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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↗

PubMed1996

A laboratory comparison of four positive pressure ventilators used in the home.

Four brands of ventilator used for noninvasive positive pressure ventilation in the home were assessed to determine their performance on a patient simulator. We tested the tidal volume (VT) preset Companion 2801 (Puritan Bennett), minute volume preset Monnal D (Taema), and two pressure preset ventilators, the Nippy (Friday Medical) and the Bilevel Positive Airway Pressure (BiPAP) (Respironics). A patient simulator was employed to investigate the relationships between VT, peak airway pressure (PAP) and mean airway pressure (MAP), the responses to an additional leak in the circuit and patient effort of a variable duration, which was modelled using a negative pressure pump. For equivalent VTs, >300 mL, the Monnal D and Nippy generated a PAP up to 100% greater than the Companion 2801 and BiPAP. When an additional leak was introduced to the circuit, the VT of the Companion 2801 and Monnal D fell by >50%, while the Nippy and the BiPAP responded by increasing flow and maintained VT close to the level achieved with no leak. When the ventilators were triggered by a simulated patient effort of 0.25 s duration with a frequency 33% greater than that of the ventilator, the minute volume increased by 41% for the Companion 2801, by 18% for the Monnal D (no change expected), and by 17% for the Nippy (less than expected), and fell by 7% for the BiPAP due to irregular triggering. When patient effort was prolonged to 1.5 s, a similar length to the inspiratory time of the ventilators, there was no further change in the minute volume of the Companion 2801 and Monnal D, while that of the Nippy and of the BiPAP increased by 38 and 71%, respectively, compared to baseline. These results show that distinct brands of ventilator respond to changes in the patient and patient circuit in different ways, which are not always predictable from a simple description of their operating principles. This should be borne in mind when choosing a positive pressure ventilator for noninvasive ventilation.

Equipment Design↗

PubMed1997

Problem-based learning at the University of Southern California School of Dentistry.

Responding to the recent Institute of Medicine report on dental education, the Center for Craniofacial Molecular Biology (CCMB) of the University of Southern California School of Dentistry has developed a parallel track program in dental education leading to the D.D.S. degree. This program was proposed in May of 1995, and the first class of twelve students was admitted in September of that year. Currently two classes are enrolled and plans to admit a further twelve students (Class of 2001) are in place. The educational strategy for this program is totally problem-based. Students work in groups of six with a faculty facilitator, not necessarily a content expert. Facilitators are largely drawn from the multidisciplinary pool of research faculty at the center. All learning is mediated through biomedical and biodental problem cases. No formal lectures or classes are scheduled. The learning of clinical dental skills is promoted through focussed dental patient simulations in which students review clinical charts, radiographs, medical reports and then explore identified, hands-on learning needs using patient simulators in a clinical context. Early patient exposure is obtained through dental office visits and other special patient clinics. Initial experience with this program suggests that the problem-based learning (PBL) students learn as well (if not better) than their traditional program peers and develop excellent group and cognitive analytical skills. The absence of a pool of dentally related biomedical cases suitable for a PBL program has necessitated the use of innovative approaches to their development and presentation. It is believed that this educational approach will produce dental clinicians equipped with the self-motivated, life-long learning skills required in the ever-changing world of bio-dental sciences in the twenty-first century.

California↗

PubMed1990

Effect of station examination item sampling on generalizability of student performance.

This article may be of interest to physical therapy educators who are responsible for structuring station or practical examinations used to evaluate physical therapy students. The global intent of the article is to provide information that may be useful in selecting test items. Specifically, the purposes of this study were 1) to examine how two item-sampling strategies (one based on different diagnostic concepts, or diagnostic probes, and the other based on different anatomical sites) influenced the generalizability of a station examination, 2) to determine the interrater reliability during the station examination, and 3) to determine whether the status of the rater (that of observer or simulated patient) influenced the rating. Using a nested study design, 24 physical therapy students were assessed by eight raters. The raters were randomly and equally assigned to four teams. Each team assessed six students. One rater acted as the simulated patient for the first three students in each group, and the other rater acted as observer. This order was reversed for the last three students. Each student performed nine mini-diagnostic patient cases consisting of three diagnostic probes reproduced at three different anatomical sites. The results demonstrate that 1) similar diagnostic concepts can be generalized across anatomical sites, although different concepts or skills cannot be generalized at a given anatomical site or across sites; 2) interrater reliability was excellent; and 3) the status of the raters (ie, simulated patient or observer) did not bias the ratings.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗

PubMedDate not supplied

Simple equations for protein catabolic rate determination from pre dialysis and post dialysis blood urea nitrogen.

Several simple equations exist for Kt/V determination from pre dialysis (Cpre) and post dialysis (Cpost) blood urea. However, comparable equations have not been available for calculation of protein catabolic rate (PCR), an essential parameter for assessing patient status. Three simple formulas for PCR determination were developed from the urea mass balance equation for an anuric patient in protein steady state receiving thrice weekly dialysis. The simplest formula, PCR = 0.0076 [Kt/V] [Cpre + Cpost] + 0.17 relates PCR (in g protein/kg/day) to Kt/V and pre and post dialysis blood urea nitrogen measurements (in mg urea nitrogen/dl) for the midweek session. When tested for 540 simulated patients spanning a range of Kt/V (0.6-1.6); PCR (0.6-1.6 g/kg/day); dialysis duration t (2-4 hrs) and interdialytic weight gain expressed as a percentage of dry body weight gained daily (0-4%), this equation yielded a maximum error of less than +/- 5%, within the accuracy generally required for clinical needs. A more accurate formula, [formula: see text] where Clm is the logarithmic mean of Cpre and Cpost, gave maximum errors in PCR estimation for the same 540 simulated patients of less than +/- 0.6%. Both formulas require a precise value of Kt/V. The equation below incorporates a very accurate simple Kt/V equation recently published by the authors, allowing PCR to be expressed in terms of Cpre, the ratio of Cpost to Cpre (R), the ratio of session ultrafiltration volume (delta BW) to urea distribution volume (V), and dialysis time (t, in min). [formula: see text] This equation was accurate to within a maximum error of +/- 1% for the simulated patient group. These equations allow simple and accurate patient PCR determination, and should be used in conjunction with a simple formula for accurate Kt/V determination to guide end-stage renal failure patient therapy.

Blood Urea Nitrogen↗

PubMed1996

The Periotest method: implant-supported framework precision of fit evaluation.

PURPOSE: In this study, the Periotest instrument was used to measure the precision of fit between cast high noble-metal frameworks and the supporting implants in a patient-simulation model. Three framework conditions and three implant-location variables were used to evaluate the rigidity of the assembly as measured by the Periotest method. The framework variables were (1) one-piece castings (OPC); (2) sectioned-soldered inaccurate castings (SSIC); and (3) sectioned-soldered accurate castings (SSAC). The implant-location variables were right anterior (RA), center (C), and left anterior (LA). MATERIALS AND METHODS: The patient simulation model used consisted of three self-tapping Branemark implants in a reasonable arch curvature in bovine bone. Three working casts were fabricated from the patient-simulation model using polyvinyl siloxane and tapered impression copings. From the working casts, three sets of three frameworks were fabricated as OPCs, SSICs, and SSACs using type 3 high noble alloy. The SSICs were fabricated with a quantitative misfit of 101.6 microns at the facial surface, between the abutment-to-gold cylinder interface at the C implant location. Periotest value (PTV) measurements were made at the midfacial surface of the frameworks directly above each abutment-to-gold cylinder interface. Three measurements were made for each test condition. The data were analyzed to compare framework condition(s) and implant location(s) using ANOVA and Fisher's Protected Least Significant Difference Comparison Test. RESULTS: The ANOVA showed that significant differences exist between the mean PTV data for framework condition and for implant location (p < .01). Significant differences were shown between the mean PTV data for the SSAC assemblies and the OPC and SSIC assemblies. The SSICs displayed a more positive (+) mean PTV than the OPCs. The OPC assemblies had a more positive mean PTV than the SSAC assemblies. The mean PTV data for the SSAC assemblies had a significantly different PTV (p < .01) than the other two framework condition assemblies. The OPC and the SSIC assemblies had PTVs that were not significantly different. The C implant location was significantly different from the RA and the LA implant locations (p < .01). The RA and the LA implant locations were not significantly different from each other. The C implant location always demonstrated the most positive mean PTV regardless of the framework condition being tested. CONCLUSIONS: The Periotest instrument quantified differences in the precision of fit between three framework conditions. The SSAC assemblies were significantly more rigid than the OPC and SSIC assemblies. The OPC and SSIC assemblies' mean PTVs were not significantly different. The mean PTVs for the C implant location and the RA and LA implant locations were significantly different (p < .01). The mean PTVs of the RA and LA implant locations were not significantly different. The implant-location PTVs followed the same rank order for all three framework conditions. The procedures used to fabricate a more precise fit between the framework and the supporting implants is influenced by the skill of the clinician and technician.

Analysis of Variance↗

PubMed1997

Nonmedical influences on medical decision making: an experimental technique using videotapes, factorial design, and survey sampling.

OBJECTIVE: To study nonmedical influences on the doctor-patient interaction. A technique using simulated patients and "real" doctors is described. DATA SOURCES: A random sample of physicians, stratified on such characteristics as demographics, specialty, or experience, and selected from commercial and professional listings. STUDY DESIGN: A medical appointment is depicted on videotape by professional actors. The patient's presenting complaint (e.g., chest pain) allows a range of valid interpretation. Several alternative versions are taped, featuring the same script with patient-actors of different age, sex, race, or other characteristics. Fractional factorial design is used to select a balanced subset of patient characteristics, reducing costs without biasing the outcome. DATA COLLECTION: Each physician is shown one version of the videotape appointment and is asked to describe how he or she would diagnose or treat such a patient. PRINCIPAL FINDINGS: Two studies using this technique have been completed to date, one involving chest pain and dyspnea and the other involving breast cancer. The factorial design provided sufficient power, despite limited sample size, to demonstrate with statistical significance various influences of the experimental and stratification variables, including the patient's gender and age and the physician's experience. Persistent recruitment produced a high response rate, minimizing selection bias and enhancing validity. CONCLUSION: These techniques permit us to determine, with a degree of control unattainable in observational studies, whether medical decisions as described by actual physicians and drawn from a demographic or professional group of interest, are influenced by a prescribed set of nonmedical factors.

Age Factors↗

PubMed1988

Simulation of patient flow in a picture archival and communications system network.

As hospital radiology departments expand their use of digitally formatted imaging devices, these machines will be connected in local area networks called Picture Archival and Communications Systems (PACS). The purpose of this paper is to demonstrate the use of computer simulation to analyze the process of patients using a PACS. The flexibility of using simulation on a proposed PACS is shown, starting with the description of a basic model. Different machine networks are run and the results compared. Simulation modeling provides a valuable tool to hospital and department administrators in detecting possible problem areas which may occur with proposed PACS configurations under assumed patient loads.

Computer Communication Networks↗

PubMedDate not supplied

Physician's interviewing styles and medical information obtained from patients.

This paper investigates the association between physicians' interviewing styles and medical information obtained during simulated patient encounters. The sources of data are audiotapes and transcripts of two standardized patient cases presented by trained patient simulators to 43 primary care practitioners. Transcripts were scored for physician proficiency using expert-generated criteria and were content-analyzed to assess the process of communication and information content. Relevant patient disclosure was also scored from the transcripts based on expert-generated criteria. Findings were: 1) On the whole, physicians elicited only slightly more than 50% of the medical information considered important according to expert consensus, with a range from 9% to 85%. 2) Both open and closed questions were substantially related to patient disclosure of medical information to the physician, but open questions were substantially more so (Pearson correlations of 0.37 and 0.72, respectively). 3) Patient education, particularly information regarding prognosis, cause, and prevention, was substantially related to patient disclosure of medical information to the physician (Pearson correlations of 0.44, 0.36, and 0.34, respectively). 5) Finally, clinical expertise was only weakly associated with patient disclosure of medical information to the physician (Pearson correlation of 0.16).

Humans↗

PubMed1992

Treatment of terminal cancer pain in Finland: a second look.

A questionnaire concerning the treatment of cancer pain was sent to 10% and 5% random samples of Finnish physicians in 1985 and in 1990, respectively. The physicians were asked about their current practice in the treatment of pain in their cancer patients, and about their main clinical problems when treating pain. Three simulated patient cases were presented, and the adequacy of the suggestions for therapy was evaluated. The results indicated that Finnish physicians had adopted a more rational and effective analgesic therapy during the 5-year period. Treatment suggestions for the simulated patient cases had improved both in terms of daily doses of analgesics and of dose intervals, but the doses of opioids were still below those commonly used in chronic cancer pain. The clinical difficulties experienced by the physicians had changed: instead of being frustrated by the inefficacy of their treatment as in 1985, physicians were now working on the problem of finding a suitable preparation and dosage. The results suggest that the voluntary activity of patient organizations, a few pain clinics, and a few clinicians interested in pain treatment have been able to improve the practising physicians' theoretical knowledge in 5 years. In contrast to the improvement in the knowledge and skills, changing attitudes takes much longer. As many as 39% of physicians who see cancer patients at least occasionally, reported that they still had not acquired the prescription sheets necessary to prescribe opioids to outpatients.

Analgesics↗

PubMed1993

Detecting the faking of amnesia: performance differences between simulators and patients with memory impairment.

This study attempted to establish criteria for distinguishing patients with genuine memory problems from those who are attempting to simulate amnesia. The performance of simulators and genuine amnesics was compared under distraction conditions in which subjects had to count backwards between presentation and recall, and under no-distraction conditions in which the retention interval was unfilled. Genuine amnesics performed significantly worse than controls under distraction conditions, but did not perform significantly worse than controls under no-distraction conditions. However, those attempting to fake amnesia performed significantly worse than controls under no-distraction as well as under distraction conditions. They also exaggerated the memory deficit overall relative to genuine amnesics. It is suggested that these two criteria might be used successfully in clinical settings to assist in the detection of simulators.

Adult↗