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Simulated patients have been used to foster active learning and problem solving skills in an undergraduate programme of reproductive medicine. These simulators were trained to present a series of clinical problems and were used in a variety of approaches. They served to highlight communication skills and to force attention on the recognition, assessment and management of patient problems.
A study was undertaken whereby a set of standardized (simulated) patients visited general practitioners without being detected, in a health care system where doctors had fixed patient lists. Thirty nine general practitioners were each visited during normal surgery hours by four standardized patients who were designed to be indistinguishable from real patients. The objective of the study was to see whether the actual performance of general practitioners, as assessed by standardized patients, met predetermined consensus standards of care for actual practice. The patients presented standardized accounts of headache, diarrhoea, shoulder pain and diabetes. The mean group scores of the doctors on the predefined standards of care for the different complaints ranged from 33 to 68%. The results show that standardized patients may be the method of choice in the assessment of the quality of actual care of doctors. It is hypothesized that the substandard scores of the doctors do not reflect inadequate competence, but are a result of the difference between competence and performance.
The Internist-1/Quick Medical Reference (QMR) knowledge base (KB) describes the clinical manifestations of some 600 diseases in the domain of internal medicine. This KB, while not representing deep causal modelling of disease processes, is nonetheless effective in providing medical diagnostic assistance through the QMR medical decision support system. One potential application of this extensive KB is the generation of simulated patient cases for use in educating health professionals. However, the "flat" KB is not adequate for this because the clinical manifestations used in the disease descriptions are not mutually independent. While it is theoretically possible to construct disease descriptions which embody pathophysiologic mechanisms of disease causality, it is not practical from the standpoint of resource utilization. Short of constructing a causal knowledge base, the authors herein describe the generation of realistic appearing simulated patient case data using existing information in the knowledge base. This existing information in the KB is in the form of properties which represent a shallow form of interrelationships of the manifestations. The authors conclude that this ability to generate simulated cases represents another view in which to look at an extensive knowledge base, as well as having application to constructing intelligent tutoring systems for health professionals in training.
Actors were trained to simulate a young asthmatic woman in the high risk category. Sixty-four of the 195 general practitioners and family medicine registrars in Christchurch city agreed to take part in the study in which they would be consulted by a simulated patient remaining blind to identification of the patient, the time and the medical problem. The simulators were trained to record information from the consultation and rate doctor behaviour when presenting, as a new patient on transfer, for a repeat prescription of asthma medication. Forty-nine doctors had one consultation and of these 25 had a second. Consultation time averaged 15.6 minutes and waiting time 17.4 minutes. Practice nurses and physiotherapists were rarely utilised. There were no specialist referrals. Serum theophylline levels were estimated in 4%. The chest was examined in 39% of consultations, the peak flow in 59%, both in 30% and neither in 32%. Drug prophylaxis was encouraged in 62%, home peak flow meter monitoring was encouraged in 49%, smoking was discouraged in 41%, aerosol technique was checked in 1%, a crisis plan was provided in 57% and asthma education in 42%. Doctor behaviour and communication skills were rated highly except that clear instruction on follow up appointments was given in only 24%. The second consultation appeared to be a briefer rerun of the first, indicating episodic care rather than planned long term management. A number of issues were identified for further study and education.
In large-scale performance-based assessment of medical professionals' clinical competence, simulated patients (standardized patients-SPs) are used not only to simulate case problems but also to record on check-list the examinees' clinical performance during their encounter with the SPs. The purposes of this study were to determine the SPs' overall accuracy in recording check-list items, and whether their accuracy was affected by the various characteristics of the check-list, and by the different times during a day and the different days within the examination when the recordings were obtained. Results showed that the SPs' accuracy in recording check-list items was good to very good and was affected by the length of the check-list, as well as by the type and the clarity of the check-list item. It was further found that the SPs' accuracy was consistent and did not vary over the course of a one-day or a 15-day examination.
This pilot study assessed a novel approach to the evaluation of clinical performance in the practice setting, using actors trained to simulate real patients. Thirteen general practitioner teachers, 10 family medicine training programme registrars, and 10 recent graduates of the FMTP were recruited. They agreed to be consulted by an unknown simulated patient. Two young patients with classical migraine were selected. Two young actors, a male and a female, were trained to simulate their symptomatology and history. A scoring system was devised to broadly assess a single general practice first consultation, and the simulators were trained to score. Eighty-five percent of respondents were willing to take part in a further study. Seventy-three percent had no suspicion at all that the patient was simulated. The average consultation time was 17 minutes (range 4-40). The average score was 67% (range 10-100%). The diagnosis was made in every case and a wide variety of treatments were prescribed. This appears to be a practical and acceptable method of assessing clinical performance.
A study has been undertaken to determine whether it is possible for a set of standardized (simulated) patients to visit general practitioners, without being detected, in a health care system where doctors have fixed patient lists. Since sending standardized patients into doctors' offices is a new way to assess the performance of general practitioners; this paper describes in detail the methodology that has been used for visits. The paper looks first at the general preparation for visits and secondly at the specific preparation concerning the fine detail of the individual visit. The method was tested in 156 consultations with 39 general practitioners and in no cases were the standardized patients detected. None of the doctors visited felt offended and all were prepared to cooperate in future studies with standardized patients. It is concluded that the standardized patient method, following the step-by-step procedure described, is feasible in actual practice.
Use of reconstituted lyophilized protein-based materials in the clinical laboratory is partly based on the assumption that these materials adequately simulate patients' sera. We examined several of these materials and found that certain ones do not have the same adsorbancies at 340 and 380 nm as do most sera. The implication of this is examined with respect to glucose determination by the hexokinase method on a dual-wave-length blank-subtraction instrument.
Primary care physicians in one Southern city were asked to return a mail questionnaire stating their attitudes toward relicensure issues. Respondents overwhelmingly preferred continuing education as the method of creditation for relicensure, but as a second choice preferred the simulated patient procedure to formal examinations. Nearly one half of the respondents agreed to participate in a pilot study of this method. The MD author received more positive replies than the PhD author, possibly because different segments within well matched subsamples were motivated to respond.
The design and uses of an innovative technology-based approach which addresses critical problems with bedside teaching during ward rounds in the current health care situation are described. A cardiology patient simulator (HARVEY) and an accompanying computer-based interactive laserdisk system provide medical students, house officers and other health professionals with the opportunity to encounter a wide variety of clinical problems for learning and assessment. A group of cardiologists and medical educators from a consortium of US medical schools has guided the development and formal assessment of the entire system over the past 10 years. The system and simulator can be configured and programmed to provide appropriate heart sounds, laboratory data, and test results upon request; hands-on experience to practise examination skills is also available. The system, whole or in part, can be used in a variety of instructional modes from self-instruction to demonstration teaching, and from self-assessment to the final clinical examination. The system's effectiveness for teaching medical clerks is summarized, as is its use in providing continuing education for primary care doctors in rural practice.
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.
Fifty-four interns agreed to a study in which their clinical performance in an out-patient unit with standardized patients was recorded on videotape. In order to examine whether they could distinguish standardized from real patients, the interns were asked to note any patients who they thought might be simulating their complaints and report these to the researchers at the end of each 2-day period of study. Thirty-two of the interns were assessed again at the end of their internship, using the same clinical problems presented by different simulators. The consultations took place in the casualty department of a large urban hospital. At the beginning of the year there were 152 consultations with standardized patients and 328 consultations with appropriate genuine patients. Standardized patients were identified definitely as 'not genuine' in only 12 of the 152 consultations (sensitivity 7.8%) whereas 320 of the 328 genuine consultations were accepted by the interns as genuine (specificity 97.8%). When the level of confidence required to distinguish the two groups was reduced from 'definite' to 'probable', the number of correctly identified simulator consultations increased to 36/152 (27%) but the rate of misclassification of genuine patients also increased from 8 to 37 out of 328 consultations (11%). At the end of the year there were 81 consultations with standardized patients and 149 consultations with genuine patients. Identification rates were only slightly changed. We conclude that simulator identification is not a problem in applying standardized patients to evaluate the quality of care provided in a hospital casualty.
An observational study examined the care that was provided by 61 interns for three simulated (standardized) patients in a casualty department within a large teaching hospital. The consultations were recorded on videotape and were scored by reference to explicit criteria that were set by an expert panel. The criteria described standards of clinical competence, communication skills and preventive care for each of the three cases. An additional list of the general opportunities for preventive advice that were suggested by the patients' case histories also was compared with the interns' actual behaviour. Clinical competence was not demonstrated uniformly across the three cases. The problem of urinary-tract infection was managed best; 19% of the interns complied with all criteria, and 93% of the interns complied with 75% of the criteria. For tension headache, only 3% of the interns complied with all the criteria but 67% of interns complied with 75% of the criteria. In the case of bronchitis, only 3% of interns complied with all the criteria but 58% of interns met 75% of the criteria. The quality of preventive care also varied from case to case, being best for the patient with bronchitis and worst for the patient with tension headache. Over all, only three of the 13 criteria were met by more than half the interns. The communication-skills criteria identified three behaviours which the interns were most likely to omit: the interns summarized the patients' problems in only 73 of the 173 consultations; they explained the aetiology of the problems in only 127 of the 173 consultations; and they ensured that the patients understood their plan of management in only 21 of the 173 consultations.
An 18-year-old patient requiring steroid treatment for severe bronchial asthma and with atopic dermatitis acquired a cowpox-like virus infection clinically similar to smallpox from a domestic cat as carrier. In spite of intensive care, with controlled pressure breathing and the last available vaccinia hyperimmunoglobulin, the patient died of pulmonary embolism although viral spread had ceased some days before.
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