Evaluating students’ clinical performances can be difficult when clinician trainees work in diverse clinical settings where they may not see the same types of patients. Students at the University of Louisville learn and polish their clinical skills and are evaluated doing so through the School of Medicine’s Standardized Patient Program.
UofL Today talked to Carrie Bohnert, assistant director, recently about the program and its role in health care education.
What is the standardized patient program?
The standardized patient program at UofL’s School of Medicine hires everyday people and trains them to portray different symptoms and different affects, such as how someone who has a pain classification of level 10 might act differently than someone who has level one pain. The purpose is for medical students to practice before they see actual patients, and so we can evaluate their skills.
Can you explain what is meant by “affect” and why it is important?
Someone who is in a lot of pain may give one word answers, not be able to make eye contact, they may scrunch up their face. Someone whose pain is less intense may be able to carry on a conversation. Students are going to see patients that run the gamut between terrible pain and more manageable pain, and it’s important that we train them to be able to respond to anything.
At what stages of their medical training do you work with students?
We see students beginning in their second or third week of school all the way through their fourth year.
When they first come in we are a formative learning experience. We teach them the basics of asking a patient about their medical history, then we go into teaching them about the physical exam. The idea is that instead of learning it in a lecture hall, they can learn the skills of physical exam an actual person. They’ll talk about it in their classes, early on, but this gives them the hands-on skills that really round out their experience.
By the time students are in their fourth year, we are used to evaluate their clinical skills. Are they asking the right questions, performing the physical exam properly, and communicating with patients in a way that is satisfying to the patient?
What kinds of skills do you work on with students?
We work on all kinds of skills, from taking a history and doing a physical to complex communications skills. We start with the easier communications skills, such as exercise counseling and move up through breaking bad news, admitting mistakes, dealing with difficult patients, and “do not resuscitate” orders. The faculty set up their learning objectives — for instance, they want to know how complete a history the students are taking — and they set up a checklist based on what they want to assess. We write a scenario based on what they want to know about a student’s skills, so we can evaluate how well a student is performing.
As an example, at the end of their family medicine rotation, students come in and see three patients in the clinic. Our program gives faculty the opportunity to standardize what students see and assess them on it — we can see if all students know how to treat a pneumonia, for example. In their work with actual patients, we can’t guarantee that every student will even see a pneumonia. So this allows us to equalize the curriculum, so we can get objective standards on which to evaluate students’ performance in the clinic.
How long has it been operating?
How do you describe the goal of the program?
The mission is to provide a supportive environment in which students of medicine and other health science fields can learn, practice and be assessed for skills that contribute to the highest quality patient-centered care. We see mostly medical students, but we also work with students from the nursing, social work, and dental schools.
What types of disease/conditions do you simulate?
We really cover a lot. In psychiatry, we do borderline personality disorder, obsessive-compulsive disorder, schizophrenia, among others. In pediatrics, we do things like meningitis and failure to thrive. In surgery, we cover things like appendicitis and cholecystitis. In family medicine, we cover asthma, reflux, hypertension, migraine, high cholesterol, and other conditions and diseases.
Off-site, we work with second year students at the Center for Women and Families, to help them practice domestic violence and sexual assault history. We work with pediatric residents in the pediatric intensive care unit, on admitting a mistake, dealing with an angry parent, dealing with end-of-life issues, decisions about heroic measures.
How do you simulate the situations you’ve described?
With pediatrics, there is not a child in the room, there is just a “parent,” and the students interact with the parent. With cases like appendectomy, the patient would actually start out lying on the bed, curled tightly in a ball, holding his stomach; they are trained so that if a student accidentally bumps the table, they may cry out in pain, and if the student pushes on a certain place on their belly, they give a certain reaction.
For certain conditions, like gout, we use a type of medical make-up called moulage, which allows us to simulate rashes, burns, lacerations, bruises and blisters. For gout, we create an inflamed toe joint. The program has also been involved in the past with bioterrorism training, and we can use moulage to simulate radiation burns, ebola, smallpox. We’ve done work with first responders, both military and non-military, and with them we’ve done more injury simulation — gunshot wounds, eviscerations, shrapnel.
Who are the actors (generally speaking, where do they come from)?
When the program started, we mostly had actors, and now we’re mostly not actors. It’s kind of a debate in SP circles, are we actors, or are we not actors — in my opinion we are everyday people, who have symptoms. We don’t want to create Oscar-worthy performances, we want to simulate everyday people. I’m as much myself as possible but today I have a really bad headache, for instance.
The people we get are all referred by word-of-mouth, either they hear about it from a friend, or from staff. We have a broad brush of demographics — age, race, sexual orientation, socieoeconomic status, body type.
We have a roster of 70 people, and we call on whatever demographic is needed. We want to do an Alzheimer’s case, I would call on older people. Today we did pediatrics, so we needed young parents. If we’re doing sickle cell disease, we need a minority.
The people we have tend to stick around for a long time. They have to go through a 20- to 30-hour training program, and there is a lot of home study involved in the training. They also have to pass an exam, so they make a big investment in becoming qualified. So because of that, they self-select; I started with 27 new folks this past fall and I have about 20 left. Generally, about a fourth to a third will self-select out and we’ll be left with the people who are really committed to the work. They are paid an hourly rate of $15. We always need people, and we are always interviewing and hiring. We always need 40-year-old men, or around that age; we always need people under 25 who have flexible schedules and we always need folks over 70. We also always need any minority, any foreign language.
How successful has the program been in achieving its goal?
Incredibly successful, considering we started 10 years ago and the whole purpose then was to come up with one exam for students to take. We went from a plan of seeing students once in their medical career to seeing them for more than 20 hours. Now we’re deep into the curriculum.
What kind of feedback do you get from students?
The number one thing that students say is we provide them feedback that they will never get from patients in real life. They get information about how patients see them, and we can provide insight into the difference between what the student intends to convey and what they actually convey.