The use of standardized patients to teach medical students clinical skills in ambulatory care settings

Abstract

Background: Ambulatory medicine is being increasingly emphasized in undergraduate medical education. Because of the limited availability of real patients, we introduced a standardized patient (SP) encounter program in an ambulatory care setting.

Aims: This study was undertaken to assess the usefulness of SPs for teaching undergraduate students clinical skills in ambulatory settings.

Method: Third-year medical students met two different SPs, who presented common authentic problems, during internal medicine clerkship. Each SP encounter of 30 min was followed by SP and a tutor's feedback, using a video recording of the SP encounter. We surveyed students for program evaluation purposes at the end of their three-year internal medicine clerkships (from 2006 to 2008).

Results: Most students found that the consecutive SP sessions were instructive and helpful. Video recordings of clinical encounters allowed students to reflect on their behavior and receive feedback from tutors. However, students identified several weaknesses of these SP encounters. For example, pre-exposure to the SP scenario reduced tension of the experience and inconsistent feedback from tutors caused confusion.

Conclusions: SP encounters in an ambulatory care setting, followed by tutor's feedback based on a video recording, can be used for teaching basic clinical ambulatory care skills.

Introduction

One of the most dramatic changes in healthcare during the past decade has been the shift of care from the inpatient to the ambulatory care setting. The changes in healthcare delivery mean that the inpatient setting is less than ideal for teaching undergraduate students (Irby 1995; Levinsky 1998). Since inpatients tend to be more representative of subspecialty conditions or be more critically ill, they become less representative of routine medical practice. Patients in hospital are more likely to be under acute active management than convalescing. As contemporary practice and patient expectations are in favor of a shorter hospital stay, more patients with common conditions are being treated as outpatients than as inpatients. These changes place the emphasis of clinical teaching on ambulatory care rather than the traditional inpatient setting (Fincher et al. 1997; Cardarelli & Sanders 2005; Dent 2005).

Patient interactions have always been an integral part of undergraduate medical education. Patient interactions help students build integrated skills for history taking and communication, physical examinations, and clinical reasoning (Dammers et al. 2001; Littlewood et al. 2005; Dornan et al. 2006).

Table

Practice points

The SP encounter program was introduced to help undergraduate students acquire clinical skills in ambulatory care settings with the limited availability of real, educational patients. This program followed by a tutor's feedback with video recording was feasible, practical and useful in ambulatory care setting. Students were satisfied with the program, and regarded it as instructive and helpful program. This SP encounter program has its unique value, especially in a teaching hospital which has outpatient clinic unfavorable to education for medical students.

However, to maximize educational efficiency, appropriate patient selection is essential. As described in a previous qualitative study, several key factors, such as, educational value, the doctor-patient relationship, and time efficiency should be considered to find “the best” patients for medical teaching (Simon et al. 2003). However, despite the importance of appropriate patient selection, this can be a difficult and time-consuming process in the ambulatory care setting. Barrows described several advantages of using standardized patients (SPs) as compared with real patients, including their availability, flexibility, and standardization (Barrows 1993). Other studies demonstrated that students regarded the standardization of the learning experience, a safe learning environment and the feedback offered by SP as important advantages (Bokken et al. 2008, 2009).

Given that increasing proportion of care is delivered in ambulatory settings and access to real patients with educational value are limited, we describe the design, implementation, and evaluation of a simulated outpatient clinic using SPs.

Methods

The simulated outpatient clinic was designed to help third-year students develop clinical reasoning, communication, history taking, and physical examination skills in a safe environment. The program was composed of three parts, a student–SP encounter, and SP and tutor feedbacks (Figure 1).

Figure 1. Flowchart of the ambulatory care teaching program for medical students using SP during internal medicine clerkship. SP, standardized patient.

Subjects

The subjects of the study were third-year medical students undergoing internal medicine clinical clerkship at Seoul National University College of Medicine (Republic of Korea) from 2006 to 2008. Students undergoing an internal medicine clinical clerkship were offered two sessions of SP encounters in ambulatory care settings, and later reviewed video recordings of the encounters with their tutors. In addition, students were asked to complete a questionnaire regarding their opinions of the SP program at the end of their internal medicine clerkships.

Resources

A room at an outpatient clinic was equipped with a DVD recording system, a microphone, an examination bed, and clinical examination equipment, such as, a blood pressure gauge and an alcohol-based hand washing sanitizer, for these student–SP encounters.

Procedures

A pool of SPs was trained regarding common presentations at outpatient clinics, such as, fever or abdominal pain and so on. The SPs were paid, semi-professional actors with considerable SP experience.

At student–SP encounters, which lasted 30 min, students took histories, performed physical examinations, and undertook counseling. After these encounters, students were allowed 10 min to complete medical records, and SPs provided individual students with feedback for 10 min. Student–SP encounters were recorded on DVD and students reviewed their performances with their tutors. Tutors decided on passes or failures and students who failed repeated the same SP encounter.

In the end of internal medicine clinical clerkships, students were asked to complete a questionnaire. The questionnaire used in 2006 contained the following questions: (a) Do you think the frequency of SP encounter appropriate? (b) Were the tutor's feedback and the video recording playback satisfactory and helpful? (c) Are you satisfied with the program? (d) Suggestions for improving the SP encounter program. In 2007, the evaluation form was redesigned because by that time the format of the program, such as, the number of encounters and the feedback time had been accepted by students and tutors. Accordingly, we asked the students two questions: (a) Are you satisfied with the program? (b) Suggestions for improving the SP encounter program.

Data analysis

Students’ satisfactions and evaluations of the SP program were analyzed both quantitatively and qualitatively. In multiple choice questionnaires, the numbers (percentage) of students were shown for each option. In open-ended questionnaires, students’ responses were classified based on similarity of contents and the numbers (percentage) of students were presented for representative responses.

Results

A total of 499 third-year students (169, 182, and 148 students in 2006, 2007, and 2008, respectively) participated in the program. Table 1 presents the quantitative data of the student survey conducted in 2006.

Table 1.  Students’ program evaluation questionnaire

	N	(%)
Do you think the frequency of standardized patient encounter appropriate?
Yes	155	(92)
No	14	(8)
NA	0	(0)
Were the tutor's feedback and the video recording playback satisfactory and helpful?
(1) How long was the length of feedback time?
30 min	25	(15)
30–60 min	127	(75)
>60 min	9	(5)
NA	8	(5)
(2) Do you think that this feedback duration was adequate?
Yes	142	(84)
No	19	(11)
NA	8	(5)
(3) Did your tutor point out your strengths and weaknesses well?
Yes	155	(92)
No	7	(4)
NA	7	(4)
In general, are you satisfied with the program?
Fully satisfied	46	(27)
Satisfied	102	(60)
Dissatisfied	13	(8)
Too dissatisfied	8	(5)

Note: NA, not available.

(a) Do you think the frequency of SP encounter appropriate?

Most of the students (92%) considered twice was adequate. Some replied that four or five times would be desirable, because SP encounters were found to be more useful for developing clinical and communication skills than other programs, such as, real patient encounters in wards.

(b) Were the tutor's feedback and the video recording playback satisfactory and helpful?

Most students (75%) received 30–60 min of tutor feedback, whereas some tutors reviewed the videotape and gave students feedback for over an hour. However, some tutors provided less than 30 min of feedback time.

The students found that 30 to 60 min of feedback was satisfactory. Tutors pointed out errors, suggested corrections, and also encouraged students by reinforcing students’ strengths.

(c) Are you satisfied with the program?

Of the 169 students in 2006, 147 (87%) were satisfied with the program (27%, fully satisfied; 60%, satisfied), and in 2007 and 2008, students also expressed satisfaction with the program (7%, fully satisfied; 80%, satisfied).

(d) Suggestions for improving the SP encounter program

– Students requested more various cases and diseases, because SP encounters and feedback sessions with SPs and tutors were found to be helpful for learning clinical and interpersonal skills (N = 51, 10%).

– Confidentiality about the scenario is an important aspect of the SP program. Information regarding the SP scenario might reduce tension and the reality of the SP encounter (N = 43, 9%).

– Tutors’ feedbacks were found to be inconsistent. For example, one tutor had said that a comprehensive physical examination should be performed, whereas another favored a focused examination. This finding indicates that tutorials should be standardized (N = 36, 7%).

– Generally, the SP encounters were found to portray clinical scenarios well, but it was felt that SPs should concentrate more on the ‘sickness’ aspect of the role (N = 7, 1%).

Discussion

In this study, we present our experiences regarding the use of SPs and video feedback to teach clinical skills to undergraduate students in an ambulatory care setting. The purpose of the SP program was not to judge the ability of students to reach a correct diagnosis or to grade students, but rather to help students acquire clinical skills.

Changes in current patient care have made the ambulatory care environment more suitable for undergraduate teaching than routine hospital wards. Furthermore, outpatient facilities offer a large numbers of patients with common medical conditions, and thus, better represent general medical practice (Fincher et al. 1997; Dent et al. 2001; Cardarelli & Sanders 2005; Dent 2005).

The former teaching program for ambulatory care in our curriculum involved a preliminary medical examination by students before a meeting with a professor. At this meeting, the professor reviewed the students’ medical record and provided the student with feedback. However, this program had several shortcomings. First, the majority of patients in a tertiary hospital tend to have some subspecialty condition or to be more critically ill, and few patients are suitable for undergraduate teaching. Second, outpatient clinics are very busy in tertiary hospitals, and teaching staff cannot allocate enough time to teach students. Third, the pressures of service commitments often compromise traditional patient encounter-based teaching in outpatient clinics. Fourth, obtaining consent from patients for a student's preliminary examination is not straightforward in busy outpatient clinics. Thus, to overcome these limitations, we introduced the SP program.

However, as shown by the student feedback obtained, the SP program also has its weaknesses. In particular, an understanding of the aims of this program by tutors is critical. It should be emphasized that the program was not devised to teach students how to reach a correct diagnosis.

Security regarding the details of a case is also important, because having any information regarding the SP session beforehand, especially regarding the diagnosis, is likely to jeopardize the integrity and educational merit of the SP program for students.

Finally, the design and implementation of SP encounters in an ambulatory care setting can be intensive in terms of financial and human resources, which will probably limit its general adoption.

However, the SP program has its unique strengths. First, students are allowed sufficient time to practice clinical skills free of the pressures of a busy outpatient clinic. Second, students receive feedback from SPs, which increases awareness of the importance of verbal and non-verbal behavior affecting patients. Third, students have the opportunity to review meetings with a professor with the aid of a DVD recording. Like other studies, we found that video recordings have great value as a basis for self-reflection, because DVD recordings offer the learners to review their own behavior (Zick et al. 2007). In fact, students demonstrated considerable insight regarding both the positive and negative aspects of their encounters with SPs. As opposed to examining a specific set of behaviors, an open-ended approach encourages students to reflect on behavior in a personally meaningful way. In other words, open-ended self-reflection triggered by SPs, tutors, and critical reviews of video recordings provides students with a more expansive view of their strengths and weaknesses than could be provided by a checklist. Each of these components has the potential to stimulate reflection and motivate self-improvement by helping learners identify their strengths and weaknesses.

Our study suggests that ambulatory care education based on encounters with SP and tutor-guided critical analysis of video feedback is feasible, practical, and valuable. We tried to emphasize the formative value of self-assessment rather than a summative value. We conclude that the use of SPs to teach medical students clinical skills in the ambulatory care setting provides students with an important learning experience during clinical clerkship, especially in teaching hospitals with a busy outpatient clinic that is unsympathetic with the educational requirements of medical students.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.