., & Sowb, Y. A. (2001). Simulationbased training in anesthesia crisis resource management (ACRM): A decade of
experience. Simulation and Gaming, 32(2), 175-193.
Gordon, J. A., Wilkerson, W. M., Shaffer, D. W., & Armstrong, E. G. (2001). (2001).
practicing medicine without risk: Students' and educators’ responses to high-fidelity
patient simulation. Academic Medicine, 76(5), 469-470.
Jackson, J. (2005). Teaching with multimedia. Retrieved 5/31, 2006 from
http://www.healthsystem.virginia.edu/internet/ome/edtech/teachingWmultimedia.cf
m
Jansen, J., Berden, H., van der Vleuten, C., Grol, R., Rethans, J., & Verhoeff, C. (1997).
Evaluation of cardiopulmonary resuscitation skills of general practitioners using
different scoring methods. Resuscitation, 34, 35-36, 37, 38, 39, 40, 41.
Jha, A. K., Duncan, B. W., & Bates, D. W. (2001). Making health care safer (Evidence
Report/Technology Assessment No. 43). Rockville, MD: Agency for Healthcare
Research and Quality. (patient safety and simulation) Retrieved January 25, 2006,
from google database.
Jonassen, D. H., & McAleese, T. M. R. (Undated). A manifesto for a constructivist
approach to technology in higher education. Retrieved 5/30, 2006 from
http://apu.gcal.ac.uk/clti/papers/TMPaper11.html
Jones, A., Forrest, F. & Glavin, R. (2005). An international survey of simulation centres.,
January 25, 2006 from http://www.anestech.org/publications/imms_2002/Jones.html
Kaufman, D. M. (2003). Applying educational theory in practice. British Medical
Journal, 326, 213-214,215,216.
Kell, S. O., Kirk, M. A., Rowden, A. K., Holstege, C. P., & Asarkaya, Y. (2005). Effects
on learning using human patient simulation in teaching pharmacology principles.
Clinical Toxicology, 43(6), 700.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a
safer health system. Washington, D. C.: National Academy Press.
Landauer, T. K. (1995). The trouble with computers. Cambridge, MA: MIT Press.
Luck, J., Peabody, J. W., Dresselhaus, T. R., Lee, M., & Glassman, P. (2000). How well
does chart abstraction measure quality? A prospective comparison of standardized
HPS in Medical Education 68
patients with the medical record. American Journal of Medicine, 108(8), 642-643,
644, 645, 646, 647, 648, 649.
Mayer, R. E. (Ed.). (2005). The cambridge handbook of multimedia learning. New York
City, New York: Cambridge University Press.
McIndoe, A., & Jones, A. (2005). Bristol medical SimulationCentre. Retrieved 4/28,
2006 from http://www.bris.ac.uk/Depts/BMSC/
Mergel, B. (2001). Instructional design and learning theory. Retrieved 5/30, 2006 from
http://www.usask.ca/education/coursework/802papers/mergel/brenda.htm
Miller, G. E. (1990). The assessment of clinical skills/competence/performance.
Academic Medicine, 65(S), 63-68.
Morgan, P. J., Cleave-Hogg, D., McIlroy J., & Devitt, J. H. (2002). Simulation
technology: A comparison of experiential and visual learning for undergraduate
medical students. Anesthesiology, 96(1), 10-16.
Pavio, A. (1986). Mental representations; A dual coding approach. Oxford, UK: Oxford
University Press.
Peugnet, F., Dubois, P., & Rouland, J. F. (1998). Virtual reality versus conventional
training in retinal photocoagulation: A first clinical assessment.. Computer
Aided Surgery, 3(1), 20-21, 22, 23, 24, 25, 26.
Salomon, G. (2000). It's not just the tool, but the educational rationale that counts. EDMEDIA 2000WORLD CONFERENCE ON EDUCATIONAL
MULTIMEDIA,HYPERMEDIA & TELECOMMUNICATIONS, Montreal,
Canada.from http://construct.haifa.ac.il/~gsalomon/new/
Schwid, H. A., Rooke, G. A., Michalowski, P., & Ross, B. K. (2001). Screen-based
anesthesia simulation with debriefing improves performance in a mennequin-based
anesthesia simulator. Teach Learn Med, 13(2), 92-93, 94, 95, 96.
Sica, G. T., Barron, D. M., Blum, R., Frenna, T. H., & Raemer, D. B. (1999).
Computerized realistic simulation; A teaching module for crisis management in
radiology. AJR Am J Roetgenol, 172(2), 301-302, 303.
Surry, D. W., & Ensminger, D. (2001). What’s wrong with media comparison studies?
Educational Technology, 41(4), 32-35.
HPS in Medical Education 69
Sweller, J., van Merrienboer, J. G., & Paas, G. G. W. C. (1998). Cognitive architecture
and instructional design. Educational Psychological Review, 10, 251-252-296.
Tan, G. M., Ti, L. K., Suresh, S., Ho, B. S., & Lee, T. L. (2002). Teaching first-year
medical students physiology: Does the human patient simulator allow for more
effective teaching? Singopore Med J, 43(5), 238-242.
Tuggy, M. L. (1998). Virtual reality flexible sigmoidoscopy simulator training: Impact on
resident performance. Journal of the American Board of Family Practice, 11, 426427,428,429,430,431,432,433.
Van Merriënboer, J. J. G., Kirschner, P. A., & Kester, L. (2003). Taking the load of a
learners' mind: Instructional design for complex learning. Educational Psychologist,
38(1), 5-6,7,8,9,10,11,12,13.
Vu, N. V., & Barrows, H. S. (1994). Use of standardized patients in clinical assessments:
Recent developments and measurement findings. Educational Researcher, 23(3), 2324, 25, 26, 27,28, 29, 30.
Wang, E. E., & vozenilek, J. (2005). Addressing the systems-based practice core
competency: A simulation-based curriculum.. Academic Emergency Medicine,
12(12), 1191-1192,1193,1194.
Wong, A. K. (2004). Full scale computer simulators in anesthesia training and evaluation.
General Anesthesia, 51(5), 455-464.
Ziv, A., Small, S. D., & Wolpe, P. R. (2000). Patient safety and simulation-based medical
education. Medical Teacher, 22(5), 489-491.
HPS in Medical Education 70
APPENDIX A
Interview questions:
1. How was your attention level different in the lecture and simulator-based learning
experiences?
2. Describe your feelings towards each teaching method.
3. How did the two teaching methods, lecture and simulator-based, effect your
learning of the subject matter?
4. Why did the method work well in increasing your knowledge?
5. How did the two teaching methods, lecture and simulator-based, effect your
retention of the subject matter?
6. Why did the method work well in increasing your retention of knowledge?
7. How did the two teaching methods, lecture and simulator-based, effect your
clinical readiness pertaining to the subject matter?
8. Why did the method work well in increasing your clinical readiness pertaining to
the subject matter?
9. Why do you prefer one method of learning more the other?
10. What makes one method more effective than the other?
11. What are your recommendations for teaching this subject matter based on your
experiences in this study?
12. If you were responsible for teaching these subjects how would you present the
subject matter?
HPS in Medical Education 71
APPENDIX B
February 17, 2006
Sue Kell
John Bunch
Blue Ridge Poison Center
PO Box 800774
Dear Sue Kell and John Bunch:
Thank you for submitting your project entitled: "Students Response to
Learning with Human Patient Simulation in Teaching Pharmacology
Principles" for review by the Institutional Review Board for the Social
& Behavioral Sciences. The Board reviewed your Protocol on February
17, 2006.
The first action that the Board takes with a new project is to decide
whether the project is exempt from a more detailed review by the Board
because the project may fall into one of the categories of research
described as "exempt" in the Code of Federal Regulations.
Since the Review Board, and not individual researchers, is authorized
to classify a project as exempt, we requested that you submit the
materials describing your project so that we could make this initial
decision.
As a result of this request, we have reviewed your project and
classified it as exempt from further review by the Board. This means
that you may conduct the study as planned and we recommend that you not
use the Consent Form.
This project # 2006-0055-00 has been exempt for the period February 17,
2006 to February 16, 2007. If the study continues beyond the approval
period, you will need to submit a continuation request to the Review
Board. If you make changes in the study, you will need to notify the
Board of the changes.
Sincerely,
Pryor Hale, Ph.D.
Chair, Institutional Review Board for the Social and Behavioral
Sciences
HPS in Medical Education 72
In reply, please refer to: Project # 2006-0098-00
July 6, 2006
Sue Kell
John Bunch
Blue Ridge Poison Center
1222 Jefferson Park Ave., Room 4606
Charlottesville, VA 22901
Dear Sue Kell and John Bunch:
Thank you for submitting the modification to your project entitled: "Comparison of Patient
Evaluation and Treatment of Venomous Snakebites by Residents taught with Human Patient
Simulation and Lecture Educational Formats" for review by the Institutional Review Board for the
Social & Behavioral Sciences. The Board reviewed your Protocol on July 6, 2006.
The first action that the Board takes with a new project is to decide whether the project is exempt
from a more detailed review by the Board because the project may fall into one of the categories
of research described as "exempt" in the Code of Federal Regulations.
Since the Board, and not individual researchers, is authorized to classify a project as exempt, we
requested that you submit the materials describing your project so that we could make this initial
decision. As a result of this request, we have reviewed your project and classified it as exempt.
This project # 2006-0098-00 has been exempt for the period July 6, 2006 to April 9, 2010. If the
study continues beyond the approval period, you will need to submit a continuation request to the
Board. If you make changes in the study, you will need to notify the Board of the changes.
Sincerely,
Pryor Hale, Ph.D.
Chair, Institutional Review Board for the Social and Behavioral Sciences
HPS in Medical Education 73
APPENDIX C
Promotional Flyer
HPS in Medical Education 74
APPENDIX D
***Original signed letter and stamped consent forms will be sent through messenger mail***
In reply, please refer to: Project # 2004-0408-00
January 26, 2005
Sue Kell
Mable Kinzie
Blue Ridge Poison Center
P. O. Box 800774
Dear Sue Kell and Mable Kinzie:
The Institutional Review Board for the Behavioral Sciences has approved your revisions
submitted on January 26, 2005 for the research project entitled "Comparison of knowledge and
retention of pharmacological principles in students receiving human patient simulation and lecture
teaching formats." You may proceed with this study. Please use the enclosed Consent Form(s)
as the master for copying forms for participants.
This project # 2004-0408-00 has been approved for the period January 26, 2005 to
January 11, 2006. If the study continues beyond the approval period, you will need to submit a
continuation request to the Review Board. If you make changes in the study, you will need to
notify the Board of the changes.
Sincerely,
Luke Kelly, Ph.D.
Chair, Institutional Review Board for the Social & Behavioral Sciences
HPS in Medical Education 75
APPENDIX E
Pharmacological Principles
HPS scenario
Learning objectives
 The student will understand routes of exposure
 The student will understand the life of a drug: absorption, distribution,
target organ effect, metabolism and elimination.
 The student will be familiar with dose response
 The student will be familiar with drug interactions
Scenario algorithm
Pharmacological Principles
Route of exposure
Administer IV med/aerosol
medication
(Medicine X)
Baseline
Baseline HR and BP rise over 60 seconds to a
peak level of 180 and 220/110 then dissipate over
next 2 minutes
Dose-Response
Administer incremental doses of
epi to observe HR and BP
Baseline HR and BP rise by an increment over 5
doses to a peak level of 180 and 220/110.
Instructor will give a final dose that causes severe
toxic effects?
Dose-Response
Administer incremental doses of
morphine and observe RR and
mental status
Baseline RR and mental status will slow by an
increment over 5 doses to a level of 2 breaths per
minute and mental status of coma. The instructor
will give a final dose that causes severe toxic
effects?
Drug interactions
Administer morphine then valium
Drug interactions
Administer morphine then narcan
Baseline RR and mental status will slow
with initial dose and will double in effect
with dose of valium. Endpoint will be RR 2
and Coma.
Baseline RR and mental status will slow to
RR 2 and coma with initial dose and return
to baseline with dose of narcan.
HPS in Medical Education 76
Physiological programmable factors
Rewrite in simulator understandable terminology
State
Clinical
parameter
Physiology/pathology Simulator
Terminology
Col 5
Equipment Needed
ECS
Student supplies: Worksheets, Stopwatch
IV supplies: IV catheters (22 gauge), tubing, solution, syringes (TB), and tape
Medications: TB syringes, saline for injection, 22 gauge needles, empty vial of
epinephrine, morphine, narcan, valium, aerosol respiratory care machine?, spray
bottle of cleaning agent?
Other supplies: stethoscope, BP cuff,
HPS in Medical Education 77
Session Overview
6 students per session
2: observers
2: administer agents thru IV (already established)
2: record information on worksheet
Scenario
A volunteer has agreed to participate in our experiment. He is a healthy 30 year
old man. We have taken all precautions not to harm him.
Observe normal function as introduction to simulator
 Eyes
 Monitor for HR and BP, have students feel for pulse
 Count respirations or show RR on monitor
 Listening to lung sounds
 Skin
 Secretions
 Copy of normal labs with normal ranges (basic metabolic panel)
 Neurological exam: eyes open, for this exercise describe how he would
interact or could we use remote microphone?
Instructions to students:
I will guide you through the experiment. We will not be harming him.
Use worksheet to guide the observations you need.
Think out loud and work as a group.
Discuss routes of entry of drugs into body and ADTME
 After baseline observations
 Administer epi through IV (call it drug A since we are accelerating the true
effects) allow it to peak at 60 seconds then subside over next 2 minutes.
 Administer spray (aerosol or cleaning agent) and observe effects rapidly
occur, peak then subside.
 Make observations on worksheet every 30 seconds
Discuss dose response
 After baseline observations
 Administer epi through IV.
 Make observations on worksheet for HR and BP
 Repeat dose and make observations (mild-moderate) break into 5
increments to make the point of incremental effects
 Instructor now takes over and administers toxic dose
HPS in Medical Education 78





After baseline observations
Administer morphine through IV.
Make observations on worksheet for respiratory rate and mental status
Repeat dose and make observations (mild-moderate)
Instructor now takes over and administers toxic dose
Discuss drug interactions
 After baseline observations
 Administer morphine through IV.
 Make observations on worksheet for respiratory rate and mental status
 Administer a dose of valium make observations (moderate)




After baseline observations
Administer morphine through IV.
Make observations on worksheet for respiratory rate and mental status
Administer a dose of narcan and make observations
HPS in Medical Education 79
Student worksheet
Route of exposure and ADME
Drug:_________________________________________
Dose:___________
Route of exposure: _____________________
Record observed responses:
Baseline 30 sec
60 sec
90 sec
120 sec
180 sec
Heart
rate
Blood
pressure
Dose Response
Drug:_________________________________________
Route of exposure: _____________________
Record observed responses:
Baseline Dose 1 Dose 2
Dose 3
Dose 4
Dose 5
Heart
rate
Blood
pressure
Drug:_________________________________________
Route of exposure: _____________________
Record observed responses:
Baseline Dose 1 Dose 2
Resp
rate
Mental
status
Dose 3
Dose 4
Dose 5
HPS in Medical Education 80
Drug interactions
PART 1
Drug 1:_________________________________________
Dose:___________
Route: _____________________
Drug 2:_________________________________________
Dose:___________
Route: _____________________
Record observed responses:
Baseline
Drug 1
Drug 2
Resp rate
Mental status
PART 2
Drug 1:_________________________________________
Dose:___________
Route: _____________________
Drug 2:_________________________________________
Dose:___________
Route: _____________________
Record observed responses:
Baseline
Resp rate
Mental status
Drug 1
Drug 2
HPS in Medical Education 81
APPENDIX F
Rattlesnake envenomation simulation
Case: You are with the Wintergreen rescue squad as they arrive on the scene of a “snake
bite.” The patient is a 21 year old male who was hiking when he was bitten on the left
index finger by a snake after he tried to pick it up. He complains of severe pain at the
site.
Pre-hospital: Major goals here are: 1. rapid transport to hospital 2. immobilization in
functional position. Wound clensing is acceptable. “Zero points” for incision, sucking,
tourniquet, hot/cold therapy. ABCD evaluation is normal except for some tachycardia
secondary to pain. Physical exam shows fang marks but is otherwise normal. There is a
ring on one of the fingers and a watch which should both be removed. Establishing IV
access and putting patient on oxygen are good form here.
History for pre-hospital and initial-presentation states:
pain – yes, severe in finger and hand.
trouble breathing – no.
confusion – no.
nausea – a little because it hurts so badly.
vomiting – no.
metallic taste in mouth – yes.
perioral paresthesia – not really.
tingling in arms or leg – feels like I have worms under my skin.
have you been bitten by a snake before – yes but I didn’t go to the doctor.
Snake description:
what kind of snake was it – copperhead.
head – big triangle.
eye – slanted.
PHM: obesity, asthma
Meds: None
All: pcn, ees  rash
SH: tobacco, alcohol
Initial-presentation: Patient has normal VS except for some tachycardia secondary to
pain. ABCD intact. The patient is not that sick at this point, but there are many critical
actions that are expected: 1. good history 2. snake identification 3. appropriate limb
measurements and neurovascular check 4. analgesia 5. ordering of appropriate labs (cbc,
coags, bmp, ck, fibrinogen). 6. establishment of IV access and possibly beginning some
fluids. 7. tetanus.
**8. Key here is to use this information to decide if the patient needs CroFab. It can
either be initiated at this time or the scenario can involve transfer to a tertiary care
hospital depending on how the moderator sets up the case.
Limb measurements:
HPS in Medical Education 82
Transfer: Patient is still doing pretty well. His blood pressure has dropped a little bit
unless the participants have been aggressive with fluids. The key here is reassessment
either at the new hospital or after time has passed if patient is at the same hospital. Labs
return showing coagulopathy and thrombocytopenia but there is no active bleeding.
ABCD intact. Critical actions are: 1. measurement of limb 2. analysis of labs (blood
products not needed, CroFab is needed) 3. analgesia **4. participants must initiate
CroFab at this point. Ideally they would have an epi drip, full monitoring, and
resuscitation meds at bedside.
Limb measurements: increase by 3cm distal, 2cm middle, 2cm proximal
Anaphylactoid-moderate: The RN boluses the CroFab too quickly. Patient develops
pruritis, urticaria, shortness of breath, and garbled speech. Tachycardia worsens but there
is no hypotension. Exam reveals moderately swollen tongue and wheezing. Critical
actions: 1. Stop CroFab infusion 2. Diphenhydramine, famotidine, methylprednisone,
IVFs. If these are all initiated rapidly, the patient can go to the recovery state. If
something is left out, patient progresses to anaphylactoid-severe.
Anaphylactoid-severe: Patient is critically ill with hypotension and airway problems.
Critical action is 1. epinephrine drip. If this is done rapidly, the patient goes to recovery
and the airway issue resolves. If not, the patient requires intubation.
Hypotension: The patient becomes hypotensive secondary mostly to capillary leak and
third spacing. The SVR and venous return are decreased and there is mild decrease in
contractility. Fluid resuscitation should resolve this issue but a pressor such as dopamine
or norepinephrine is reasonable. If CroFab is not running, do not put fluids or pressors
into the computer. Critical actions: 1. CroFab 2. IVFs.
Recovery: Go to this state when moderator is pleased with the amount of CroFab and
fluid resuscitation. Critical actions: 1. reassess limb 2. disposition to an ICU.
Limb measurements:
 Prophylactic antibiotics are not necessary but are also not unreasonable.
 Hand xrays are not necessary but are available if asked for.
 Other states could be:
o Altered mental status.
o Active bleeding.
o ARDS.
 Orthopedics can consult for concern of compartment syndrome.
 Telemedicine: Mike Patterson.
HPS in Medical Education 83
APPENDIX G
Curriculum for Snakebites
Curriculum for snakebite lecture and simulation






Characteristics of snake bite victims
Venom components
o mechanism of action
o pathophysiology
First aid measures
o Actions to avoid
Acute hospital management
o History
o Physical exam
 General exam
 Affected limb
 How to take and record measurements
o Expected Complications to evaluate for
o Causes of death
Immediate actions
o Life-saving interventions
o Antivenin administration
 Indications
 Contraindications
 Preparation and administration
 Dosing
 Adverse effects
Consultation, Disposition and additional care (treating infection)
HPS in Medical Education 84
APPENDIX H
Patient Chart:
Patient Name: Jessie Shorts________________________________________________
Chief Complaint: snakebite on L finger________________________________________
VS: BP 100/60 P: 100 T: 37.7
RR: 20 SaO2: 100%
Present Illness:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Past Medical History:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Physical Exam:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
HPS in Medical Education 85
Diagnostics:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Assessment Plan and Written Report:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Actions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
HPS in Medical Education 86
APPENDIX I
Pre-test
Pharmacology Principles Examination
1. Compared to oral administration of capsules, which of the following strategies would
decrease first-pass hepatic metabolism of a drug to the greatest extent?
A.
B.
C.
D.
E.
The use of timed-release preparations
Intravenous administration
The use of enteric-coated tablets
Rectal administration
The use of liquid formulations
2. This question refers to the graph below. T is the time of administration of a drug.
What interval is represented for:
Time to peak effect
Maximum therapeutic
effect
Intensity
Of Effect
Minimum detectable
effect
T
U
V
W
X
Y
Z
Time
A.
B.
C.
D.
E.
F.
T to U
T to V
T to W
T to Z
U to Y
U to Z
3. The process by which the amount of drug in the body is reduced after administration
but before entering the systemic circulation is called
A. excretion
B. first-pass effect
C. first-order elimination
D. metabolism
E. pharmacokinetics
HPS in Medical Education 87
4. Giving a drug intravenously eliminates the need for:
A.
B.
C.
D.
Absorption
Distribution
Metabolism
Excretion
5. You have diagnosed asthma in a 19 year old patient with recurrent episodic attacks of
bronchospasm with wheezing. Avoidance of allergens has been tried unsuccessfully. She
is to receive therapy with several drugs. You are concerned that drug interactions may
cause changes in drug metabolism for this patient. Drug metabolism usually results in a
product that is
A.
B.
C.
D.
E.
More likely to distribute intracellularly
Less lipid soluble than the original drug
More likely to be reabsorbed by kidney tubules
More lipid soluble that the original drug
More likely to produce adverse effects
6. You decide to give an intravenous dose of a medication to a patient before transferring
him to the ICU. You draw the medication into the syringe and you are ready to inject.
What should you double check before injecting the medication?
A.
B.
C.
D.
E.
How many milligrams of drug per milliliter of solution
Name of medication on vial that drug was drawn from
Patient’s name on identification bracelet
How rapidly it can safely be pushed intravenously
All of the above
7. Full activation of the sympathetic nervous system, as occurs in maximal exercise, can
produce all of the following responses EXCEPT
A.
B.
C.
D.
E.
Bronchodilation
Decreased intestinal motility
Increased renal blood flow
Mydriasis
Increased heart rate (tachycardia)
8. A young male patient is brought to the emergency room of a hospital suffering from
an overdose of cocaine after its intravenous administration. His symptoms are
UNLIKELY to include:
A. Agitation
B. Bradycardia
C. Hyperthermia
D. Myocardial infarction
E. Seizures
HPS in Medical Education 88
9. A crop duster pilot has been accidentally exposed to a high concentration of an
agricultural organophosphate insecticide. If untreated, the cause of death from such a
poisoning would probably be:
A.
B.
C.
D.
E.
Cardiac arrhythmia
Gastrointestinal bleeding
Heart failure
Hypertension
Respiratory failure
10. Acetylcholine causes:
A.
B.
C.
D.
pinpoint pupils
paranoid aggression
dry mouth and armpits
fast heart rate
11. Fentanyl patches contain opioids that are used to provide analgesia. The most
dangerous adverse effect of this mode of administration is:
A. Cutaneous reaction
B. Diarrhea
C. Hypertension
D. Muscle weakness
E. Respiratory depression
12. A patient presents with low respiration rate, a falling oxygen saturation level and
altered mental status. Which of the following is a possible cause of these symptoms?
A. Allergic Reaction
B. Cocaine Overdose
C. Pesticide poisoning
D. Heroin overdose
13. A 42 year old homemaker suffers from anxiety with phobic symptoms and occasional
panic attacks. She uses over-the-counter antihistamines for allergies and drinks 1-2
glasses of wine with dinner. Alprazolam (benzodiazepine) is prescribed. After several
days of use, her family is noticing that her speech is slurred in the evenings and she
stumbles when she walks. Which of the following statements about the use of
alprazolam in this patient is TRUE?
A. She is most likely abusing other drugs
B. This reaction is not likely drug related
C. Antihistamines should counteract any CNS depression effects from the
alprazolam
D. Additive CNS depression will occur with ethanol and with over-the-counter
antihistamines.
E. Alprazolam’s effects can be reversed with naloxone
HPS in Medical Education 89
14.
A
Intensity
Of Effect
Dose
A drug is administered to a patient and the effect recorded. A second drug is then given
and the effects recorded. The arrow marked A demonstrates:
A.
B.
C.
D.
E.
Additive effect on a drug’s action
Adverse drug reaction
Agonist effect on a drug’s action
Antagonist effects on a drug’s action
Partial agonist effect on a drug’s action
15. An unconscious patient is given naloxone and dramatically awakens. 30 minutes
later the patient is once again comatose. Which of the following best explains this
observation?
A.
B.
C.
D.
E.
Naloxone is a competitive agonist
Opioids are metabolized more rapidly than naloxone and have worn off
The competitive effects of naloxone do not last as long as the opioid
Naloxone is not specific for opioids
The patient must have taken another opioid overdose
16. Which of the following terms best describes a drug that reversibly blocks the action
of epinephrine at its receptors by occupying those receptors without activation?
A.
B.
C.
D.
E.
Partial agonist
Noncompetitive agonist
Physiological antagonist
Competitive antagonist
Chemical antagonist
HPS in Medical Education 90
17. A heroin addict comes to the emergency department in an anxious and agitated state.
He complains of vomiting, sweating and fever. His heart rate and breathing are fast. His
pupils are dilated. He claims to have had a “fix” approximately 12 hours ago. What is
the most likely cause of these signs and symptoms?
The patient has overdosed with an opioid
These are early signs of the toxicity of MPTP, a contaminant in “street heroin”
The patient likely overdosed on cocaine
The signs and symptoms are those of withdrawal syndrome
This is an expected additive effect of opioids and benzodiazepines
18. Which of the following drugs will be most effective in alleviating the symptoms of
opioid withdrawal?
A.
B.
C.
D.
E.
Acetaminophen
Diazepam (valium)
Methadone
Naloxone
Epinephrine
19. A 3 year old child has been admitted to the emergency department with a suspected
drug overdose. He has increased heart rate, dilated pupils and dry skin and mucous
membranes. Which of the following is most likely to have caused his condition?
A.
B.
C.
D.
E.
Pesticide poisoning
Atropine poisoning
Narcotic poisoning
Cocaine poisoning
Valium poisoning
20. A man ingests a substance that causes pinpoint pupils, drooling, eye tearing, and
decreased heart rate. The most likely substance that he ingested was?
A.
B.
C.
D.
Malathion pesticide
Crack cocaine
Ethanol
Amphetamines
HPS in Medical Education 91
APPENDIX J
SUE KELL, M. ED., CSPI
EDUCATION
2003–
UNIVERSITY OF VIRGINIA
PhD Student, Instructional Technology
1995–2003
UNIVERSITY OF VIRGINIA
M. Ed.., Instructional Technology
1977–1979
UNIVERSITY OF VIRGINIA
BS Ed, Speech Pathology and Audiology
1975–1976
LYNCHBURG COLLEGE
VA
Early Childhood Education
1973–1975
GUILFORD COLLEGE
Liberal Arts
Charlottesville, VA
Charlottesville, VA
Charlottesville, VA
Lynchburg,
Greensboro, NC
CURRENT POSSITIONS
Education Director, Blue Ridge Poison Center
American Association of Poison Control Centers’ (AAPCC) Board
of Directors
AAPCC Research Awards Committee Liaison
AAPCC Public Education Committee Liaison
AAPCC Board Liaison to 5 New York Poison Centers
SERVICE TO AAPCC
Member 25 years
CSPI 20 years, Educator 8 years
Contributor, Poison Line, FYI
AAPCC Scientific Review Committee member
AAPCC Research Awards Committee member, 2002-2004
PEC Steering Subcommittee, 2000-2004
PEC Educators’ Archive Subcommittee, Co-Chair, 2002-2004
PEC Publisher and Contributor Educator’s Antidote, 1998-2002
PEC Nominations Subcommittee, 1999-2002
PEC Listserv Liason, 2000-2002
PEC Poison Prevention Campaign Subcommittee, 1999-2001
PEC Mentor Subcommittee member, 2000-2004
HPS in Medical Education 92
PROFESSIONAL ABSTRACTS
Kell, SO, Spyker, DA. Hymenoptera Stings. International Congress of
Clinical Toxicology. Salt Lake City, UT, 1981.
Kell SO, Rosenberg SA, Conlon TJ, Spyker DA. A peek at poke:
Mitogenicity and epidemiology. International Congress of Clinical
Toxicology. Snowmass, CO, 1982.
Spyker DA, Kell SO, Sauer K, Guerrant RL. A castor bean poisoning and a
widely available bioassay for ricin. International Congress of Clinical
Toxicology. Snowmass, CO, 1982.
Collins HL, Kell SO, Walsh WM, Spyker DA. Mark-Sense versus direct
data entry for the AAPCC standard data form. AACT/AAPCC/ABMT
Annual Scientific Meeting. Boston, MA, 1983.
Vernberg DD, Kell SO, Collins HL, Spyker DA. Results of a primary
poison prevention program in Virginia. AACT/AAPCC/ABMT Annual
Scientific Meeting. Boston, MA, 1983.
Kell SO, Oneida B, Thompson J, Holstege C. Intranet System: A Valuable
Tool. AACT/AAPCC/ABMT Annual Scientific Meeting. Tucson, AZ,
2000.
Kell SO, Holstege C, Thompson, J. Current Ipecac Recommendations,
What Does It Mean For Future National Materials?
AACT/AAPCC/ABMT Annual Scientific Meeting. Montreal, CA, 2001.
Kell S, Dagenais J, Farrar R, Holstege C. Time Saving Archive for
Educators. International Congress of Clinical Toxicology. Seattle, WA,
2003.
Kell SO, Waring E, Soloway RA. Train the Trainer Programs Increase
Public Education Outreach. International Congress of Clinical Toxicology.
Seattle, WA, 2004.
Kirk MA, Kell S, Dobmeier S, Baer A, Holstege CH, Huff S, Jackson J.
Using New Technologies for Medical Toxicology Education. International
Congress of Clinical Toxicology. Seattle, WA, 2004.
Kirk MA, Kell S, Littlewood K, Eldridge D, Shukla A. Teaching
Toxicology Concepts Using Human Patient Simulation. International
Congress of Clinical Toxicology. Seattle, WA, 2004.
HPS in Medical Education 93
ARTICLES
Kell SO. Top 10 Reasons to Re-evaluate Penetrance. Poison Line.
Volume 20, No 12, December 2002.
Kell SO. Certification Testing for SPI’s. Poison Line. Volume
21, No 1, December 2002.
NATIONAL PRESENTATIONS






Presenter, HRSA-MCHB Stakeholders Meeting Webcast,
Education Outreach, June 2004
Presenter, HRSA-MCHB Webcast, Online Research, June
2003
Presenter, Bites and Stings, PEC Pre-conference, 2002
Presenter, Bites and Stings, PEC Conference, 2001
Presenter, Top 10 Toxins, PEC Conference, 2000
Poster, Bites and Stings, PEC Conference, 1999
FAX (434) 982-3158 • SOK@VIRGINIA.EDU
BLUE RIDGE POISON CENTER• CHARLOTTESVILLE, VA 22908-0774• PHONE (434) 982-3158
HPS in Medical Education 94
APPENDIX K
Faculty Observation
Faculty Observation – History
o Rapidly assesses patient status (stable or unstable)
o Assesses quality of pain
o Assesses where is pain now
o Assesses time of bite
o Assesses progression of pain and swelling
o Assesses nausea, vomiting
o Assesses dizziness, metallic taste in mouth, twitching muscles
o Assesses first aid administered
o Assesses attempts to identify snake
o Assesses history of allergic reactions (medications, animals or other) or
asthma
o Assesses bleeding problems (surgery, trauma or anemias)
o Assesses medication history (ASA, blood thinners)
Comments
Faculty Observation - Physical exam
o
o
o
o
o
o
o
o
o
o
o
Performs complete physical exam
Evaluates presence of fang marks
Evaluates swelling
Evaluates bleeding from bite site
Evaluates pain and tenderness
Evaluates tense compartment
Evaluates pain with passive stretch of distal extremity
Evaluates palpable lymph nodes and tenderness
Compares affected limb with other side
Measures near bite site
Measures multiple sites
Comments
Actions
o
o
o
o
o
o
Manages pain by application of splint
Manages pain by elevation
Recognizes indications for antivenin administration
Recommends antivenin to patient
Describes to the patient the possible adverse effects of the antivenin
Recognizes that this is an infection prone wound and orders antibiotics
and tetanus
o Marks site of measurements accurately for consistent repeated
measurements
HPS in Medical Education 95
o Tells patient medication will be ordered to relieve pain
Comments
HPS in Medical Education 96
APPENDIX L
Participant__
Snakebite Treatment Research Study
Prior Experience Checklist:
I am a:
Fourth year medical student
Intern
First year resident
Second year resident
I have observed or treated a victim of a venomous snakebite
I have attended an education program in medical school on treatment of snakebites
I have had previous EMT training or experience
I have had previous military training or experience
I have had other previous educational experiences with snakebites
(please explain)_____________________________________________________
HPS in Medical Education 97
APPENDIX M
Snake pretest/posttest
Draft: 27 June 2006
1. Envenomations by which of the following snakes is most likely to produce onset of
neurologic toxicity?
a) Cottonmouth (Agkistrodon piscivois)
b) Eastern diamondback rattlesnake (Crotalus adamanteus)
c) Sonoran coral snake (Micruroides euryoxanthus)
d) Eastern coral snake (Micrurus fulvius)
e) Timber rattlesnake (Crotalus horridus)
2. Which is the most appropriate treatment for severe coagulopathy without bleeding
following rattlesnake envenomation?
a) Cryoprecipitate
b) Antivenom
c) Fresh-frozen plasma
d) Plasmapheresis
e) Vitamin K
3. Which of the following is most appropriate in the prehospital management of North
American crotalinae envenomation?
a) Lymphatic constriction bandage
b) Venom extraction
c) Ice and elevation
d) Immobilization of envenomated extremity
e) Local wound incision and drainage
4. Which of the following is an indication for fasciotomy following rattlesnake
envenomation?
a) Muscular weakness
b) Severe Pain
c) Compartment pressure = 90 mm Hg
d) Extensive extremity swelling
e) Blue discoloration of digits
5. Which of the following is an indication for treatment with antivenin following
rattlesnake bite?
a) Pain
b) Presence of puncture wounds
c) Positive identification of snake as a rattlesnake
d) Paresthesias at bite site
e) Progressive extremity swelling
HPS in Medical Education 98
6. Which of the following is indicated in the routine management of a rattlesnake bite?
a) Tetanus prophylaxis
b) Antibiotics
c) Steroids
d) Antihistamines
e) Cryotherapy
7. Which of the following is TRUE regarding Crotalidae polyvalent immune Fab?
a) It is an equine-derived whole IgG antivenom
b) It prevents tissue necrosis
c) It limits progression of swelling
d) It does not produce hypersensitivity reactions
e) It is indicated in management of all North American elapid envenomations
8. A patient sustained a rattlesnake bite to his hand 1 hours ago. His hand is swollen to
the forearm and he is diaphoretic, pale, with a blood pressure of 60/40. All of the
following actions are indicated for rattlesnake venom-induced hypotension EXCEPT?
1. Administer whole blood for presumed severe anemia
2. If rapid onset (minutes) treat for anaphylaxis
3. Administer intravenous fluid boluses
4. Administer antivenin
5. Infuse vasopressors
indicate the patient has experienced a “dry bite”?
No edema or systemic signs after 8 hours
Locally limited edema
9. Which of the following is TRUE regarding copperheads?
1. Venom contains components similar to other Crotalidae
2. Is the most toxic pit viper in Virginia
3. Antivenin is not effective in treating the local venom effects
4. They are easily identified by their small copper colored head and rattle
5. Causes coagulopathy and thrombocytopenia in most cases
10. Which of the following is TRUE regarding Rattlesnake bite wounds?
1. Are more prone to infection after incision and oral suction
2. Have a high incidence of wound infection
3. Often require foreign body (broken fang) removal
4. Bleb formation requires aggressive debridement and early skin grafting
5. Oozing of blood from bite wound indicates systemic coagulopathy
HPS in Medical Education 99
11. Which of the following immediate actions is appropriate to take in the ED when
treating a rattlesnake envenomation?
1. Rapid assessment of severity of envenomation to determine need for antivenin
administration
2. Constricting band and ice to prevent spread of venom
3. Incision and manual extractor device to remove venom (snake bite kit)
4. Nonsteroidal anti-inflammatory drugs for pain and edema
5. Immediately administer the initial dose of antivenin regardless of severity
12. A patient sustaining a timber rattlesnake bite received 6 vials of CroFab on arrival.
He is reevaluated 6 hours after antivenin infused and his affected extremity is found to
have swelled an additional 1 cm at the bite site and at two points proximal to the bite. All
of the following are true regarding his recurrent swelling EXCEPT:
1. Recurrences do not typically involve coagulopathy
2. Because antivenin is cleared renally, one dose may be insufficient treatment
3. Recurrence occurs in over one quarter of patients
4. Retreatment with antivenin is recommended for recurrent effects of
envenomation
5. Scheduled retreatment is recommended for moderate/severe envenomation
13. Proper administration of CroFab requires which of the following?
1. Gentle agitate vials after instilling 10 cc of sterile water
2. Drop vials in warm water to accelerate reconstituting antivenin
3. Rapid intravenous administration to expedite antivenin delivery
4. Administered dose based on body weight (mg/kg)
5. Its safety eliminated the need for administration in monitored unit
14. Which of the following bedside evaluations and diagnostic tests are routinely helpful
in the determination of antivenin therapy?
1. Intramuscular compartment pressures
2. Serial extremity measurements
3. Platelet count
4. Prothrombin time
5. Fibrinogen
15. Which of the following findings would cause you to suspect DIC following
rattlesnake bite?
1. Infracted kidney
2. Platlets = 5000/mm3
3. Elevated fibrin degradation products
4. Prothrombin time > 100 sec
5. Hemorrhagic bullae and oozing of blood at the bite site
HPS in Medical Education 100
16. A patient with a severe rattlesnake bite had a 6 vial CroFab infusion initiated 5
minutes ago. He develops an urticarial rash and a blood pressure of 70 systolic.
Immediate actions to take include all of the following EXCEPT:
1. Abandon the use of antivenin no matter how severe the envenomation
2. Immediately stop the infusion
3. Administer H1 and H2 blockers
4. Check the rate of infusion
5. Administer intravenous epinephrine infusion and titrate to effect
HPS in Medical Education 101
APPENDIX N
Toxicology: Rating Scale for Post Encounter Exercise
2006
History: Content
5 - VERY GOOD. The patient history was recorded completely and accurately.
4 - GOOD. Most, but not all history was recorded. Most pertinent history was
recorded and few important items were excluded.
3 - FAIR. Some, but not all history was recorded. Some pertinent history was
recorded, but some important items were excluded.
2- POOR. Most history reported was inappropriate or irrelevant given the patient’s
complaint.
1– VERY POOR. Almost all history reported was inappropriate or irrelevant given
the patient’s complaint.
Physical Exam: Content
5 - VERY GOOD. All pertinent physical exam items specified in the case were
recorded.
4 - GOOD. Most, but not all pertinent physical exam items specified in the case were
recorded.
3 - FAIR. Some, but not all pertinent physical exam items specified in the case were
recorded
2- POOR. Few pertinent physical exam items specified in the case were recorded.
Most relevant items were excluded.
1 – VERY POOR. Mostly no pertinent physical exam items specified in the case were
recorded. All relevant items were excluded.
Diagnostics: Content
5 – VERY GOOD. All labs/tests/procedures requested are appropriate. The
selection is neither too broad nor too narrow.
4 – GOOD. Most labs/tests/procedures requested are appropriate.
3 - FAIR. Some labs/tests/procedures requested are appropriate.
2 - POOR. Few labs/tests/procedures requested are appropriate. At least one is
contraindicated or detrimental.
1 – VERY POOR. Almost no labs/tests/procedures requested are appropriate. More
than one is contraindicated or detrimental.
Assessment Plan and Written Report
5 - VERY GOOD. All recorded items are accurate and complete.
4 - GOOD. Most, but not all recorded items are accurate and complete.
3 - FAIR. Some, but not all recorded items are accurate and complete.
2 - POOR. Few items are accurate and complete.
1– VERY POOR Almost no recorded items are accurate and complete.
Actions
5 - VERY GOOD. All recorded actions are appropriate and reasonable given the
patient’s. All appropriate steps are included and none are excluded.
4 - GOOD. Most, but not all recorded actions are appropriate given the patient’s
complaint AND the differential diagnosis. Most appropriate steps are included and
none are excluded.
HPS in Medical Education 102
3 - FAIR. Some, but not all recorded actioins are appropriate given the patient’s
complaint AND the differential diagnosis. Some appropriate steps are included, but
some are excluded.
- POOR. Most recorded actions are inappropriate given the patient’s complaint.
Most appropriate steps are excluded.
1– VERY POOR. All recorded actions are inappropriate given the patient’s. All
appropriate steps are excluded.
HPS in Medical Education 103
APPENDIX O
Focus Group Discussion points:
1. 1. List three positive things about the education program you attended. (Notes: These
questions concern the classroom experience you had with Dr. Kirk (either lecture or
simulation))
2. List 3 negative things about the education program you attended.
3. How did your learning experience prepare you to succeed with the standardized
patient experience? What could have been done better?
4. What do you think are the best ways to prepare for live patient contact?
5. How well do you think you performed in treating the standardized patient? What
could you have done better? What did you do well?
6. How well do you think your medical school or residency experience is preparing you
to be successful in gaining the knowledge, skills and experience to be successful in
treating patients?
7. What teaching methods do you prefer and why?
8.
If you were responsible for teaching these subjects how would you present the
subject matter?
HPS in Medical Education 104
APPENDIX P
Global Assessment (GA)
1. Standardized patient was satisfied with this learner physician encounter.
( ) Yes ( ) No
History (Hx)
2. The learner asked me where the pain was initially and where it has spread.
()
Yes
()
No
3. The learner asked me to describe the intensity OR the quality of the pain.
()
Yes
()
No
4. The learner asked me to describe that time of bite, the progression of swelling ( )
and other symptoms.
Yes
()
No
5. The learner asked me if I experienced any other symptoms (nausea, vomiting, ( )
dizziness, metallic taste, twitching muscles, other.)
Yes
()
No
6. The learner asked me about any first aid that I administered before coming for ( )
help.
Yes
()
No
7. The learner asked me to describe the appearance of the snake.
()
Yes
()
No
8. The learner asked me if I had a history of allergies to medications, animals or
other substances.
()
Yes
()
No
9. The learner asked me if I had bleeding problems, GI bleeding recent trauma
or "blood thinning" medications.
()
Yes
()
No
Physical Exam (PE)
10. The learner looked closely at the wound.
()
Yes
()
No
11. The learner palpated around the wound and my squeezed forearm.
()
Yes
()
No
12. The learner measured my arm at several spots and also the unaffected arm. ( )
Yes
()
No
13. The learner palpated (pressed) my abdomen in at least ONE place.
()
Yes
()
No
14. The learner moved my hand and fingers up and down and had me make a
fist. (checked range of motion.)
()
Yes
()
No
Clinical Courtesy (CC)
15. The learner discussed with me what he/she thought might be causing my pain.
()
Yes
()
No
16. The learner introduced him/herself to me. (Notes: YES: If the learner tells you his/her last
name AT ANY TIME NO: If the learner only tells you (s)he: -is a medical learner -was told to come
and see you -doesn’t tell you anything about who they are. )
()
Yes
()
No
17. The learner washed hands BEFORE or AFTER doing the physical exam OR put on gloves before
the physical exam. (Notes: YES: You MUST SEE the learner actually wash their hands OR they
MUST put on gloves before doing the PX. NO: It is NOT good enough if the learner tells you they
washed their hands before they came in to see you NOR if they merely pantomime washing their
hands! )
()
Yes
()
No
18. The learner considered my comfort during the Physical exam. (Notes: YES: The learner did not
unduly hurt you/was not unnecessarily rough AND/OR apologized for hurting you and explained
why it was necessary to perform the maneuvers. NO: The learner was unnecessarily rough AND
offered no explanation OR continued in the same fashion even after you indicated that they were
hurting you. )
()
Yes
()
No
HPS in Medical Education 105
Patient Interaction (PI)
Poor - Excellent Scale
poor fair good very excellent
good
19. How was the learner's ability to speak to you in a direct manner about
the seriousness of your condition? (Notes: EXCELLENT: If the learner
actually tells you on their own (without any prompting) that your symptoms
are serious OR that you might need to have an operation OR that they
would like to do some more tests right away so that you as a patient have a
clear understanding of what might be wrong with you. There should be
some sense of immediacy about resolving your pain. GOOD: If you get
some sense of urgency in the manner of the learner even if they do NOT tell
you directly that you might need surgery, etc. FAIR: If the learner “beats
around the bush”, leaving you unsure about the diagnosis. POOR: If the
learner avoids telling you in any way how serious your condition is OR
reassures you by either sending you home with pain medication or telling
you to come in at a later date for further tests. )
()
()
()
()
()
20. How was the learner you just saw at demonstrating sensitivity
regarding your anxiety and physical complaints? (Notes: EXCELLENT: The
learner must verbally and non-verbally show you that he/she understands
how you must be feeling. The learner should try to appropriately reassure
you by his/her words and/or actions. FAIR: The learner ignores your
emotional state and just continues as if nothing were happening. POOR: If
the learner saddens/upsets you even more than you already are by the
manner in which they deal with you )
()
()
()
()
()
21. How well did the learner attend to treating your pain?
()
()
()
()
()
22. How was the learner's ability to speak with confidence about your
condition and the therapies recommended? What level of TRUST did you
have for the learner's knowledge and skills?
()
()
()
()
()
23. How clearly did the learner answer your questions regarding adverse
effects of the recommended therapy?
()
()
()
()
()
24. How was the learner you just saw at behaving warmly, but
professionally throughout the encounter? (Notes: Excellent: If the learner
can demonstrate genuine care and concern without losing their objectivity
and ability to deal with the medical aspects of your pain. Poor: The learner
should not remain cold and aloof, nor become overly informal and chummy.
Either extreme merits a "Poor.")
()
()
()
()
()
25. How was the learner you just saw at using words you can understand
when discussing your problem? (Notes: Excellent: If you understood all the
terms. Very Good: If only one term was unfamiliar to you. Good: If only
two terms were unfamiliar to you. Fair: If more than two terms were
unfamiliar to you. Poor: If pretty much everything the learner said to you
was in 'Medspeak")
()
()
(x)
()
()
26. How was the learner you just saw at treating you like you're on the
same level; never talking down to you or treating you like a child? (Notes:
Excellent: If you felt the learner treated you like an equal in your care,
concerns and treatment. Poor: If you felt the learner was generally
condescending through the encounter OR if you felt the learner was
lecturing you.)
()
()
()
()
()
27. How was the learner you just saw at encouraging you to ask questions
and never avoiding giving an answer? (Notes: Excellent: If the learner
specifically asks if you have questions-- and answers them directly or
promises to get the answer. Good: If the learner doesn't specifically ask
you if you have questions but gives you the impression that you could ask
questions and that you would get a direct answer. Poor: If the learner never
asks if you have any questions, gives you the impression of not being open
to questions OR avoids answers to anything you ask.)
()
()
(x)
()
()
Comments (Cmts)
28. Comments from the standardized patient regarding satisfaction with this learner
physician encounter. (Notes: Base your response on whether you would return to the
learner for additional care. Do not refer to the checklist items.)
HPS in Medical Education 106
APPENDIX Q
Researcher’s Observational Protocol
Participant:
Date and time:
Descriptive Notes:
a.
Patient Care that is compassionate, appropriate, and
effective for the treatment of health problems and the
promotion of health
b.
Medical Knowledge about established and evolving
biomedical sciences and application of this knowledge
to patient care
c.
Practice-Based Learning and Improvement
appraisal and assimilation of scientific evidence
d.
Interpersonal and Communication Skills effective
information exchange and teaming with patients, their
families, and other health professionals
e.
Professionalism, carrying out professional
responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population
f.
Systems-Based Practice, awareness of and
responsiveness to the larger context and system of
health care and the ability to effectively call on system
resources to provide care that is of optimal value
Reflective Notes:
HPS in Medical Education 107
APPENDIX R
JESSIE SHORTS
SP TRAINING MATERIALS
A. CASE SUMMARY
Jessie Shorts is a 21 year old male or female who was hiking on the
Spotswood trail in Shenandoah National. While climbing rocks, he/she
encountered a snake on a hand hold. He tried to move away but the snake
struck at him. He immediately felt a hot, piercing pain in his left index
finger. He noticed two small puncture wounds on his finger. The wounds
are bleeding and will not stop oozing. He tried to suck the poison from the
wound with his mouth then hiked 20 minutes down the path back to his car.
He drove 45 minutes to the ED. He now complains of severe (intense) pain
at the site and into his hand. He noticed swelling of his finger, hand and
wrist. He also noticed that the area around the bite wounds is turning blue.
He is nauseated and sweating.
Your challenge, as the standardized patient, is threefold:
1. To appropriately and accurately reveal the facts about Jessie
Shorts’ snakebite injury while faithfully reproducing the pain of a
timber rattlesnake throughout the encounter, especially during the
physical exam;
2. To observe the learner’s (this is the student MD) behavior while
you are performing this case; and
3. To accurately recall the learner’s behavior and accurately complete
the performance checklist which will partially determine the
learner’s grade on this clinical skills examination.
PRESENTATION/EMOTIONAL TONE
When the learner enters the room, you are sitting in a chair holding your arm
and rocking back and forth. You are in obvious pain, which shows on your
face. You are not moaning, but you are preoccupied with the pain. You are
cooperative, and answer all of the learner’s questions with short answers;
you cannot be drawn into a lengthy conversation because of the severity of
the pain. It should be apparent to the learner that you are concerned; you
HPS in Medical Education 108
verbally relay your anxieties because you are worried about the possibility
dying from a snake bite.
When the learner asks why you have come to the Emergency Room, you
reply (in exactly the following words):
“A snake bit me on the hand. I think it was a rattlesnake. I have horrible pain in my
hand and it is getting worse. Make this pain go away.”
Beginning of the encounter:
You are cooperative, though not as pleasant as you usually are. You are
anxious because the pain is so intense.
Middle of the encounter:
You become more and more fatigued as the encounter wears on. The pain
has not subsided.
End of the encounter:
Only if the learner doesn’t seem to be handling your situation well will you
become impatient. No matter how the learner handles you, you will ask for
some relief for your pain.
MEDICAL HISTORY
Your pain started in your finger immediately after the bite. The bite
occurred about 1 hour ago. It began to bleed from the two puncture wounds
on the finger. The pain became almost unbearable within minutes of the
bite. The pain is burning, sharp, throbbing and is getting worse and is
spreading up the arm. The pain is so intense that you are distracted from
concentrating on the learners questions. But try to answer them as best you
can.
You are nauseated and complain of a terrible metal taste in the mouth. You
feel pins and needles in your arm, it feels like worms crawling under your
skin and you feel numbness around your mouth. You feel dizzy.
You do not have trouble breathing, chest pain, or abdominal pain.
HPS in Medical Education 109
You immediately tried to suck the poison from the wound and hiked to your
car to get to the hospital. You did not put on a tourniquet, use ice or cut the
wound. You used a small towel to try to stop the bleeding. (You have a
bloody towel in your hand holding it on the wound)
The Pain:
Where: If the learner asks where the pain was when it STARTED:
“The pain started in the finger and my hand within
seconds of the bite.”
NOW, the pain has spread up the forearm to the elbow.
Intensity:
The pain is severe, excruciating: the worst pain that you
have ever experienced. On a scale of 1 to 10, this pain is
a 10.
Constant/Intermittent: The pain is constant: “It never goes
away...”
Better or worse: The learner might ask you if anything makes the
pain better or if anything makes the pain worse.
If the learner asks you if you can do anything to
lessen the pain, if there is anything that increases
the pain, or if there is any position that relieves the
pain, you answer:
“If I hold my hand up in the air it feels a little
bit better. I can’t stand to have it hanging
down. Please do not touch it.”
Nausea/Vomiting:
You are nauseated and complain of a terrible metal taste in the mouth. You
have not vomited but feel like you are about to.
Fever/sweating/chills:
If asked, you don’t know if you had a fever but you became drenched in
sweat right after the bite. You have continued to sweat profusely.
HPS in Medical Education 110
Snake description:
I am sure it was a rattlesnake. I heard it rattle. It was about 4 feet long,
coiled up and it struck at me. It looked dark with lighter bands. Its head
looked flat like a big triangle. I looked it right in the eyes but it was on the
rocks above me, so I didn’t see it very well.
PAST MEDICAL HISTORY
Healthy. No surgeries and no major illnesses.
No asthma
No allergies to medications but allergic to poison ivy.
No animal allergies
No bleeding problems, stomach ulcers, or anemia
No recent trauma.
PAST HOSPITALIZATIONS
None
MEDICATIONS
Prescription drugs:
None
Specifically no coumadin or other blood thinners
Over-the-Counter (OTC) drugs:
None
Specifically no aspirin
Illicit/street drugs:
None
SEXUAL HISTORY
Single, dates frequently. “What does this have to do with my snake bite
and fixing my pain.”
LIFESTYLE/HABITS
Alcohol:
Sometimes. Not today.
Tobacco:
You have never smoked.
HPS in Medical Education 111
Caffeine:
You drink two cups of coffee per day, lots of cokes.
Diet:
You try to watch what you eat, but you are not on any particular diet.
Activities/Hobbies:
Hiker
FAMILY MEDICAL HISTORY
No significant illnesses in the family. Mother and Father are alive and
healthy.
PERSONAL/FAMILY HISTORY
You are a student at UVA. You are studying international affairs.
HPS in Medical Education 112
PHYSICAL EXAM
(General Checklist Guidelines: On the survey you fill out after the
encounter a ‘No’ response should be marked on the applicable questions if
the learner does not attempt the maneuvers below.)
If the examiner looks at your finger, hand and arm carefully.
NOTE: You should speak out about what the learner is looking for, what
they are seeing and verify those findings. This wound and swelling will be
somewhat artificial.
Swelling of finger, hand, wrist, forearm and slight at upper arm.
Measurement at wrist = measurement in cm + 4cm, at forearm = +3 cm, just
below elbow = +2 cm, upper arm = +1 cm, tip of L index = +3 cm. You will
need to tell the learner to add these cm amounts to the measurement they
take.
NOTE: Make-up should include:
1) TWO fang marks on the LEFT index finger at the proximal phalynx– the
patient should complain that “they just keep bleeding” (it is common for
blood to ooze from the fang wounds for a while after the bite).
2) Ecchymosis (bruising) around the fang marks and on the back of the hand
for 5-6 cm.
When the examiner looked at your hand:
1) Complain of terrible pain and twitching muscles in the forearm.
2) Tell the learner that the pain seems to be moving up the arm. The hand
has a
3) The finger, hand and arm are painful (this is a severe pain). Patients are
often fidgeting and trying to find a comfortable position. Holding it up in
the air makes it feel a little better (sometimes people hold it over their head
with their arm resting on top of their head.)
When the examiner examines your finger, hand and arm carefully by
palpating the hand, wrist, forearm, upper arm and moved fingers,
hand, wrist and elbow through range of motion. (passively by doing it
for you or asking you to move it yourself)
ANY movement or touching of the finger, hand, or arm up to the elbow is
PAINFUL. IF the learner touches any of these areas or straightens the
fingers, bends the wrist or elbow, it will cause excruciating pain. If you are
HPS in Medical Education 113
asked to move the fingers, open close the hand, bend the wrist or bend the
elbow will cause pain. You hold your index finger slightly bent and cannot
bend it or straighten it. You can barely open and close your hand (because it
hurts and because the swelling makes it feel tight)
If the learner’s exam involves any of these:
1) The first time the learner attempts to touch or move the hand, grab his
hand trying to prevent them from touching you (do not be too aggressive and
only do this once) and say:
“Oh my God, is it really necessary for you to do that. The pain is
unbearable.”
2) Keep repeating with each additional contact:
“That hurts, please stop.”
Palpated by axilla (arm pit)
The lymph nodes are often swollen and tender. If the learner palpates your
armpit then complain of discomfort NOT excruciating pain.
Measured hand, forearm upper arm with a tape measure
The arm must be marked with a washable marker on BOTH sides of the tape
measure. The RIGHT arm should also be measured. Both arms should be
measured at hand, just above wrist, just below elbow and middle of upper
arm. Allow the learner to perform this without too much difficulty.
Complain verbally but do not pull away.
The learner should create a measurement flow sheet that records time, place
of measurement and actual measurements.
After the learner completes the measurements and records them:
Your Response: wrist = measurement in cm + 4cm, at forearm = +3 cm,
just below elbow = +2 cm, upper arm = +1 cm, tip of L index = +3 cm
QUESTIONS YOU MUST ASK THE LEARNER:
End of encounter:
“Are you going to treat me with something to counteract the venom?”
If the learner mentions antivenin (Crofab) then ask:
“Is it risky?”
Before the learner leaves the room ask:
“Is there anything that you can do to help ease this horrible pain?”
Guidance on answering CLINICAL COURTESY questions:
HPS in Medical Education 114
Item:
The learner discussed with you what (s)he thought the
treatment plan would be.
YES: At some point before leaving, the learner should tell you what
they think will be done. IT DOESN’T MATTER WHAT THE
LEARNER TELLS YOU. To get credit, they just have to
spend time talking with you about what they think is happening.
** Do NOT confuse this item with Item #26. Here the only thing the
learner has to do is address what they think the treatment will be.
In Item #23, the learner must discuss the SERIOUSNESS of the
cause.
Item:
Did the learner introduce him/herself to you?
YES: If the learner tells you his/her last name AT ANY TIME
NO: If the learner only tells you (s)he:
-- is a medical learner.
-- was told to come and see you.
-- doesn’t tell you anything about who they are.
Item:
Washed hands BEFORE or AFTER doing the PX OR put
on gloves before the PX.
YES: You MUST SEE the learner actually wash their hands OR they
MUST put on gloves before doing the PX.
NO: It is NOT good enough if the learner tells you they washed their
hands before they came in to see you NOR if they merely
pantomime washing their hands!
Item:
Considered your comfort during the PX.
YES: The learner did not unduly hurt you/was not unnecessarily
rough AND/OR apologized for hurting you and explained why
it was necessary to perform the maneuvers.
NO: The learner was unnecessarily rough AND offered no
explanation OR continued in the same fashion even after you
indicated that they were hurting you.
**Remember: You are in such pain that any time the learner touches
you in any way YOU ARE GOING TO FEEL PAIN.
So do NOT expect not to feel pain. What you are
looking for in the learner is someone who understands
HPS in Medical Education 115
that it is painful and acknowledges that pain
explaining that they need to perform these maneuvers
in order to determine what might be wrong with you.
PATIENT/PHYSICIAN INTERACTION
How was the learner you just saw at:
Ratings:
POOR
FAIR
GOOD
VERY GOOD
EXCELLENT
***NOTE: If descriptions of the “very good”, “good” or “fair”
assessments are not included with a given item, use your own
judgment about these gradations between the extremes of
“excellent” and “poor” that are described.
Item:
Speaking to you in a direct manner about the seriousness of
your condition.
EXCELLENT: If the learner actually tells you on their own
(without any prompting) that your symptoms are
serious OR that you might need to have an operation
OR that they would like to do some more tests right
away so that you as a patient have a clear
understanding of what might be wrong with you.
There should be some sense of immediacy about
resolving your pain.
GOOD:
If you get some sense of urgency in the manner of the
learner even if they do NOT tell you directly that you
might need surgery, etc.
FAIR:
If the learner “beats around the bush”, leaving you
unsure about the diagnosis.
POOR:
If the learner avoids telling you in any way how
serious your condition is OR reassures you by either
sending you home with pain medication or telling you
to come in at a later date for further tests.
Item:
Demonstrating sensitivity regarding your anxiety and
physical complaints. (You are assessing the learner’s empathy
for your emotional state at this time.)
EXCELLENT:
The learner must verbally and non-verbally show
you that he/she understands how you must be
HPS in Medical Education 116
feeling. The learner should try to appropriately
reassure you by his/her words and/or actions.
FAIR:The learner ignores your emotional state and just continues as if
nothing were happening.
POOR:
If the learner saddens/upsets you even more than
you already are by the manner in which they deal
with you.
Item:
Behaving warmly, but professionally throughout the
encounter.
EXCELLENT: If the learner can demonstrate genuine care and
concern without losing their objectivity and ability to
deal with the medical aspects of your pain.
POOR:
The learner should not remain cold and aloof, nor
become overly informal and chummy. Either extreme
merits a “Poor”.
Item:
Using words you can understand when discussing your
problem.
EXCELLENT: If you understood all the terms.
VERY GOOD: If only one (1) term was unfamiliar to you.
GOOD:
If only two (2) terms were unfamiliar to you.
FAIR:
If more than two (2) terms were unfamiliar to you.
POOR:
If pretty much everything the learner said to you was
in “medspeak”.
Item:
Treating you like you’re on the same level; never “talking
down” to you or treating you like a child.
EXCELLENT: If you felt the learner treated you like an equal in
your care, concerns and treatment.
POOR:
If you felt the learner was generally condescending
throughout the encounter OR if you felt the learner
was lecturing you.
HPS in Medical Education 117
Item:
Encouraging you to ask questions and never avoiding giving
an answer.
EXCELLENT: If the learner specifically asks if you have
questions -- and answers them directly or promises to
get the answer.
GOOD:
If the learner doesn’t specifically ask you if you have
questions but gives you the impression that you could
ask questions and that you would get a direct answer.
POOR:
If the learner never asks if you have any questions,
gives you the impression of not being open to
questions OR avoids answers to anything you ask.
Comments from Jessie Shorts on Item #1 regarding satisfaction with
this learner physician encounter:
No matter how you responded to Item #1, please make a short statement
here explaining how you came to your YES or NO response. It is here that
you identify your feelings about the interaction that have not been captured
by checklist items.
Your response to this item should be as “Jim Shorts” would respond -- NOT
as you, the standardized patient, would respond knowing what the learner
was being tested on in the checklist. Do NOT make statements that just
reiterate how the learner did on any other individual items in this checklist
OR on your assessment of how they did on the compilation of all other items
in this checklist! Since you just filled out the checklist, we already have that
information!!!
Jessie Short’s response should be based on whether or not:
(1) he feels he would come back to this learner physician
for the rest of his care.
(2) he feels this learner was/will be able to help him (in his
total care).
When you make your comments, please remember that these are medical
learners who are still in training, NOT seasoned physicians.
HPS in Medical Education 118
Ex. “I felt comfortable that this learner physician would get me the help I
need. His/her manner was efficient and caring”
“I felt fearful when the learner physician told me that I was going to surgery
without even doing a physical exam or taking any tests. He/she seemed to be
in too much of a hurry to take care of me appropriately.”