Using Patient Simulation to Facilitate Students’ Clinical Skills

1. Using Patient Simulation to Facilitate Students’ Clinical Skills Richard Dean Ohio University, Athens, OH C.A.P.C.S.D Palm Springs, CA April 26, 2002

2. Will Your Students Witness or Participate in the Management of the following? • Global Aphasia • Spasmodic Dysphonia • Total Glossectomy • Alaryngeal Speech • Dysphagia Assessment (without visualization instrumentation)

3. The answer to the preceding question could be “Yes” by using Patient Simulation I have personally used patient simulation since the late 1980s for some part of the instruction in clinical courses: • Disorders of Voice • Adult Language Disorders • Fluency • Neuromotor Disorders • Dysphagia • Orofacial Disorders • Augmentative Communication

4. Outline of Today’s Goals: • Origin of patient simulation/problem-based learning • Personal motivation to use patient. simulation • Using patient simulation for four different instructional purposes. • In depth description of patient simulation as a primary component of problem-based instruction in dysphagia. • Demonstration of ‘virtual’ dysphagia patient use in dysphagia management skill development. (separate slide show)

5. 1-Patient Simulation Defined: • Patient simulation as originally conceived by Howard Barrows, a California teaching physician, was the use of persons trained to portray patients for medical students to treat. • They provided practice without doing harm to real patients. • Exposure to rare conditions could be provided to better train doctors.

6. 2-Origin of Patient Simulation & Problem-based Learning. • I came to use problem based learning/teaching after first using another teaching innovation of Howard Barrow's, patient simulation. • He was the creator and author of books on both patient simulation and problem-based curriculums that he had applied to physician training in California in the 1970s.

7. My Initial Exposure to Patient Simulation. • C.O.R.E Hearing Testing of Virtual Child: Chris Halpin, doctoral candidate in audiology, UVA, 1988. • Daughters reaction to treating simulated patients during 1st year of medical School in 1990.

8. Overview of My Used of Patient Simulation I came to use patient simulation in graduate courses in fluency, adult language, and phona-tion disorders to provide more direct experiences with the assessment and management of simulated adult patients, ones less likely to be encountered in practicum.

9. My motivation was to accomplish two goals: • (1) increase students' insight in the personal experiences of such patients and • (2) provide some practical experience managing patient types that were not well represented in practicum experiences typically available at our clinical sites. Students were assigned to simulate adult patients for their peers to assess and/or apply and practice rehabilitation techniques.

10. 3-Using patient simulation for four different instructional purposes. • To provide exposure to communication disorders rarely present in our clinic. • To provide the opportuity for all class members to use tests designed for special population, e.g aphasia and stuttering. • To gain experience as a member of an interdisciplanary team managing clients.

11. …four different instructional purposes (cont). 4.To gain experience with dysphagia patients normally unavailable for assessment outside a medical environment. Inherent medical risks make such patients unavailable for trainees to assess without close supervision.

12. Initial Uses of Patient Simulation (video of 10 simulating students) • Disorders of Voice (alaryngeal speech & vocal abuse) • Disorders of Fluency (2 adults) • Broca’s aphasia (3 student patients ) • Werniche’s aphasia (3 student patients)

13. Student preparation to simulate • Motivation was facilitated via grading of performance. • Students were auditioned for voice disorder assignments. • Sometimes students were reviewed/critiqued by instructor prior to involvement with peer clinician. • Audio and video tapes of representative disorders were made available.

14. Summary: • These simulation experiences were only a small part of the otherwise traditional instruction in disorders classes. Dominant instructional mode: lecture and readings. • I no longer use these instructional modes as I do not teach the courses were they were first applied.

15. Research on Student Response: • Video clip of original assessment report. • Meaning Ratings 3 classes (1=weak;9=excellent) • Personal Seriousness 6.98 • Degree of Reality 6.44 • Patient Insight Devel. 6.86 • Relative Ed. Value 7.65

16. 4-In depth description of patient simulation as a primary component of problem- based instruction in dysphagia. • One focus of today’s presentation will be devoted to describing my use of patient simulation in Dysphagia classes.

17. First Uses of Problem-Based Learning Model • Patient simulation and problem-based teaching were combined and became the dominant instructional mode in my second dysphagia class in 1994. Although frequently modified since first used, problem-based teaching has continued to be the dominant method used to facilitate learning in dysphagia class.

18. Problem-Based Dysphagia Instruction: The basic format of my problem-based approach with dysphagia class: • to present a syllabus that outlines the requirements summarized here. • I explain that they will work in groups of five to treat six patients that I refer for swallowing evaluation. Five of these patients will be adults refered from hospital staff physicians. Each will be simulated by a trained peer from their group.

19. I explain • that in problem-based learning that they are to work in the assigned groups to determine • what they already know about the patient problem presented define • what they perceive that they need to know in order to manage the first patient.

20. (Explanation Cont.) • set out to learn the skills necessary to interpret patients' hospital charts, conduct a dysphagia assessment (clinical/bed side and instrumental/MBS sessions • prepare a written dysphagia management report. • I place them in their groups, explain the role of each member, and let them begin their group work the first session.

21. Explanation (cont.) • that I will offer 10 lectures on selected topic areas that are either very important or difficult to find well organized or current information. • that I am a major resource to be consulted for assistance in locating resources.

22. Dominant features of my problem-based approach. (Each feature is presented on a different subsequent slide.)

23. A - Students are assigned to teams of five students each. Each student has an assigned role that rotates for each of five adult patients. Roles are:1. Facilitator - is in charge of the group process; keeping action going2. Patient - assumes a the patient role when summoned.3. Reporter [writes and submits brief account of each team meeting to instructor].4. Scribe - maintains records of the information needs; assignments; the group secretary5. Report writers - actually types final copy

24. B- Students are assigned to assess and write dysphagia assessment and management recommen-dation reports for six patients: five adults and one child,

25. C -A schedule is created with due dates for each patient’s diagnostic report.Student teams are allotted 3.5 weeks to prepare for, assess and recommend management of the first patient. Each subsequent patient must be managed in progressively shorter time periods.

26. D - Ten lectures are presented through out the quarter. • Lecture topics include: interpreting modified barium videofluoroscopic, food textures, radiation safety, tracheotomy tubes, non-oral feeding, pediatric dysphagia, fiberoptic endoscopic examination of swallowing, medical communication, etc.

27. E -All student team assessments of simulated patients are conducted during class time.These are simulated bedside and videofluoroscopy assessments of one member of the team simulating a patient according to a developed 'script'. A method of illustrating the videofluoroscopic still images at several points in time between oral and esophageal phases has been developed over the years. This approach encourages students simulating patients to understand the deviant swallow so as to draw the disordered physiology as it changes in response to management strategies. And, more importantly, it give assessing members of the teams experience in making decisions in response to simulated illustrations of MBS results. Student teams are expected to meet together outside of class in preparation as needed.

28. F - Five of the referred patients are adults and are simulated by a member of each team.A plan or 'script' is developed by all the patients from each team guided by the instructor to plan appropriate behavior while simulating the patient to their team peers. The plan includes what to anticipate from the team, the problems that they will need to simulate/portray, methods to portray the swallowing problems and other appropriate behaviors (depression, confusion, impatience, etc.), how to use special illustration techniques to communicate MBS results, and the dysphagia management outcomes that they will attempt to influence their team to choose.

29. G- The sixth patient is a pediatric patient and team management is entirely via written description.

30. H - Simulated hospital charts have been authored and made available as a website for each patient. Teams are referred to these charts for medical information on their current hospital stay. A sample can be viewed at http://oak.cats.ohiou.edu/~deanr/stroke.htm

31. I - The goals of problem-based learning in the course are: • develop knowledge about dysphagia and its management • develop skills in assessing and managing dysphagia • develop ability to guide self-learning.

32. J - Grades for the course are based on: • patients management by team30% • Instructors subjective evaluation of how the three goals have been accomplished20% • patient simulation by individual15% • take-home exam10% • peer evaluation by team members10%I • ndividual oral or written report(s)10%. • weekly quiz average 5%

33. I - Each patient management problem is critiqued (in two ways). • First, each student submits a list of 10 prominent topics or skills they have learned in the period of study devoted to the patient under review; the instructor summarizes these topics and skills for frequency of mention. • Second, the instructor points out the strengths and weaknesses observed during the patient assessment and counselling sessions and noted in the various written reports.

34. J - Students are provided feedback on their class performance and standing midway through the course.Tentative grades are presented. Advice is offered for ways to increase performance and learning. Suggestions are requested/invited and sharing of personal impressions of the problem-based curriculum encouraged.

35. Additional Used of Problem-Based Instruction • Problem-based assignments have also been used in otherwise traditional didactic instruction in graduate class: Augmentative Communication, Orofacial Disorders, and web-based courses on Dysphagia.

36. 6-Demonstration of ‘virtual’ dysphagia patient use in dysphagia management skill development. (separate slide show)

37. References: • Barrows, Howard S.(1971) Simulated patients (programmed patients); the development and use of a new technique in medical education, Thomas. • Barrows, Howard S. (1985) How to Design a ProblemBased Curriculum in the Preclinical Years, Springer. • Dean, C. Richard, Manning, R. Kevin, and Thompson, Brenda K. A Virtual Patient Training Module for Training Dysphagia Assessment Skills. Paper, American Speech-Language-Hearing Assn. Convention, New Orleans, LA, Novenber 15, 2001.

38. References (cont.) • Lowe, John III, Hagstrom, F., Dean, Richard, and Champoux, Ron. Problem-based Learning in Communication Disorders, Courses. Miniseminar, American Speech-Language-Hearing Assn. Convention, Washington, D.C., Novenber 18. 2000. • Dean, Richard and Thompson, Brenda. Using Computer Based Dysphagia Assessment Simulations in Student Training. Ohio Speech-Language-Hearing Assn, Cincinnati, March 9, 1999. • Dean, C. Richard and Thompson, Brenda. A Program to Develop Dysphagia Assessment Skills using Simulated Patients. Technical session, American Speech-Language-Hearing Assn. Convention, Washington, D.C., Novenber 7, 2000.

39. References (Cont.) • Flahive, Michael J., Dean, Richard C., Gillette, Yvonne, and Slominski, Thomas J. Learning about Learning: Strategies and Observations. Seminar presented at American Speech-Language-Hearing Association Convention, Orlando, FL, December 7, 1995. • Navarro, Richard, Dean, Richard C., and Hallowell, M. Brooke. Innovative Teaching Strategies in Communication Disorders: Problem-Based Learning. Seminar presented at American Speech-Language-Hearing Association Convention, Orlando, FL, December 7, 1995.

40. References (cont.) • Dean, C. Richard. Patient Simulation: An Effective Alternative Practicum. Ohio Speech and Hearing Association Convention, March 4, 1994.