A controlled evaluation of computer assisted training simulations in geriatric dentistry

The increasing number of geriatric dental patients and the development of treatment plans that require consideration of complex psychosocial, socioeconomic, and medical/medication factors necessitates a change in the traditional teaching of treatment planning. A computer-assisted instructional program was developed to simulate the dentist-geriatric patient interaction and to train students in clinical decision making for the geriatric patient. This study compared the effects of this program with a more traditional approach based on readings from the geriatric dentistry literature. Twenty third-year dental students were matched on grade point average and randomly assigned to the computer or literature-based groups. They were pretested using a clinical analogue of a geriatric patient and then instructed to use either the computer or literature-based educational units. The students were then post-tested on a second clinical analogue. Students performed similarly at pretest. At post-test, both the computer and literature-based subjects were found to have acquired significantly greater evaluation points, to make fewer errors, and to design more involved treatment plans than at pretest. Comparison of computer and literature-based subjects' performance revealed no significant main or interaction effects regarding type of educational unit used. Consistent nonsignificant trends were noted with the computer-based subjects out-performing literature-based subjects on each outcome variable. In addition, the computer-based subjects had more positive feelings about the educational unit than the literature-based subjects at a statistically significant level. These findings suggest that the computer program is an effective alternative method for developing clinical decision skills in students treating geriatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Consumer assessment of interview skills in a family practice certification examination

BACKGROUND

In New Zealand, the family practice certification examination includes an assessment that uses simulated patients. In 1990, for the first time, consumers participated in evaluating the performance of examinees in the simulated-patient section of the examination.

METHODS

The consumer examiners and medically trained examiners observed the candidates during interactions with simulated patients. The consumers, medical examiners, and simulated patients independently scored the candidates' performances. One hundred and nine examination candidates participated in two simulations each, and the scoring behavior of each rater was compared.

RESULTS

Consumer and medical examiners showed significant differences in their scoring behaviors, disagreeing on whether the candidate should pass or fail in 7.8% of interviews. In comparing the scores given by consumers, medical examiners, and the simulated patients, low inter-observer correlations were noted.

CONCLUSION

Medical personnel, consumer observers, and simulated patients all provide a different perspective on the communication skills of physicians.

HIV infection and AIDS: the ethics of medical confidentiality

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients.

Computer-based patient simulations: hospital pharmacists' performance and opinions

The performance of pharmacists in using an interactive computer-based patient simulation program and their attitudes toward the simulations are reported. The Institutional Patient Medication Simulation program is designed to enhance and evaluate the medication problem-solving skills of pharmacists. Each simulation consists of patient data-gathering, case question, and therapy decision modules with initial assessment and monitoring nodes. Five simulations were tested: gout, urinary-tract infection, congestive heart failure, antimicrobial prophylaxis in surgery, and hypertension. Pharmacists from nine hospitals were recruited for the study. Participants were asked to perform the simulations within a specified period and to complete attitudinal questionnaires. Of the 91 pharmacists who volunteered, 72 (79%) completed the simulations and the questionnaires. The practitioners indicated that the simulations adequately tested their knowledge and that they would recommend them to colleagues. Performance scores for data gathering were less than 70%, with no significant differences among the simulations. Case question scores exceeded 80% and again were consistent among simulations, whereas therapy decision scores were more variable, with the lowest scores being recorded for antimicrobial-related simulations. Pharmacists with more hospital experience tended to perform better. Pharmacists completing a patient simulation program found the simulations to be worthwhile. Performance scores indicated some difficulty in gathering patient data and showed that correct therapeutic decisions may not always occur even if adequate information is obtained.

Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship

Recent advances in educational theory and methodology have made it possible to teach medical interviewing with as much rigor as other clinical skills. We describe a first-semester, first-year medical student course that effectively teaches basic interviewing skills. This course provides faculty development, small group learning, detailed faculty and student coursebooks, and an interview checklist that delineates specific interviewing skills and content areas, serving as a template for teaching, practice, and feedback. Students have many opportunities for practice in role play and with patients, followed by feedback by self, peers, and faculty. Use of audiotape and videotape reviews enhances the learning experience. This article describes our course, suggests educational principles and standards for the teaching of medical interviewing, and presents educational research demonstrating significant gains in students' skills associated with improvement in standardized patient satisfaction.

The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient

BACKGROUND

Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office.

METHODS

Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients.

RESULTS

Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques.

CONCLUSION

The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.

Unannounced simulated patients' observations of physician STD/HIV prevention practices

Studies describing sexually transmitted disease (STD) and human immunodeficiency virus (HIV) prevention practices of primary care physicians have relied on physician or patient reports. This study describes physician STD/HIV prevention practices as observed by unannounced simulated patient evaluators (SPEs). SPEs visited sixty-five primary care physicians. Each SPE portrayed a sexually active female, new to the area, requesting a consultation on STD prevention. One-third of the physicians in the study asked no risk questions, and over 80% failed to ask the SPE specifically about her sexual practices. Most physicians discussed the risks of STDs and HIV and covered basic recommendations (use condoms and know partners better); however, few physicians provided any individualized information or advice about safer sexual practices and the specifics of condom use, such as how to use them or what kind to use. These observations support the low rates of STD/HIV prevention indicated in physicians' self-report and further identify specific deficiencies in the thoroughness of their risk assessment and preventive counseling practices.

Problems in the interpretation of small area analysis of epidemiological data: the case of cancer incidence in the West of Scotland

STUDY OBJECTIVE

The aim was to examine the extent to which random variation alone will produce differences in observed incidence rates between small areas which will affect measures of spatial clustering and estimates of relative risk.

DESIGN

This was a study of changes in the pattern of spatial concentration of cancer incidence over a five year time period. A comparison was made of observed incidence rates for 34 tumour sites with randomly generated values and, where possible, with expected values derived from known relative risks.

SETTING

Twenty six local government districts in the West of Scotland.

MAIN RESULTS

A statistically significant relationship was observed between sample size and the stability of a summary measure of spatial concentration. Almost all observed highest:mean rate ratios were within the 95% confidence interval of the simulated distribution of these values. In three cases examined, both observed and simulated highest:lowest rate ratios were larger than those expected on the basis of known exposures to risk.

CONCLUSIONS

In the absence of a prior hypothesis, small area analysis of epidemiological data for periods of less than 10 years will almost always give misleading results for all but the most common diseases.

Bacterial contamination and the effect of filters in anaesthetic circuits in a simulated patient model

In order to investigate bacterial contamination of anaesthetic breathing circuits and means of prevention of this, six different laboratory experiments were performed. These experiments involved the bacterial contamination of Dräger Narkose Spiromat 650 and Dräger AV-1 circle system circuits and of an isolated soda lime carbon dioxide absorber. The effects of anaesthetic gas, gas flow rate and the incorporation of a hydrophobic membrane heat and moisture exchanging bacterial/viral filter (HMEF) at the patient end of these circuits were investigated. It was found that without a HMEF the whole interior of the anaesthetic circuits became contaminated with bacteria. Components closest to the simulated patient showed the highest levels of contamination. Higher gas flows were associated with decreased levels of circuit contamination, presumably because more bacteria were expelled from the system. Halothane (1 volume %) and soda lime were not found to have any demonstrable bactericidal action. The presence of a HMEF between the simulated patient and the Y-piece prevented any detectable contamination from reaching the circuit. Consequently, the presence of a HMEF provides protection of the anaesthetic circuit as well as other patients, healthcare workers and the environment.

Telephone triage by primary care physicians

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P less than .05) or injured (P less than .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P less than .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

Using patient-instructors to teach and evaluate interviewing skills

The teaching and evaluation of clinical interviewing skills is a continuing challenge for medicine and dentistry. The use of patient-instructors who provide consistency in presenting scenarios has recently been pioneered in dental education. This program focused primarily on teaching and used patient-instructors to give individual feedback from the patient's perspective to students after each of five scenarios. Feedback was constructive and behaviorally oriented so that it could be applied immediately to succeeding scenarios. Rating instruments assessed both process and content skills. Results indicated that students improved significantly in interpersonal interviewing skills as they progressed through the exercise. Content skills improved only slightly. Student and faculty reaction was positive. The program is an effective and time efficient means of teaching history taking and interviewing skills as well as an effective evaluation tool.

A survey of instructional technology in dental education

Little is known about current use of hardware and non-hardware instructional technologies in dental education. To address this area, the investigators designed a questionnaire to assess support for the development of instructional technology and determine the extent to which different instructional technologies are used in North American dental schools. Responses were received from 59 of 65 dental schools (91 percent). Respondents at most schools judged the administration at their school to be supportive of the development of instructional technology, but in general, did not feel faculty were enthusiastic about or rewarded for developing innovative methods. The most common computer-based application involves testing and record keeping, which is used extensively in about half the dental schools. Individualized instruction and paper and pencil simulations are used in at least some courses at a majority of dental schools. Schools with available support services apply certain technologies to a significantly greater extent than schools without available support services.

[Simulated cases and Minitel: a tool for the studying prescriptions]

Fictional case histories can be used as a tool by researchers interested in prescription, and they can also be used for quality control and in post-graduate medical teaching. In France the existence of the Minitel telematic system should enable an easier, although restricted, application of this tool to users. Thirty-nine physicians answered questions on 9 fictional case histories using the Minitel system. Of the 1,518 decisions made, only 24.2% corresponded to the "anticipated" or "expected" answers. The percentage of non-valid responses varied from 37.0% to 99.1%. This approach may be useful for research, evaluation, identification of problems and post-graduate medical teaching.

Interns' performances with simulated patients at the beginning and the end of the intern year

OBJECTIVE

To determine whether interns' performances of technical, preventive, and communication aspects of patient care improve during the intern year.

DESIGN

A descriptive study. At the beginning and end of the intern year, interns' consultations with three simulated (standardized) patients were videotaped and scored according to explicit criteria set by an expert panel. Problems simulated were urinary tract infection, bronchitis, and tension headache.

SETTING

The casualty outpatient department in a general teaching hospital in New South Wales, Australia.

PARTICIPANTS

Twenty-eight interns rotated to the casualty department.

RESULTS

Little improvement over the intern year in technical competence or preventive care was observed, even though initial levels of compliance with criteria were quite low for some items. Greater improvement was apparent in the area of communication skills.

CONCLUSIONS

The results suggest that the internship should be restructured to more adequately teach the skills required for primary care.

Does competence of general practitioners predict their performance? Comparison between examination setting and actual practice

OBJECTIVE

To study the differences and the relation between what a doctor actually does in daily practice (performance) and what he or she is capable of doing (competence) by using national standards for general practice.

DESIGN

General practitioners were consulted by four standardised (simulated) patients portraying four different cases during normal surgery hours. Later the doctors participated in a controlled practice test, for which they were asked to perform to the best of their ability. In the test they saw exactly the same standardised cases but in different patients. The patients reported on the consultations.

SETTING

Province of Limburg, the Netherlands.

SUBJECTS

442 general practitioners invited by a letter. 137 (31%) agreed to participate, of whom 36 were selected and visited.

MAIN OUTCOME MEASURES

Number of actions taken during the consultations across complaints and for each category of complaint: the competence and performance total scores. Combination of scores with duration of consultations (efficiency-time score). Correlation between scores in the competence and performance part.

RESULTS

Mean (SD) total score across complaints for competence was 49% higher than in the performance test (81.8 (11) compared with 54.7 (10.1), p less than 0.0001). The Pearson correlation across complaints between the competence total score and the performance total score of the participating physicians was -0.04 (not significant). When efficiency and consultation time of the consultations were taken into account, the correlation was 0.45 (p less than 0.01).

CONCLUSIONS

Assessment of competence under examination circumstances can have predictive value for performance in actual practice only when factors such as efficiency and consultation time are taken into account. Below standard performance of physicians does not necessarily reflect a lack of competence. Performance and competence should be considered as distinct constructs.

A correlation of clinical performance on written test and standardised patient

The objective of the study was to determine the relationship between written responses and actual performance on a patient with a sore throat. The written test was in a format of modified essay question. The standardised patient was a medical student who had chronic recurrent pharyngotonsillitis. The study subjects were residents in the Department of Medicine who were not aware of the study objective. The 37 residents were asked to complete the written test and 18 of them were randomly selected for actual performance assessment. The standardised patient saw the selected residents during their usual service hours. The information obtained from the standardised patient, medical records and prescription slips were analysed. The results revealed: 1) Thirty per cent of the information actually performed were not recorded. 2) Thirty-four per cent of the actions described in the written test were not actually performed, most of these actions were unnecessary and superfluous. 3) There was a good correlation between written responses and actual performance on a standardised patient.

Assessment of a triage label system during a major incident exercise

The Metag triage label system was assessed during a major incident exercise at an international airport. The exercise simulated a crash of a plane carrying 40 passengers within the airport boundaries. A secondary incident also was staged involving an explosion resulting in a fire with three victims injured. The exercise involved the airport, fire, police, ambulance, and medical services of three counties--Leicestershire, Derbyshire, and Nottinghamshire. Use of the labels enabled evaluation of the triage process, early medical intervention for victims, and completion of the cards.

An innovative method of teaching Advanced Cardiac-Life Support, or why Cosmic Osmo may someday save your life

A demonstration and discussion of the effectiveness of an animated and interactive simulation of cardiac and/or respiratory arrest with tools to allow the user to reverse the fatal course of events. The simulation is designed to reinforce and teach the American Heart Association's course in Advanced Cardiac Life Support (ACLS). Using an animated interactive simulation allows the student to rehearse various critical events without assembling all the components typically used in the ACLS course "MegaCode." The simulation is written in a commercial authoring shell made by Authorware, Inc, and currently runs on an Apple Macintosh II platform. Cosmic Osmo (Activision) is an animated and interactive exploration game based in Hypercard that allows the user to explore and control the game by clicking on various switchs, buttons, objects, even telephones. The interactive spirit of this program has been carried over to the ACLS tutorial.

Establishing criterion validity of a computer-based clinical simulation

Clinical simulations, depictions of real-life patient care situations, have been used extensively in medical education. This study determined the criterion validity of a computer-based simulation which permits natural language interface and runs interactively with videotape to be fair to good (K = .61).

Continued research on computer-based testing

The National Board of Medical Examiners has developed computer-based examination formats for use in evaluating physicians in training. This paper describes continued research on these formats including attitudes about computers and effects of factors not related to the trait being measured; differences between paper-administered and computer-administered multiple-choice questions; and the characteristics of simulation formats. The implications for computer-based testing and further research are discussed.

Use of the telephone by pediatric house staff: a technique for pediatric care not taught

Pediatric house staff had difficulty taking an adequate telephone history when given a complaint of cough, vomiting, diarrhea, or rash. Increased time in training did not seem to improve history taking. Those responsible for pediatric training programs need to consider instructing house staff in the use of the telephone.