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PubMedDate not supplied

Expert system development in nursing: implications for critical care nursing practice.

OBJECTIVE: To obtain information about how highly experienced critical care nurses reason to plan care and make decisions about a critically ill unstable patient, and to determine the usefulness of this information for expert system development. DESIGN: Descriptive, using think-aloud technique and protocol analysis. SETTING: Laboratory. PATIENT: A simulated patient case whose condition deteriorated over a 12-hour shift. The case depicted an elderly female with congestive heart failure and atrial fibrillation with rapid ventricular response. RESULTS: Protocol analysis revealed the information (data) that subjects used and how they structured that information to plan care and make decisions. Examination of subjects' reasoning processes allowed the investigators to identify "if-then" rules that could be used in expert system design. CONCLUSIONS: The reasoning processes identified would assist in expert system development. An expert system designed to represent experienced critical care nurses' knowledge and reasoning processes would preserve that expertise in a computer system that could then be used to assist less experienced nurses to improve their reasoning skills and strategies.

Adult↗

PubMed1996

[Computer-assisted education in problem-solving in neurology; a randomized educational study].

OBJECTIVE: To determine the effect of computer-based medical teaching (CBMT) as a supplementary method to teach clinical problem-solving during the clerkship in neurology. DESIGN: Randomized controlled blinded study. SETTING: Academic Medical Centre, Amsterdam, the Netherlands. METHOD: 103 Students were assigned at random to a group with access to CBMT and a control group. CBMT consisted of 20 computer-simulated patients with neurological diseases, and was permanently available during five weeks to students in the CBMT group. The ability to recognize and solve neurological problems was assessed with two free-response tests, scored by two blinded observers. RESULTS: The CBMT students scored significantly better on the test related to the CBMT cases (mean score 7.5 on a zero to 10 point scale; control group 6.2; p < 0.001). There was no significant difference on the control test not related to the problems practised with CBMT. CONCLUSION: CBMT can be an effective method for teaching clinical problem-solving, when used as a supplementary teaching facility during a clinical clerkship. The increased ability to solve problems learned by CBMT had no demonstrable effect on the performance with other neurological problems.

Computer-Assisted Instruction↗

PubMed1996

Improving outpatient clinic staffing and scheduling with computer simulation.

Patient flow in an appointment-based, outpatient internal medicine clinic involving multiple, sequential providers-registrar, triage nurse, physician, and discharger-was studied using computer simulation. Provider task time distributions were obtained through a time-motion study and then input into the computer program, which simulated the clinic situation well. Time interval and sensitivity analyses yielded insights into staffing levels, appointment times, and clinic dynamics. A bottleneck provider was shown, and patient time in the clinic was related to the time of appointment and was slowed by having too many doctors in the clinic. Subsequent operational changes significantly decreased the average observed patient total time in clinic from 75.4 (SD 34.2) minutes to 57.1 (SD 30.2) minutes (p < .001, t test).

Appointments and Schedules↗

PubMedDate not supplied

Approaches to urinary incontinence in a rural population: a comparison of physician assistants, nurse practitioners, and family physicians.

BACKGROUND: Although urinary incontinence is a challenge and a burden to older patients, many clinicians fail to query older patients about incontinence symptoms or, even when aware of a problem, fail to diagnose the underlying cause or recommend treatment. We wanted to compare the approaches of physician assistants, nurse practitioners, and family physicians to detection, diagnosis, and initial management of urinary incontinence in older adults seen in rural primary care practices. METHODS: One male and 2 female simulated patients portrayed otherwise healthy patients with urinary incontinence, including urge or obstruction-overflow type for the man, and stress or urge type for the women. The 3 simulated patients saw 3 physician assistants, 3 nurse practitioners, and 3 family physicians each, for a total of 27 visits during which they posed as new patients seeking primary care. RESULTS: Health professionals spontaneously asked about incontinence in only 18 percent of visits (33 percent for physician assistants, 11 percent each for nurse practitioners and family physicians). When incontinence was discussed (spontaneously or by patient prompting), queries were made about potential precipitants (ie, coughing, caffeine consumption) in 63 percent of visits. Questions about other urinary symptoms (eg, dysuria) were asked in 59 percent of visits. Rectal examinations were performed in 68 percent of the male simulated patient's visits but in none of the female simulated patients' visits. No pelvic examinations were performed. No attempts or recommendations were made to measure postvoiding residual volume. Tentative diagnoses were made in 48 percent of visits; some form of therapy was discussed in 52 percent of visits. CONCLUSIONS: Asking about incontinence was uncommon, and potentially important questions about precipitants and associated symptoms were often omitted. The providers examined areas potentially relating to incontinence and recommended supplementary assessments and specialized testing infrequently. Commonly, they made diagnoses and offered therapy at the end of an initial visit despite minimal history taking and examinations and lack of any additional assessment or testing.

Aged↗

PubMed1998

The effectiveness of intensive training for residents in interviewing. A randomized, controlled study.

BACKGROUND: Interviewing and the physician-patient relationship are crucial elements of medical care, but residencies provide little formal instruction in these areas. OBJECTIVE: To determine the effects of a training program in interviewing on 1) residents' attitudes toward and skills in interviewing and 2) patients' physical and psychosocial well-being and satisfaction with care. DESIGN: Randomized, controlled study. SETTING: Two university-based primary care residencies. PARTICIPANTS: 63 primary care residents in postgraduate year 1. INTERVENTION: A 1-month, full-time rotation in interviewing and related psychosocial topics. MEASUREMENTS: Residents and their patients were assessed before and after the 1-month rotation. Questionnaires were used to assess residents' commitment to interviewing and psychosocial medicine, estimate of the importance of such care, and confidence in their ability to provide such care. Knowledge of interviewing and psychosocial medicine was assessed with a multiple-choice test. Audiotaped interviews with real patients and videotaped interviews with simulated patients were rated for specific interviewing behaviors. Patients' anxiety, depression, and social dysfunction; role limitations; somatic symptom status; and levels of satisfaction with medical visits were assessed by questionnaires and telephone interviews. RESULTS: Trained residents were superior to untrained residents in knowledge (difference in adjusted post-test mean scores, 15.7% [95% CI, 11% to 20%]); attitudes, such as confidence in psychological sensitivity (difference, 0.61 points on a 7-point scale [CI, 0.32 to 0.91 points]); somatization management (difference, 0.99 points [CI, 0.64 to 1.35 points]); interviewing of real patients (difference, 1.39 points on an 11-point scale [CI, 0.32 to 2.45 points]); and interviewing (data gathering) of simulated patients (difference, 2.67 points [CI, 1.77 to 3.56 points]). Mean differences between the study groups were consistently in the appropriate direction for patient satisfaction and patient well-being, but effect sizes were too small to be considered meaningful. CONCLUSION: An intensive 1-month training rotation in interviewing improved residents' knowledge about, attitudes toward, and skills in interviewing.

Attitude of Health Personnel↗

PubMed1995

Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial.

BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

Adult↗

PubMed1994

Improving office-based physician's prevention practices for sexually transmitted diseases.

OBJECTIVE: To determine whether office-based interventions increase primary care physicians' risk assessment of and counseling practices for patients regarding sexually transmitted diseases and the human immunodeficiency virus (HIV). DESIGN: Randomized controlled clinical trial. SETTING: Washington, D.C., Metropolitan Statistical Area. STUDY PARTICIPANTS: Office-based primary care physicians (family or general practice, internal medicine, and obstetrics-gynecology). INTERVENTION: Mailed educational materials alone or coupled with a simulated patient instructor office visit. MEASUREMENTS: Self-reported and observed frequency of assessing and counseling patients regarding their risk factors for sexually transmitted diseases and HIV infection. Participants were interviewed by telephone before and after the intervention (n = 757). A subset of participants (n = 194) was also observed after the intervention by simulated patient evaluators in blinded office visits. RESULTS: 89% of physicians who received both educational materials and a simulated patient instructor visit reported that they reviewed the educational materials compared with 53% of those who only received the educational materials (P < or = 0.001). Physicians in the combined intervention group had higher self-reported and observed rates for several risk assessment questions and counseling recommendations than did physicians in the control group or the group that only received educational materials. Seventy-three percent of physicians of the combined intervention group reported an increase in counseling patients about reducing risky sexual behavior compared with 53% of the group receiving only educational materials and 42% of the control group (P < or = 0.001). CONCLUSIONS: Mailed educational materials combined with an office visit by a simulated patient instructor for role-play and feedback on clinical performance increased the frequency of office-based physicians' risk assessment and risk reduction counseling of patients for sexually transmitted diseases and HIV infection.

Counseling↗

PubMed1995

Quantifying the measurement of differential diagnosis.

Differential diagnosis is central to the work and training of all health care professionals. To develop solid differential diagnosis and skills, students required practice diagnosing numerous and varied patients. In the absence of real patients, patient simulations are commonly used to provide this range of diagnostic experiences. This study examined the benefits of interactive patient simulations on the diagnostic approaches of beginning dental students (novices) and practicing dentists (experts). The study tested the hypothesis that novices tend to use trial-and-error, while experts tend to use pattern recognition during differential diagnosis. a second goal of the study explored objective and subjective measures of a differential diagnosis approach. Seventy-five subjects comprised two treatment groups: a novice group and an expert group. Each group completed ten patient simulations and a case study test measured the diagnostic approach. A three factor MANOVA (p>0.05) was followed by univariate ANOVA's. The result indicated differences between the diagnostic approaches of experts and novices and that the subjective Ratings and the objective Maximum Decisions and Average Variation variables were the best measures of a differential diagnostic approach.

Analysis of Variance↗

PubMed1989

Factors affecting outcomes of medication-history interviewing by pharmacy students.

Factors affecting outcomes of medication-history interviewing by pharmacy students were studied. Data were obtained from fourth-year pharmacy students enrolled in a required course in fall 1984. Each student conducted a medication-history interview with one of two simulated patients who presented a predetermined history; interviews were videotaped from behind a one-way mirror. Students also completed an interviewing-orientation survey and a personal report of communication apprehension (PRCA). Trained raters evaluated the videotaped interviews using measures of interview skill and interview completeness. The simulated patients completed a patient-satisfaction form after each interview. Two path models were developed that were identical except that one had completeness and one had patient satisfaction as the dependent variable. Interview skill was the final factor in each model, preceded by variables representing the student's background and orientation factors, PRCA, and simulated-patient gender. Of 112 students conducting the interview, 107 (95.5%) and 95 (84.8%) completed the PRCA and orientation surveys, respectively. The models explained 36% and 27% of the variance in patient satisfaction and completeness, respectively. Shown in parentheses are the significant direct predictors of variables in the model of patient satisfaction: satisfaction (skill, prepharmacy grade point average [preGPA], people and health-care [PHC] orientation); skill (interviewing orientation, preGPA); interviewing orientation PHC orientation, preGPA, PRCA); and (PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation. For the model of completeness, direct predictors were as follows: completeness (skill, PHC orientation, student gender, simulated-patient gender); skill (interviewing orientation, preGPA); interviewing orientation (PRCA, preGPA, PHC orientation); and PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation and PHC orientation on completeness. Results suggest that one path model reflects the patient's assessment of interviewer competence in terms of satisfaction, and the other reflects the clinician-rater's assessment of interviewer competence in terms of interview completeness. The interviewing process positively influences both patient satisfaction and interview completeness.

Female↗

PubMed1997

An approach for the estimation of effective radiation dose at CT in pediatric patients.

PURPOSE: To estimate the effective radiation dose to pediatric and adult patients at head and abdomen computed tomography (CT). MATERIALS AND METHODS: Cylindrical water-equivalent phantoms were modeled for patients aged newborn to adult, and the energy imparted per unit axial exposure was computed. To determine the energy imparted to the simulated patients of different ages undergoing head and abdomen CT examinations, x-ray technique factors were combined with measured CT axial exposures. Body-region-specific ratios were calculated for effective dose per unit energy imparted, and these ratios were corrected for patient mass to obtain the effective dose to simulated patients. RESULTS: With use of standard techniques, the energy imparted to simulated patients at CT always increased with patient size, but the effective dose was higher in children than in adults. At CT in the head and abdomen, effective doses were highest in newborns. Effective doses ranged from 1.5 to 6.0 mSv in head CT examinations and from 3.1 to 5.3 mSv in abdomen CT examinations. CONCLUSION: The values for energy imparted at CT in pediatric patients were generally lower than in adults. The smaller mass of children, however, caused the corresponding effective doses to be higher than those in adults undergoing similar CT examinations.

Adolescent↗

PubMed1991

Effects of using two or more standardized patients to simulate the same case on case means and case failure rates.

The effects of using two or more standardized patients (multiple SPs) to simulate the same case in a performance-based examination were studied at the case level by comparing case means and case failure rates for multiple SPs simulating the same case, using data from the classes of 1988, 1989, and 1990 at the Southern Illinois University School of Medicine. For total scores and scores on the students' written answers, the effects on means and failure rates were negligible and could be explained as due to sampling error. For scores on the checklists completed by the SPs, there were more significant differences than would be expected by chance alone, even though the number of significant differences was relatively small. The results demonstrate a need for caution in the interpretation of scores obtained from a case checklist completed by multiple SPs, particularly in regard to making pass-fail decisions.

Achievement↗

PubMed1982

Description of an examination for the objective assessment of history-taking ability.

A novel examination of the ability of final-year medical students to take a targeted history is described. One hundred and nine students were examined in 1 day. Each student interviewed three patients, each with a different problem. One of these persons was a real patient, while the other two were simulated patients. Patients were able to give consistent histories and the use of simulated patients enabled a high degree of standardization to be achieved. The examination provided a useful degree of discrimination among students; the marks scored followed a normal distribution with a mean value of 22.2 and a range from 16 to 29 out of a maximum of 30 marks. We believe that this examination is valid, reliable and practical.

Australia↗

PubMed1993

An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC.

The author defines the term standardized patient (SP), the umbrella term for both a simulated patient (a well person trained to simulate a patient's illness in a standardized way) and an actual patient (who is trained to present his or her own illness in a standardized way). He first discusses the many values of simulated patients over actual patients as teaching and assessment tools in the classroom and refutes a few myths about the use of SPs. Then he recounts the origin and development of SPs over a three-decade period, beginning with his work as a neurologist at the Los Angeles County Hospital, where he trained a model from the art department to simulate a neurological patient and assist in the assessment of clinical clerks. He then describes additional roles of SPs that have developed, including: (1) their use in the Clinical Practice Examination created at Southern Illinois University School of Medicine and (2) the major use that has come into being over the last 10-15 years; facilitating the comprehensive assessment of clinical competence using multiple stations in examinations such as the objective structured clinical examination. He concludes with information about recent and current work on SPs, who are becoming more and more accepted in the assessment process, and urges skeptics not to make judgments about the value of SPs until they have experienced the technique firsthand and reviewed the literature concerning the extensive and often high-quality research about this assessment tool.

Clinical Competence↗

PubMed1992

Teaching medicine with cases: student and teacher opinion.

In a second-year family medicine course taught using simulated patients the students commented most favourably on the clinical relevance of the topics, the enthusiasm of teachers, and the opportunity to interview simulated patients with their fellow students, in contrast to their basic science courses, which did not give them patient contact. They felt most confident about skills acquired in relation to diseases with a limited number of key symptoms, signs and treatments (meningitis, otitis) and less confident about diseases with many symptoms and treatments (diabetes, trauma, arrhythmias). They made few comments about alternative cases which might have been selected. Their adverse comments were about the workload. During tutor meetings over 4 years, a key concern which emerged was to find cases with a level of complexity suitable to the students. The tutors emphasized these principles of case selection: the cases should be based on real life and include most of the signs and symptoms of the disease; contain one or at most two foci; have nodal decision-making points; emphasize clinical reasoning; reinforce prior knowledge; permit the transfer of knowledge to other cases; and permit the assessment of associated technical skills.

Attitude of Health Personnel↗

PubMed1991

Decreasing gastrointestinal morbidity with the use of small bowel contrast during treatment planning for pelvic irradiation.

Small bowel tolerance is a major dose-limiting factor in treating the pelvis with radiation therapy (RT). The use of small bowel contrast during RT simulation is one technique used to localize the bowel and identify the treatment plan that would exclude the greatest volume. To determine the influence of treatment planning with oral contrast on gastrointestinal injury, acute and chronic small bowel morbidity was analyzed in 115 patients with endometrial and rectal carcinoma who received postoperative radiation therapy at the Fox Chase Cancer Center. Mean and median time of follow-up were 31 and 27 months, respectively. Acute diarrhea was seen in 82% of the patient population. Ten percent of patients experienced major complications requiring hospitalization. Ninety-three percent of patients simulated without contrast experienced side effects compared to 77% of patients simulated with contrast (p = .026). There was an increased incidence of chronic complications in patients who were not simulated with contrast dye (50% vs 23%, p = .014). Median duration of minor side effects was 4 months for patients planned without oral contrast and 1 month for patients who had contrast at the time of simulation (p = .036). The superior aspect of the treatment field was determined to be at a more inferior location in patients simulated with contrast, thereby excluding small bowel from treatment. Seventy-four percent of patients simulated without contrast had the upper border of the field placed at the superior aspect of the sacroiliac joint or above, compared to only 40% of patients planned with oral contrast (p = .002). This study has demonstrated decreased complications (both overall and chronic) as well as a change in the location of the treatment field with the use of small bowel contrast. Multivariate analysis revealed that both the use of oral contrast (p = .026) and a lower superior border of the treatment field (p = .007) were predictive for fewer sequelae to RT, indicating that planning with contrast leads to changes in the technical delivery of RT other than field placement (e.g., block placement). The reduced incidence and duration of small bowel morbidity may be in part caused by alterations of the treatment plan made when the small bowel is visualized at the time of simulation. It is therefore recommended that oral small bowel contrast be used during treatment planning for pelvic irradiation.

Adult↗

PubMed1977

A simulated patient-physician encounter using a talking computer.

Computer-based clinical simulations provide a means for evaluating the information-gathering and patient-management competencies of physicians. The need for expensive computer terminals has restricted physician use of these simulations. This computer-based program permits physicians to complete computer-based encounters using a standard touch-tone telephone.

Clinical Competence↗

PubMedDate not supplied

An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice.

Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.

Chest Pain↗

PubMed1993

Biomechanical simulations of scoliotic spinal deformity and correction.

A new approach to surgical correction of scoliosis has been advanced by us, in the form of simulation of the surgical correction system and technique. For this purpose, we developed a finite-element model of the spinal column (SFEM), applied tractions to it and determined the model stiffness so as to watch the actual spinal geometry. Having patient-simulated this SFEM, we applied to this SFEM corrective forces and determined the optimal set of forces to gain the best correction of the spinal deformity. We then developed a special instrumentation to measure the applied corrective forces during surgery using a particular fixation system. The SFEM corrected geometry was shown to compare favourably with the post-surgical curve. We have now developed an elastic beam-column model (EBCM) to which muscle activation forces, representing asymmetrical paralysis of the vertebral column muscles, can be applied to generate a given scoliotic curve. In that process the stiffness properties of the patient-simulated EBCM are determined. Now on these patient-simulated EBCM(s), identical corrective force systems are applied as developed by the finite-element model (SFEM) and implemented surgically for these patients. It is shown that the EBCM corrected geometries compare favourably with both SFEM corrected geometries as well as with the post-surgical curves for similar corrective force systems. Thus the EBCM can be employed to presurgically simulate scoliolic correction, specify the optimal corrective system of forces so as to gain the best surgical correction.

Adolescent↗