The Role of Simulated Patients in the Education of Doctors

1. The Role of Simulated Patients in the Education of Doctors 7th Annual Conference Learning in Law Initiative January 7th 2005

2. j.s.ker@dundee.ac.uk

3. Lessons from Aviation Industry • Two Boeing 747s crashed into each other on the runway. 583 people killed. • Causes: failures in conflict resolution, assertiveness, communication, situation awareness, decision making. j.s.ker@dundee.ac.uk

4. NHS http//:savetheNHS.co.uk

5. Tayside Skills Centres • Integral to a high reliability organisation • Development of realistic clinical environments for safe practice clinical skills centre, anatomical/theatre skills, surgical skills, orthopaedic skills units • World of simulated practice • Identification of training needs • Development of competence • Assessment of performance j.s.ker@dundee.ac.uk

6. Role of Simulation in the Education of Doctors Error minimisation Classroom Workplace Novice Professional Error minimisation Expert Professional j.s.ker@dundee.ac.uk

7. 3 Levels ofhuman performance • Skill based patterns of thought • Rule based thinking • Knowledge based thinking j.s.ker@dundee.ac.uk

8. Minimising Error in human performanceThe Learning Process • Preparation ( schema activation) • Evaluate learning • Simulated Practice ( schema building) • Evaluate learning • Feedback (schema refinement) • Evaluate new learning needs • Reinforcement through real practice (schema refinement) • Evaluate new learning needs j.s.ker@dundee.ac.uk

9. Educational Underpinning in use of Simulation in learning • Operant conditioning (Thorndike and Skinner) • Cognitive Constructivism (Dewey, Bruner, Piaget) • Social Constructivism (Vygotsky,) • Social learning theory (Bandura) • Adult learning theory (Knowles, Mezirow) j.s.ker@dundee.ac.uk

10. Shaping the Future of Medical Education • European working time directive • Shifting boundaries • Modernisation agenda • Increased patient expectations • Tomorrows Doctors • Modernising Medical Careers • Scottish Doctor • Professional practice • NHS Education for Scotland • E-health j.s.ker@dundee.ac.uk

11. Role of simulated /standardised patients in Education of Doctors Simulation Classroom Workplace Novice Professional Simulation Expert Professional j.s.ker@dundee.ac.uk

12. Clarifying the Terminology • Simulated patient • Person coached to present symptoms and some of signs of an actual patient • Standardised patient • Person coached to level where they can consistently portray a medical presentation j.s.ker@dundee.ac.uk

13. Who can the simulated/ staandardised patient help? • Medical Students • Dental Students • Nursing Students • Professional Examinations e.g. MRCP • Postgraduate Education courses • Continuing professional education • Multi-professional Learning j.s.ker@dundee.ac.uk

14. Why are simulated and standardised patients used in medical education? • Exposure of students to a wider range of patient conditions • Opportunity for medical personnel to receive immediate feedback • Assessment of clinical skills • Safe and systematic learning environment j.s.ker@dundee.ac.uk

15. Value added teaching • Realism: A simulated patient can make the clinical situation real for the student by maintaining a believable character • Impact: Simulated patients can enable students to learn from rehearsing and reinforcing good practice. • Flexibility: Simulated patients are especially valuable when simulations are being repeated as a skill exercise. • Feedback: A professional SP can be trained in the art of offering unbiased, constructive feedback to the student j.s.ker@dundee.ac.uk

16. What training is required to become a simulated orstandardised patient? • Advice on scripts • Presenting and involving character • Role play / Simulation/video • Giving feedback • Group work • Practice of scenarios j.s.ker@dundee.ac.uk

17. Chief Complaint: "I’ve been having recurrent “water work” infections" Identifying Data: married, 2 children, good home life. Scenario:You have had 2 episodes of infections in the last 6 months. You have had various courses of antibiotics which initially help but the infections still return. You went through the menopause 10 years ago Patient Profile: Concerned about this problem. You experience pain when passing urine, “feels like peeing broken glass”. You have to pass urine twice as much as usual Occasionally feel unwell and have to go to bed and take paracetamol History of Present Illness :When did it start? 12 months ago. Does it interfere with your life? Yes as you have to look for toilets everywhere. Past Medical History: Answer NO to: allergies, surgery, tobacco, Relieving factors: Drinking plenty of water Medications:.Hormone Replacement tablets, an antibiotic called something ending with –cillin Alcohol: Socially, 1 or 2 glasses of wine a week Hospitalizations: Childbirth, 25 and 20 years ago. Exercise: I usually swim, walk, Family History: Live with spouse Questions to Ask: 1.What do you think is causing these infections? 2.Is this a treatable? A Simulated Patient Script j.s.ker@dundee.ac.uk

18. j.s.ker@dundee.ac.uk

19. Provide safe simulated clinical environments for clinical practice • Ward simulation exercise • GP simulated surgeries j.s.ker@dundee.ac.uk

20. The doctor-patient relationship Doctor’s agenda Patient’s agenda j.s.ker@dundee.ac.uk

21. Internal factors Personalities Clinical setting Expertise level Problem type Illness/disease Power balance External factors Treatment options Internet Specialisms in medicine Resources Targets Evidence base Public perception Factors affecting doctor-patient relationship j.s.ker@dundee.ac.uk

22. Simulated/standardised patients role in education of doctors • Physical examinations • Performing specific procedures • Clerking in different clinical settings • Hospital admission • Receiving advice & information • Receiving bad news scenarios • Clinical assessment j.s.ker@dundee.ac.uk

23. Simulated patients • History and examination skills j.s.ker@dundee.ac.uk

24. Performing specific procedures • Blood tests • Blood pressure • Patient complaint • Wound dressing • Giving set needs primed j.s.ker@dundee.ac.uk

25. Hospital admission j.s.ker@dundee.ac.uk

26. Giving advice j.s.ker@dundee.ac.uk

27. Clinical Assessment j.s.ker@dundee.ac.uk

28. Advantages of simulated patients • Availability • Staged to level of experience • Safe to make and analyse errors • Opportunity for patient feedback • Links with community • Realistic scenarios • Sensitive consultations j.s.ker@dundee.ac.uk

29. Advantages of standardised patients • Participation in the assessment process • Toleration levels • Provide consistency j.s.ker@dundee.ac.uk

30. Developing a simulated patient bank • Recruitment & retention • Selection / Screening • Training (Initial and ongoing) • Cost (Expenses or Payment) • Time • Script Writing • Logistics j.s.ker@dundee.ac.uk

31. Simulated Medical Ward for Assessment of PRHOs Aim: To identify the realistic components for a simulated medical ward j.s.ker@dundee.ac.uk

32. Methodology • Design of exercise • Content realism • PRHO shadowing • Multi-professional focus groups • Literature review • Inpatient admission review • PHAST screening tool • Process realism • Timed interruptions by AHPs • SP cues • Staffing • Common pitfalls/errors in practice • Design of evaluation • Semi-structured interviews j.s.ker@dundee.ac.uk

33. Results Aspects of realism in relation to content Realistic Patients j.s.ker@dundee.ac.uk

34. Realistic Emergencies j.s.ker@dundee.ac.uk

35. Results Aspects of realism in relation to process • Ward handover • Interruptions • Errors/Pitfalls • Nursing support • External contacts j.s.ker@dundee.ac.uk

36. Teamwork Communication Time Management Decision Making ResultsNon-technical skills of PRHOs j.s.ker@dundee.ac.uk

37. Conclusions • Feasibility study • Different sources for design • Trade off between patient care and focus on performance • Future use in assessment • Future use in remediation • Future use in other professional groups • Future role for patients j.s.ker@dundee.ac.uk

38. What support simulated patient want? • Aim to ascertain training needs of SPs • Methodology Likert type questionnaire on types of training and desired frequency j.s.ker@dundee.ac.uk

39. Simulated Patient Programme Session 2003 / 2004 Evaluation of Training Please allocate your preference for the following training sessions which could be offered to you as a simulated patient. Desire least Desire most Giving feedback to students 1 2 3 4 5 Instructions on scripts 1 2 3 4 5 Role play skills 1 2 3 4 5 Written feedback on your performances 1 2 3 4 5 Verbal feedback on performance 1 2 3 4 5 Video feedback on your performance 1 2 3 4 5 Standardised OSCE performance 1 2 3 4 5 How often do you wish to receive this training? (Please tick only one for each training session) 3/12 6/12 12/12 Giving feedback to students [] [] [] Instruction on scripts [] [] [] Role play skills [] [] [] Written feedback on your performances [] [] [] Verbal feedback on performance [] [] [] Video feedback on your performance [] [] [] Standardised OSCE performance [] [] [] j.s.ker@dundee.ac.uk

40. Six monthly training sessions were most frequently requested for receiving verbal feedback Results 1 = 3 months 2 = 6 months 3 = 12 months 4 = Non Applicable j.s.ker@dundee.ac.uk

41. The majority of Simulated Patients requested training in giving feedback to students. Results 1 = Desired Least 5 = Desired Most 6 = Non Applicable j.s.ker@dundee.ac.uk

42. Opportunities for law • Simulated clients • Individual • Commercial company • Standardised clients • For standard performance assessment • Simulated juries • Develop cross examination skills j.s.ker@dundee.ac.uk