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PubMed1985

A comparison of four empathy instruments in simulated patient-medical student interactions.

Prior investigations of empathy in medicine have used several available instruments for assessment, including a scale developed by Hornblow, Hogan's empathy scale, the Carkhuff-Truax empathic understanding scale, and the Barrett-Lennard relationship inventory. The purpose of the study reported in this article was to investigate the intercorrelations of the scores on these four instruments when used in a medical student-simulated patient interaction. The results showed that measures of empathy based on observed behavior of the students were highly intercorrelated but that empathy self-assessed by the students themselves as having that trait did not correlate significantly with any of the behavior-based measures. No significant effect on these findings was attributable to the timing of the instrument administration, to the students' interpersonal skills training or experience in taking histories and performing physical examinations, or to the sex of the students and the observers.

Clinical Competence↗

PubMed1996

The use of the McCoy laryngoscope in patients with simulated cervical spine injuries.

We studied the laryngoscopic view in 167 patients with their head and necks held in the neutral position with manual in-line stabilisation and cricoid pressure to simulate the patient with a suspected cervical spine injury. Each patient underwent laryngoscopy using both a McCoy and a Macintosh laryngoscope. The best view obtained by each larngoscope was graded according to standard guidelines. The results showed that the McCoy was never worse than the Macintosh. It improved the Macintosh grade by 1 grade in 41% and by 2 grades in 8% (p < 0.001). Difficult laryngoscopy, defined as the inability to see the glottis (grade 3 or 4), was found in 56 (33%) with the Macintosh laryngoscope and only eight (5%) (P < 0.001) with the McCoy laryngoscope. We suggest that patients with a suspected cervical spine injury and a full stomach should be intubated using a McCoy in preference to a Macintosh laryngoscope.

Adolescent↗

PubMed1995

A demonstration of the virtual nursing college.

This demonstration will illustrate the operation of a virtual nursing college (VNC) through the Internet. The key concepts to be shown include: Distance and remote learning and teaching; Multi-site collaboration in teaching and clinical research using groupware; Multimedia courseware found in programmable virtual classrooms; Personal knowbots that manage information; Virtual clinics with virtual patients and simulated patients.

British Columbia↗

PubMed1992

Continuing medical education software: a comparative review.

Personal microcomputers can be used by physicians for continuing medical education (CME). Advantages of computerized CME include local control over the topic, time, place, and pace of instruction. Computers can be interactive, providing selected information that depends on the desires and needs of the physician. Learners have different preferred styles of receiving information, and computer programs can be written to appeal to a particular style of learning. Three examples of commercial software programs available for CME are reviewed. Cyberlog should appeal to those who like to learn from reading textbooks but also desire simple computer graphics and case simulations to reinforce key concepts. Patient Simulator II is a detailed patient simulation for those who learn best by doing. A subscription to Discotest provides patient management problems, and multiple choice questions (no graphics) based on information in Scientific American Medicine. No one program is suitable for all family physicians.

Computer Simulation↗

PubMed1996

Sleep history is neglected diagnostic information. Challenges for primary care physicians.

Sleep problems are treatable causes of morbidity and mortality, but little is known about how often the history fundamental to diagnosis is obtained. We recorded the frequency of sleep histories during encounters with simulated patients by 20 experienced primary care practitioners, 23 uninstructed medical interns, and 22 interns who had previous instruction about sleep disorders. Sleep histories were uncommonly obtained by uninstructed physicians (0% of practitioners, 13% of interns), but trained interns more often (81.8%) asked about sleep. If sleep problems are to be prioritized, major changes in physician education and behaviors are essential. Focused instruction about sleep influences physician behavior.

Education, Medical, Continuing↗

PubMed1997

The use of standardized patients in research in general practice.

Standardized patients (SPs) are simulated patients or actual patients who have been carefully coached to present their illness in a standardized way. Much is known about the use of standardized patients in medical education. This article reviews advantages and disadvantages, reliability and validity of the use of standardized patients in general practice and primary care research. Performance in general practice can be measured with direct or indirect methods. With direct methods the physician-patient contact is directly observed or heard. Indirect methods are seldom complete and seldom accurate and therefore often invalid. Direct methods (observation, video, audiotapes, etc.) have face validity, but nevertheless have shortcomings. The SP method can mainly avoid the disadvantages of the other methods. The presentation of the case by the SP is accurate. The judgement of physician's behaviour during the consultation by the SP is accurate and reliable. SPs are generally believable. Less than one in five SPs is detected by the physicians, so the method has face validity. To obtain sufficient reliability and validity, a thorough selection and training of SPs is required, as is careful organization with an eye for detail. The SP method also has some important shortcomings. The method is time and work demanding, limiting the number of physicians that can be measured. In addition, measurement is usually limited to one consultation. In reality, however, diagnostic and therapeutic interventions are often spread over several consultations. This 'first-visit-bias' hampers conclusive answering of some research questions.

Family Practice↗

PubMed1988

Treatment of terminal cancer pain in Finland. A questionnaire survey.

A questionnaire concerning current practice in the treatment of cancer pain was sent to 783 Finnish physicians. This study is based on the replies from 421 physicians who stated that they at least sometimes see cancer patients. Three simulated patient cases were presented in the questionnaire, and the adequacy of the treatment suggestions was evaluated. The results indicated that drugs predominate in the treatment of cancer pain. The suggested doses of narcotic analgesics were well below the minimum effective daily doses. As many as half of the physicians failed to use the therapeutic modalities correctly, irrespective of the frequency of their seeing cancer patients. Education in effective pain treatment should therefore be intensified to ascertain that all physicians involved in clinical practice have satisfactory knowledge of the treatment of cancer pain.

Analgesics, Opioid↗

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↗

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↗