Medical School Strategies for Teaching and Assessing Student Competencies Using Live Patient Simulations and Patient Simulators

Tony Errichetti, Ph.D. PCOM

Q: How do you create an osteopathic “patient-centered”

physician when medical education is “teacher-centered”?

A: Include patients actively in the teaching process via simulations

Simulation

Placing people in realistic settings for the purpose of training and / or performance assessment

Varieties of Med Ed Simulations

Standardized / simulated patients

Robotics

Virtual reality / computer simulations

Changing the model

OJT Systematic Training

Because medical training is too important to be left to chance

Models

War Games

Models

Flight Simulators

What’s Driving the Change (urgency)?

• Public demanding quality

Need to reduce medical errors

•44,000 – 98,000 die in hospitals due to medical errors

•If airline industry had the same record as the medical profession ,

there would be 63 airline crashes / day

Performance-based board exams

• ECFMG / USMLE in June 2004

•COMLEX-USA-PE

Why simulate?

Control of Training and Assess

Logistical Issues in Pre-Clinical Training

Getting students the training they need when they need it

Getting them to a training site, and back

In-School Possibilities….

Bring the community / hospital / clinic into the school via…

Simulated clinics using standardized / robotic patients

Computer simulations

Allowing For…

Creating patient cases, scenarios as needed

Patients available as needed

Videotaping to review performance

Feedback from SPs and faculty

Why simulate?

#2: Provides StandardizedBasic Clinical Training

Most med students have had little or insubstantial previous patient contact prior to clinical years

PCOM Student Survey1999-2001

0

5

10

15

20

25

30

35

40

PaidExperience

Volunteer Passive NoExperience

Why simulate?

#3: Standardization of Clinical Training and

Assessment

Pedagogical Issues

Faculty often not trained as educators, don’t understand “educational objectives” and “outcome measures”

Don’t agree on what’s important to teach and how to teach it

Can’t get faculty to show up for a meeting

Losing Control of Curriculum

Med schools lose control of the student during clinical years

Evaluating clinical performance from 3rd year through residency years is inconsistent, non-standardized

Gaining Control of Curriculum

Bring students back periodically for standardized performance exam, but logistically difficult

Possible Solution

Standardized within school clinical training program (I.e. get all faculty on same page)

Individual school approaches to teaching

Standardized assessment between schools

Compare results

Training Objectives

Why simulate?

#4: Development and Control of Assessment Protocols

Changing the conversation

“What are the core competencies”“How will students demonstrate them?”What does their performance say about

our teaching?”

Assessment Issues

Technical skillsAsking the right questionsPerforming the right PEs correctly

Exam qualityAsking the right questions the right wayPerforming a quality PE

Clinical Training Strategy

Communicate the objectives

(competencies)

Test the competencies

(outcome assessment)

Provide feedback

Remediate / re-test as needed

Skills / Exam BlueprintCase 1 Case 2 Case 3 Case 4

Hx X X X X

Px X X X X

Dx X X X X

Commun X X

Labs X X

Tx Plan X

OMT X X X X

Wellness X

Skills / Exam BlueprintHistory Questions

The student asked…

Yes / No

About location of pain

About quality of pain

About diet

Asked about previous treatment

Skills / Exam BlueprintENT Examination

The student …

Yes / No

Palpated external ear and mastoid process

Examined inner ear

Palpated frontal and maxillary sinuses

Internal examination of nose

Skills / Exam BlueprintExam Quality

The student …

Scale

1-6

Asked questions clearly

Performed a smooth PE

Treated me with respect

Was not crabby, rude

Why simulate?

#5: Patient Safety

Simulations leave actual patients unhurt / not left untreated by inexperienced clinicians

Why simulate?

#6: Building Competence Through Confidence

Simulations reduce anxiety

Failure is a great teacher, but it’s better to make mistakes in a simulation lab than in the clinic

GOAL: Reduce the “You stupid motherfucker” syndrome in clinical

education

Reduce the abuse, the smoking gun of medical errors

Learning Model

Simulation Considerations

Expenses

Hardware

Software

Space

Human Resources (SPs, staff)

Verisimilitude

How realistic does it need to be?

Authentic SimulationsStandardized Patients

Standardized Patients

Individuals who like to:

LieTake their clothes offGet touched by strangers

David Blackmore, Med. Council of Canada

Standardized Patients

Individuals trained to portray a health problem or condition in a standardized repeatable manner

SP Types

Individuals with real health problems, fixed findings

Hypertension to AIDS

SP Types

Healthy individuals trained to simulate medical problems, conditions

Disadvantages

“They’re fake patients!”

Actually, they’re real patients but the situation is simulated

SP Programs

90% of U.S. medical schools use SPs to teach and / or assess clinical skills

In the osteopathic system, 14 of 20 schools

Training Topics

History-takingComprehensive physical exam, including genital, breast and rectal examsCommunicationAssessment and treatment planningDocumentationReportingMulticultural competenceHouse calls

How Do You Standardized PE Training on Campus

Use SPs trained as physical teaching associates

SPs as Physical Teaching Associates

SPs trained to teach PE skills

Frees clinicians to teach medicine

Standardizes the teaching of PE skills

Costs

1 professor @ $100,000 + 27%

= 7,055 SP hours @ $18./hr

RoboticsHuman Simulators

Robotics

“We’re in a medical education arms race!”

Ken Veit, DO

Dean, PCOM

Model-Driven Simulators

Programmed to have real time physiologic and pharmacologic reactions to interventions and therapies

Produce a realistic patient response 

METI Human Patient Simulator

Normal, abnormal breath sounds

Chest excursion

Palpable pulses

Airway patency

Heart Sounds

Urine excretion

Human Patient Simulator(HPS)

ALS, BLS, ACLS, ATLS

50 intravenous drugs (bolus and infusion) and 5 inhalation agents (anesthetics)

Over 100 physiologic parameters can be adjusted to simulate a disease state's signs and symptoms.