The Past, Present, and Future of the United States Medical Licensing Examination Step 2 Clinical Skills Examination

In January 2021, the United States Medical Licensing Examination (USMLE) announced the permanent suspension of their Step 2 Clinical Skills (CS) examination. Launched in 2004, the Step 2 CS examination was intended to ensure that physicians entering graduate medical education possess the necessary information gathering, clinical reasoning, and communication skills necessary to provide patient care. Although the requirement that doctors pass a clinical skills examination as a condition of licensure likely improved some elements of medical education and physician practice, the Step 2 CS examination was deeply unpopular among many medical students since its inception. The demise of USMLE Step 2 CS provides an opportunity to re-examine the test’s value and incorporate improvements in future iterations. However, doing so requires a clear understanding of why the test was so vigorously challenged. Here, we review the history of clinical skills examinations used for medical licensure in the United States and highlight the persistent concerns regarding Step 2 CS’s cost, value, validity, and lack of examinee feedback before proposing future improvements to address each concern.

Using the Higher Learning Commission's Assessment Culture Matrix to Support Continuous Quality Improvement of a Simulated Patient Program

The purpose of this commentary is to advocate for the use of the Higher Learning Commission's Assessment Culture Matrix to support continuous quality improvement (CQI) of simulated patient (SP) programs. We will share examples from our program demonstrating our maturation as it relates to leadership, shared mission and vision, faculty, and resources. While we are at the beginning stages of engaging students, we continue to make progress accessing and systematically using assessment data. We anticipate that sharing our process for utilizing this matrix may help other institutions as they conduct CQI with their SP programs and in other areas of their assessment portfolio.

Effect of a standardized patient encounter on first year medical student confidence and satisfaction with telemedicine

CONTEXT

Although the coronavirus 2019 (COVID-19) pandemic has accelerated the use of telemedicine platforms across the country, medical students may lack confidence in their ability to conduct satisfactory patient encounters and practice clinical medicine through telemedicine.

OBJECTIVES

To evaluate the role of a standardized patient encounter on first year medical student confidence and satisfaction in using telemedicine.

METHODS

One hundred and sixty two first year medical students recruited from Edward Via College of Osteopathic Medicine-Carolinas campus were surveyed on their confidence and satisfaction with using telemedicine platforms before and after conducting a patient encounter. Participant confidence and satisfaction were assessed with a five point Likert scale: "not confident," "a little confident," "somewhat confident," "confident," and "extremely confident."

RESULTS

Of 162 students, 103 (63.6%) completed the preencounter survey and 74 (45.7%) completed the postencounter survey. Before the standardized patient encounter, 37 participants (35.9%) reported that they were "a little confident" and 20 participants (19.4%) reported that they were "not confident" in their ability to conduct a patient interview using a telemedicine platform. Following the encounter, 24 students (32.4%) reported feeling "somewhat confident", and 32 (43.2%) reported feeling "confident" in their ability.

CONCLUSIONS

Medical students' confidence and satisfaction with telemedicine improved after a standardized patient telemedicine experience in this study. This experience allowed students to practice the unique skills required for telemedicine. Medical schools might consider adding a telemedicine curriculum and standardized patient experiences in the undergraduate medical setting.

Comparing the Quality of Primary Care between Public and Private Providers in Urban China: A Standardized Patient Study

Previous studies have been limited by not directly comparing the quality of public and private CHCs using a standardized patient method (SP). This study aims to evaluate and compare the quality of the primary care provided by public and private CHCs using a standardized patient method in urban China. We recruited 12 standardized patients from the local community presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. We measured the quality of primary care on seven criteria: (1) adherence to checklists, (2) correct diagnosis, (3) correct treatment, (4) number of unnecessary exams and drugs, (5) diagnosis time, (6) expense of visit, (7) patient-centered communication. Significant quality differences were observed between public CHCs and private CHCs. Private CHC physicians performed 4.73 percentage points lower of recommended questions and exams in the checklist. Compared with private CHCs, public CHC providers were more likely to give a higher proportion of correct diagnosis and correct treatment. Private CHCs provided 1.42 fewer items of unnecessary exams and provided 0.32 more items of unnecessary drugs. Private CHC physicians received a 9.31 lower score in patient-centered communication. There is significant quality inequality in different primary care models. Public CHC physicians might provide a higher quality of service. Creating a comprehensive, flexible, and integrated health care system should be considered an effective approach towards optimizing the management of CHC models.

Doctor-patient communication during the Corona crisis - web-based interactions and structured feedback from standardized patients at the University of Basel and the LMU Munich

Background: Due to the pandemic-related restrictions in classroom teaching at the medical faculties of the LMU Munich and the University of Basel, teaching methods with standardized patients (SPs), were shifted to a digital, web-based format at short notice as of April 2020. We report on our experiences with the WebEncounter program, which was used for the first time in German-speaking countries. The program enables one-to-one encounters between SPs and students. Students receive an invitational email with brief instructions and background information on the case. SPs use case-specific criteria that are compliant with the learning objectives for digital evaluation during the encounter. A feedback session takes place immediately following the encounter. The SPs address the didactically relevant sections and can illustrate them with the corresponding video sequences. Finally, the students receive the links to the video recordings of the encounter and the feedback unit by email. Project description: The aim of this pilot study was to analyze the practicability of the program and its acceptance by students and SPs. In addition, we examined whether the operationalization of the learning objectives in the form of assessment items has an impact on the content and thematic development of courses in the area of doctor-patient communication. Methods: To implement the program, patient cases previously tested in communication seminars in Munich and Basel were rewritten and case-specific evaluation criteria were developed. SPs were trained to use the program, to present their patient figure online and to give feedback. The experience of those involved (faculty, SPs and SP trainers, students) in implementing the program was documented at various levels. The frequency and causes of technical problems were described. Student results on the patient cases and on the feedback items were collected quantitatively and, where possible, supplemented by free-text statements. Results: Data from 218/220 students in Basel and 120/127 students in Munich were collected and evaluated. Students were very satisfied with the patient cases, the encounter with the SPs and their feedback: 3.81±0.42. SPs experienced the training as an increase in their competence and the structured feedback as particularly positive. The training effort per SP was between 2.5 and 4 hours. The results show predominantly normally-distributed, case-specific sum scores of the evaluation criteria. The analysis of the individual assessment items refers to learning objectives that students find difficult to achieve (e.g. explicitly structuring the conversation). Problems in the technical implementation (<10 percent of the encounters) were due mainly to the use of insufficient hardware or internet connection problems. The need to define case-specific evaluation criteria triggered a discussion in the group of study directors about learning objectives and their operationalization. Summary: Web-based encounters can be built into the ongoing communication curriculum with reasonable effort. Training the SPs and heeding the technical requirements are of central importance. Practicing the virtual consultation was evaluated very positively by the students - in particular, the immediate feedback in the protected dialogue was appreciated by all involved.

The Efficacy of Hybrid Telesimulation with Standardized Patients in Teaching Medical Students Clinical Lactation Skills: A Pilot Study

Introduction: Medical students lack competencies in clinical lactation. We determined the effect of hybrid telesimulation with a standardized patient (SP) on medical students' clinical performance in lactation support. We assessed students' engagement and satisfaction with the experience. Materials and Methods: Undergraduate medical students (n = 13) completed (1) preparatory case scenarios with multiple-choice questions and (2) three telesimulations with SPs wearing a high-fidelity breast model. Students had the option to complete the Encounter Documentation. SPs used the Formative Assessment Rubric (FAR) to evaluate students' interpersonal skills and clinical lactation experts used the Summative Assessment Rubric to evaluate documentation skills. Investigators collected satisfaction data from a focus group and written evaluation. Dunn's multiple comparison and Freidman tests were used to measure differences in FAR scores between cases and telesimulations. Qualitative data were analyzed using thematic analysis. Results: Most students (70%) attempted case questions multiple times and scores improved (p < 0.0001) between attempts. FAR scores suggest students were prepared for telesimulations (5.5/6-pt Likert) and interpersonal skills were appropriate (5.4/6), with no differences by case (p = 0.11). FAR scores increased between telesimulation 1-2 (+24.5/114, p = 0.002) and 2-3 (+17.5/114, p = 0.014). Students were satisfied with the experience and would recommend it to classmates (both 4.6/6). Thematic analysis revealed feedback regarding interpersonal skills was helpful. Conclusions: Medical students must develop skills to support breastfeeding in virtual settings. Telesimulation can be incorporated into existing curricula to support clinical lactation competencies.

Assessment of Diagnostic Competences With Standardized Patients Versus Virtual Patients: Experimental Study in the Context of History Taking

BACKGROUND

Standardized patients (SPs) have been one of the popular assessment methods in clinical teaching for decades, although they are resource intensive. Nowadays, simulated virtual patients (VPs) are increasingly used because they are permanently available and fully scalable to a large audience. However, empirical studies comparing the differential effects of these assessment methods are lacking. Similarly, the relationships between key variables associated with diagnostic competences (ie, diagnostic accuracy and evidence generation) in these assessment methods still require further research.

OBJECTIVE

The aim of this study is to compare perceived authenticity, cognitive load, and diagnostic competences in performance-based assessment using SPs and VPs. This study also aims to examine the relationships of perceived authenticity, cognitive load, and quality of evidence generation with diagnostic accuracy.

METHODS

We conducted an experimental study with 86 medical students (mean 26.03 years, SD 4.71) focusing on history taking in dyspnea cases. Participants solved three cases with SPs and three cases with VPs in this repeated measures study. After each case, students provided a diagnosis and rated perceived authenticity and cognitive load. The provided diagnosis was scored in terms of diagnostic accuracy; the questions asked by the medical students were rated with respect to their quality of evidence generation. In addition to regular null hypothesis testing, this study used equivalence testing to investigate the absence of meaningful effects.

RESULTS

Perceived authenticity (1-tailed t81=11.12; P<.001) was higher for SPs than for VPs. The correlation between diagnostic accuracy and perceived authenticity was very small (r=0.05) and neither equivalent (P=.09) nor statistically significant (P=.32). Cognitive load was equivalent in both assessment methods (t82=2.81; P=.003). Intrinsic cognitive load (1-tailed r=-0.30; P=.003) and extraneous load (1-tailed r=-0.29; P=.003) correlated negatively with the combined score for diagnostic accuracy. The quality of evidence generation was positively related to diagnostic accuracy for VPs (1-tailed r=0.38; P<.001); this finding did not hold for SPs (1-tailed r=0.05; P=.32). Comparing both assessment methods with each other, diagnostic accuracy was higher for SPs than for VPs (2-tailed t85=2.49; P=.01).

CONCLUSIONS

The results on perceived authenticity demonstrate that learners experience SPs as more authentic than VPs. As higher amounts of intrinsic and extraneous cognitive loads are detrimental to performance, both types of cognitive load must be monitored and manipulated systematically in the assessment. Diagnostic accuracy was higher for SPs than for VPs, which could potentially negatively affect students' grades with VPs. We identify and discuss possible reasons for this performance difference between both assessment methods.

Improving Health Professions Students' Understanding of Interprofessional Roles Through Participation in a Patient Stabilization Simulation

Objective. To teach interprofessional communication and teamwork skills to health professions students through a standardized patient simulation on acute patient stabilization and measure the impact on learners' perceptions of interprofessional collaboration.Methods. Medical and pharmacy students in their final year and post-licensure nurses in their initial six-month probationary period worked together to stabilize a simulated acutely ill standardized patient. Perceptions of IPE were assessed pre- and post-simulation using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument, version 2 (SPICE-R2). Medical student participants' scores were compared to those of a concurrently enrolled cohort of medical students who did not participate in the simulation.Results. Eighty learners participated in the simulation and all completed pre and post SPICE-R2 assessments. Learners' perceptions increased significantly in all domains, including understanding of roles in collaborative practice, interprofessional teamwork and team-based practice, and patient outcomes from collaborative practice. Compared to the control cohort, participants' perceptions of team-based practice and the impact on patient outcomes improved significantly, while a statistically similar improvement in scores for understanding of roles and responsibilities was seen. The SPICE-R2 scores increased similarly among students in each profession. Repeat exposure to the simulation continued to improve perceptions but not as robustly as the initial simulation.Conclusion. This simulation changed learners' perceptions of how interprofessional collaboration affects patient care, which supports the incorporation of standardized patient-based interprofessional education even in the late-stage education of health professionals.

Telemedicine Training in the COVID Era: Revamping a Routine OSCE to Prepare Medicine Residents for Virtual Care

BACKGROUND

During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to virtual modalities for providing routine care to patient panels. Like training programs nationwide, telemedicine training and assessment had not been systematically incorporated into our residency. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a remote modality to become virtual care-focused learning experience for trainees and to provide valuable feedback to educators.

METHODS

Standardized Patients (SPs) rated residents on their communication (including information gathering, relationship development and patient education), patient activation and satisfaction, and telemedicine skills. Analyses included a comparison of domain scores for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident comments about the virtual OSCE.

RESULTS

During 2020's video visit OSCE (VOSCE), residents (n = 23) excelled at nonverbal communication but struggled with virtual physical exams and information gathering. In debrief, residents expressed substantial interest in more opportunity to practice virtual visit skills going forward. In comparing scores of the virtual care (2020) OSCE with the in-person (2019) version, the small subset of residents who participated in both assessments (n = 9) performed similarly on communication skills, patient satisfaction and activation. Patient education scores were significantly lower during the virtual care OSCE (P = .008).

CONCLUSION

Our reformulated OSCE accomplished 3 goals including; (1) physically distancing residents from SPs per COVID regulations, (2) providing residents with the opportunity to practice critical virtual visit skills, and (3) alerting our educators to curricular improvement areas. Our methods are useful for other institutions and have applications to the larger medical education community.

Simulated Patients for Competency-Based Undergraduate Medical Education Post COVID-19: A New Normal in India

The conventional medical curriculum in India needed more focus on explicit teaching and assessment of interpersonal and communication skills, professionalism, team-work and reflection for prevention and better management of increasing incidences of violence against doctors by building good doctor-patient relationships. Increasing number of seats in Indian medical colleges, decreasing hospital stay of patients, and decrease in faculty requirements will hamper adequate supervised authentic clinical experiences of undergraduates for developing clinical skills. The recent COVID-19 pandemic has led to a significant decrease in student-patient encounters. Simulated patients are being used in many countries to address many of these issues. To make the Indian medical graduates competent to function as primary physician of first contact, competency-based medical education along with guidelines for use of skill-lab and simulation has been introduced from 2019. The current review is focused on the need and use of simulated patients; their advantages, limitations and role in students' teaching and assessment. It also gives a brief outline of their training process. Simulated patients should be used to supplement day-to-day learning, help in transition to attending real patients and also save enormous faculty time in the post-COVID-19 new normal. However, simulated patients are unlikely to completely replace real patients' experiences.

An assessment of the efficacy of clinical skills simulation using standardized patient in teaching behavior management and modification skills in Pediatric Dentistry to dental undergraduate students: A double-blinded, randomized, controlled trial

BACKGROUND

Clinical skills simulation (CSS) is an important tool in teaching and learning. The literature review showed a scarcity of research data regarding the use of CSS,in teaching, especially in dentistry. The use of CSS in dental teaching was found restricted to the use of low fidelity typhodonts fitted to phantom heads used in teaching cavity preparation and crown cutting.

AIM

The aim of the study was to determine the efficacy of CSS using standardized patient in teaching behavior management and modification skills to dental undergraduate students.

SETTINGS AND DESIGN

This double-blinded, randomized controlled trial was undertaken among 3^rd year dental undergraduate students, and the study was undertaken at the Department of Pediatric and Preventive Dentistry.

MATERIALS AND METHODS

Fifty, 3^rd year BDS students were randomly allotted to simulation and nonsimulation groups. Baseline data regarding their knowledge in the behavior management of child patients were assessed. Simulation group was further divided into group of six students and underwent CSS with standardized patient. Pretest and posttest knowledge regarding behavior management was assessed in the simulation group using questionnaires approved by an expert committee. The results were analyzed to see if there is any improvement in their knowledge after CSS. Students in simulation and nonsimulation groups were assessed for their behavior management skills during patient management, by an independent observer, using a checklist.

STATISTICAL ANALYSIS

Mean, standard deviation (SD), and unpaired student t-test were done to assess the baseline knowledge of students who participated in the study. Mean, SD, and paired t-test were used to compare the pretest and posttest score of students who underwent simulation. Mean, SD, and unpaired t-test were used to compare the behavior management skills of both groups of students.

RESULTS AND CONCLUSIONS

The knowledge of students in both groups before the study was comparable with no statistically significant differences. There was a statistically significant improvement in the knowledge of students who underwent CSS regarding behavior management of child patients. The unpaired Student's t-test showed a significant difference in the behavior management skill of dental undergraduate students when treating a child patient. The students who underwent CSS fared better compared to students who were taught behavior management methods by traditional methods only. Clinical skill simulation using standardized patient is an effective adjunct to be used along with traditional method of teaching while teaching behavior management and modification skills to dental undergraduate students.

Delivering a geriatric OSCE station in times of Covid-19 using makeup artistry

In the wake of the Covid-19 pandemic, people over 65 or suffering from certain conditions were deemed at high risk and asked to isolate themselves. This led to the simulated patient (SP) program at the University of Bern being depleted of middle-aged and elderly SP. Meanwhile, an OSCE had to be delivered using adapted cases that minimized physical contact between candidates and SP. Short of suitable cases at such short notice, the case of an elderly patient with postural instability had to be added to the exam blueprint. With elderly SP off the roster, it was decided to use makeup effects to achieve visual authenticity. A combination of wigs (grey hair, hairdo), 3D Probondo transfers (forehead wrinkles), old age stipple (crow's feet), and colouring (age spots) were used to achieve the old-age effects, while SPs wore scarves to cover their neckline. The lower face was covered with protective face masks in accordance with the exam's Covid-19 hygiene protocol. Case-related feedback from candidates and examiners was analysed for any direct or indirect remark attributable to the ageing effects. As no comment touched upon the subject of the appearance of age, this was interpreted as success, as any distracting effect from the SPs' appearance in this regard would surely have prompted remarks or even complaints. The SPs' feedback revealed how applying the ageing effects helped them adopt the octogenarian's role. This report explains how SP in their fifties were made fit for an octogenarian's case in an OSCE using makeup effects. The effort required for the ageing simulation was considerable, but it is hoped that in future, with more planning time, the amount of effort required can be reduced. The feedback obtained from the candidates suggest the appearance of SPs was not experienced as a distraction, which was the primary objective of this exercise. Adapting our approach to their own contexts allows educators to include cases with elderly patients in their OSCE that cannot be re-written for younger SP, so long as Covid-19 prevents elderly SP from participating.

Sexual Health in Child and Adolescent Psychiatry: Multi-Site Implementation Through Synchronized Videoconferencing of an Educational Resource Using Standardized Patients

Objective: Matters of sexuality and sexual health are common in the practice of child and adolescent psychiatry (CAP), yet clinicians can feel ill-equipped to address them with confidence. To address this gap in training and practice, we developed, implemented, and evaluated an educational module enhanced by videotaped depictions of expert clinicians interacting with professional actors performing as standardized patients (SPs). Methods: We developed an educational resource highlighting common issues of sexual health relevant to CAP practice, including sexual development, psychotropic-related side effects, and sexuality in children with autism. We wrote original scripts, based on which two clinicians interacted with three SPs. Digital recordings were edited to yield 5 clips with a cumulative running time of 20 min. The clips were interspersed during a 90-min session comprising didactic and interactive components. Due to the COVID-19 pandemic, we used synchronous videoconferencing, which allowed content dissemination to several training programs across the country. Results: We recruited 125 learners from 16 CAP training programs through the American Academy of CAP's Alliance for Learning and Innovation (AALI). Routine inquiry into adolescent patients' sexual function was uncommon, reported by only 28% of participants, with "awkward" and "uncomfortable" the most common terms mentioned in reference to the clinical task. The didactic intervention led to measurable improvements after 2 weeks in skills and knowledge (p = 0.004) and in attitudes (p < 0.001). The three items with the greatest improvement were: (a) availability of developmentally tailored resources; (b) comfort in addressing sexual development with underage patients; and (c) with parents or guardians of neuroatypical or developmentally disabled patients (p < 0.001 for each). Conclusions: A sexual health curriculum enriched by video-based examples can lead to measurable improvement in outcomes pertinent to the clinical practice of CAP. These educational materials are available for distribution, use and adaptation by local instructors. Our study also provides proof-of-principle for the use of multisite educational initiatives in CAP through synchronized videoconferencing.

Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: a Case Study and Lessons Learned

INTRODUCTION

Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care.

AIM

This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents.

SETTING

Primary Care Internal Medicine residents at a large urban academic hospital.

PROGRAM DESCRIPTION

In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter.

PROGRAM EVALUATION

Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development.

DISCUSSION

Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.

Impact of Standardized Patients on First Semester Nursing Students Self-Confidence, Satisfaction, and Communication in a Simulated Clinical Case

Background

Utilizing standardized patients (SPs) as a strategy to potentially improve beginning level nursing students’ confidence, satisfaction, and communication after simulated clinical cases is an innovative approach in nursing education.

Aim

The aim of this study was to examine to what extent an SP affected first semester nursing students’ self-confidence, satisfaction, and communication using a simulated clinical case.

Methods

First semester undergraduate students in a bachelors of nursing program at a large university in the South-Central region of the United States (N = 100), were randomly assigned to one of the two groups. Each group was assigned the same case using either an SP or high-fidelity manikin. Students completed postsurveys immediately following completion of the simulation. Student’s self-confidence, satisfaction, and communication were measured using the National League for Nursing Student Satisfaction and Self-Confidence in Learning for Nursing Education Research and an SP/Faculty Communication Checklist.

Results

An independent sample t test comparing the two student groups on each of the outcome variables was conducted for each of the research questions. Students who completed the simulation with an SP, reported greater satisfaction, and improved communication. Student reflective comments were significantly more positive in the SP group. There was no statistical difference between the two groups in self-confidence.

Conclusion

Further research is needed to determine whether the use of SPs versus high-fidelity manikins in simulated cases results in increased self-confidence in beginning level nursing students. Student satisfaction and communication are key components for nursing student success. The impact of SPs and the effect on student outcomes could have long-term benefits for undergraduate nursing programs.

Assessing Advanced Communication Skills via Objective Structured Clinical Examination: A Comparison of Faculty Versus Self, Peer, and Standardized Patient Assessors

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.

Use of Simulated Patients in Disaster Medicine Training: A Systematic Review

Simulation is an effective teaching tool in disaster medicine education, and the use of simulated patients (SPs) is a frequently adopted technique. Throughout this article, we critically analyzed the use and the preparation of SPs in the context of simulation in disaster medicine. A systematic review of English, French, and Italian language articles was performed on PubMed and Google Scholar. Studies were included if reporting the use of SPs in disaster medicine training. Exclusion criteria included abstracts, citations, theses, articles not dealing with disaster medicine, and articles not using human actors in simulation. Eighteen papers were examined. All the studies were conducted in Western countries. Case reports represent 50% of references. Only in 44.4% of articles, the beneficiaries of simulations were students, while in most of cases were professionals. In 61.1% of studies SPs were moulaged, and in 72.2%, a method to simulate victim symptoms was adopted. Ten papers included a previous training for SPs and their involvement in the participants' assessment at the end of the simulation. Finally, this systematic review revealed that there is still a lack of uniformity about the use of SPs in the disaster medicine simulations.

Use of Standardized Patients in Endocrinology Fellowship Programs to Teach Competent Transgender Care

Purpose

Transgender and gender-nonconforming individuals have unique health care needs and have difficulty accessing health care services because of a lack of qualified health care providers, insurance coverage, mistreatment, and bias by the medical community. Medical trainees and physicians report a lack of education in, and exposure to, the clinical care and unique aspects of this field. We assessed the use of a standardized patient as a tool to evaluate 4 core medical competencies (patient care, medical knowledge, professionalism, and interpersonal communication) of endocrinology fellows at a single training program.

Methods

Endocrine fellows were evaluated by faculty in different aspects of transgender care and completed a self-assessment before and after the exercise. Faculty viewed the fellows during the Objective Clinical Structured Examination. Fellows were provided feedback by a faculty member and the standardized patient after the exercise.

Results

Deficits were found in patient care and professionalism. Fellows scored well in medical knowledge. Fellows did not report an improvement in comfort and communication skills after the exercise. Interestingly, fellows’ self-assessment scores in several domains declined after the standardized patient encounter, highlighting an occasion for self-reflection and growth within the realms of cultural competency and medical knowledge.

Main conclusions

We conclude that use of standardized patients to teach medical competencies in transgender medicine may be one approach to improve exposure to, and training in, transgender medicine. Endocrine fellows still had discomfort treating transgender individuals after the standardized patient encounter and require other training activities that may include didactics and clinical case discussions.

A Web-Based Alcohol Screening and Brief Intervention Training Module Within Physician Assistant Programs in the Midwest to Increase Knowledge, Attitudes, and Confidence: Evaluation Study

BACKGROUND

Preventing and reducing risky alcohol use and its side effects remains a public health priority. Discussing alcohol use with patients can be difficult; dedicated training for health care providers is needed to facilitate these conversations. A Web-based alcohol screening and brief intervention (SBI), comprising didactic and skills application training, was designed for physician assistant students.

OBJECTIVE

This paper details experiences and outcomes in developing an alcohol SBI training curriculum and coordinating virtual encounters with standardized patients. We also explain challenges faced with developing an alcohol SBI training and a Web-based learning management site to fit the needs of 5 different physician assistant programs.

METHODS

Training development comprised 3 phases-precourse, development, and implementation. The precourse phase included developing the initial training curriculum, building a website, and testing with a pilot group. The development phase refined the training curriculum based on user feedback and moved into a three-component module: didactic training module, guided interactive encounter with a simulated patient, and live encounter with a standardized patient. A learning management system website was also created. In the implementation phase, 5 physician assistant schools incorporated the Web-based training into curricula. Each school modified the implementation method to suit their organizational environment. Evaluation methods included pre- and postchange over time on trainee attitudes, knowledge, and skills (confidence) on talking to patients about alcohol use, trainee self-reported proficiency on the standardized patient encounter, standardized patient evaluation of the trainee proficiency during the alcohol use conversation, user evaluation of the type of technology mode for the standardized patient conversation, and overall trainee satisfaction with the Web-based training on alcohol SBI.

RESULTS

Final evaluation outcomes indicated a significant (P<.01) change over time in trainee knowledge and skills (confidence) in the conduct of the alcohol SBI with a standardized patient, regardless of the program implementation method. Trainees were generally satisfied with the Web-based training experience and rated the use of the videoconference medium as most useful when conducting the alcohol SBI conversation with the standardized patient. Training that included a primer on the importance of screening, individual participation in the Web-based didactic alcohol SBI modules, and virtual encounters with standardized patients through a university-based simulation center was the most widely accepted. Successful implementation included program investment and curriculum planning. Implementation barriers involved technical challenges with standardized patient encounters and simulation center logistics, and varying physician assistant school characteristics.

CONCLUSIONS

Development and implementation of Web-based educational modules to educate health care professionals on alcohol SBI is effective, easy to reproduce, and readily accessible. Identifying challenges affecting development, implementation, and utilization of learned techniques in practice, enhances facilitation of learning and training efficacy. As the value of technology-based learning becomes more apparent, reports detailing what has worked versus what has not may help guide the process.

Enhancing Medical Learners' Knowledge of, Comfort and Confidence in Holding Serious Illness Conversations

OBJECTIVES

Having early discussions with seriously ill patients about their priorities and values can improve their peace of mind and family outcomes during bereavement; however, physicians and medical students report feeling underprepared to hold serious illness conversations. We evaluated the impact of the Serious Illness Care Program clinician training workshop on medical learners' knowledge of comfort and confidence in holding such conversations.

METHODS

Eligible learners were penultimate- or final-year medical students or first-year residents of generalist programs (Family Medicine, Internal Medicine). Learners participated in a 2.5-hour workshop involving reflection on serious illness discussions, didactic teaching and demonstration of the Serious Illness Conversation Guide (SICG), role play with standardized patients, direct observation, and feedback from experts. Participants completed pre- and post-intervention questionnaires with Likert-type scale and open-ended questions, which were analyzed using paired t tests and qualitative content analysis, respectively.

RESULTS

We enrolled 25 learners. The intervention was associated with an increase in knowledge (P < .001) and self-efficacy (P < .001). All learners reported gaining new skills, with a majority specifically identifying a framework for structuring serious illness conversations in the qualitative analysis (n = 14, 56%). Participants stated the workshops would improve their comfort in holding serious illness conversations (n = 24, 96%), and that it would be valuable to integrate the workshops into their formal curricula (n = 23, 92%).

CONCLUSIONS

Training on the use of the SICG is novel for medical students and first-year residents and associated with the improvement in their knowledge of and perceived capacity to hold serious illness conversations. This study suggests that the integration of SICG training into medical curricula may have educational value.

Effect of SEGUE-based communication education on nursing simulation practice: a quasi-experimental design

Background: Effective educational approaches are required to enhance nursing students' communication competency.Objectives: To  evaluate the effectiveness of SEGUE ('set the stage,' 'elicit information,' 'give information,' 'understand the patient's perspective,' and 'end the encounter')-based communication education.Design: A non-equivalent control group pretest-posttest design.Methods: Students were randomized into the control group (n = 41) and experimental group (n = 57). Communication competency and efficacy were measured via a self-report questionnaire and via ratings of the students from professor and standardized patient.Results: Scores by students (self-evaluations; p < .001), professor (p < .001), and standardized patient (p < .042) showed higher communication competency in the experimental group. Compared with the control group, the pre-post difference in communication efficacy in the experimental group was increased (p = .004).Conclusions: Simulation practice to reflect the various clinical situation is recommended to improve students' communication.Impact statement: SEGUE-based communication education in nursing simulation practice with the standardized patient was an effective strategy for improving nursing students' communication.

Transgender Standardized Patient Simulation: Management of an Oncological Emergency

Introduction: This article describes the development process of Transgender Standardized Patient Simulation (TSPS) as an innovative cultural competence education and its pilot testing as part of the students' program of study. The multidimensional education strategy, TSPS, aimed to improve students' knowledge, skills, attitudes, and confidence in providing culturally sensitive care to a transgender patient experiencing an oncological emergency. Methodology: The design of the TSPS followed the cultural competence and confidence model and international simulation guidelines. Content validity of the TSPS was established. As our usual simulation assessment survey, the adapted simulation effectiveness tool-modified was used to evaluate if the TSPS met with students' learning need. Results: Participants (n = 32) strongly agreed that the TSPS met with their learning expectations and needs and improved their ability to provide culturally sensitive care. Discussion: Training and practice in this area is much needed and well-received by nursing students and faculty.

Enhancing Nursing Students' Competency Skills With a Workplace Violence Nursing Simulation: Translating Knowledge Into Practice

The phenomenon of workplace violence (WPV) is prevalent in clinical settings affecting nurses and nursing students. Mental health nursing simulations may be used to impart knowledge and skills to nursing students to manage and prevent incidents of WPV. This article presents attained competency skills by nursing students after attending a simulation, and how they implemented their knowledge learned in their clinical rotations. Students attended a Mental Health Nursing Simulation on WPV and completed surveys. The simulation enhanced the students' communication skills, empathy, ability to manage verbally aggressive patients, ability to set personal boundaries, and ability to seek support from others. Participants reported physical and verbal forms of WPV and application of learned evidence-based skills in their clinical rotations. Evidence-based skills to manage and prevent WPV taught to nursing students via mental health nursing simulations can enhance their clinical competency, and they should be embedded in a nursing curriculum.

Reliability of scores obtained from standardized patient and instructor assessments

INTRODUCTION

To obtain more reliable results from observation-based assessments, high-quality raters are key. Although this quality can be obtained by using instructors, extra workload can be a burden on them. To overcome this problem, one alternative to instructor raters can be standardized patients (SPs).

METHOD

In this study, the students carried out an SP interview related to communication with an applicant/patient in the context of clinical skills training course. SPs rated student interviews just after interview and after watching a recording. Instructors rated students just by watching the recordings. To determine the appropriateness of use of SPs as raters, ratings of SPs and instructors were compared by using mean scores given to the interview performances of students' communication skills. Moreover, G theory was used to determine the reliability of scores.

RESULTS

Standardized patients' ratings immediately after the interviews showed the highest scores, and these ratings were statistically different from the SPs' and instructors' ratings done while watching recordings. Besides, the G coefficient for the 4 instructors was 0.71, while that for the 12 SPs was estimated as 0.73. However, even when using 12 SPs, the obtained reliability coefficient of 0.73 brings into question the reliability of their ratings. Moreover, it was found that the one who contributed the most to reliability among instructors was the most experienced person in subject area.

CONCLUSIONS

If SPs are to be used as raters, they will need more comprehensive training. More importantly, regardless of who the rater is, rater training is one of the most important factors in achieving more reliable and valid results. Moreover, having experience and knowledge about assessed topic is another crucial point of performance assessment by means of obtaining reliable results.

Breastfeeding Simulation With the Standardized Patient

Despite an emphasis on lactation and the availability of resources to support and sustain lactation, our community hospital's rates of exclusive breastfeeding remained less than the 50% to 70% benchmark recommended by The Joint Commission and the World Health Organization. Concluding that we had exhausted the majority of evidence-based best practices described in the literature, we sought to find a new way to provide an engaging, useful medium for nursing education and improvement of clinical nurses' skills related to breastfeeding. Here, we describe the simulation program we developed using the standardized patient model. Although our rates of exclusive breastfeeding remained unchanged after introducing the simulation program, the experience enabled us to identify inconsistent practices and knowledge gaps.