Medio, F.

Morewitz, Stephen J.

English

San Jose State University

Four Approaches to Using Patients to Teach and Evaluate Clinical Skills of Residents, Interns, and Students

SJSU ScholarWorks

San Jose State University SJSU ScholarWorks Faculty Publications, Sociology Sociology and Interdisciplinary Social Sciences January 1992 Four Approaches to Using Patients to Teach and Evaluate Clinical Skills of Residents, Interns, and Students F. Medio Stephen J. Morewitz San Jose State University, stephen.morewitz@sjsu.edu Follow this and additional works at: https://scholarworks.sjsu.edu/sociology_pub  Part of the Sociology Commons Recommended Citation F. Medio and Stephen J. Morewitz. "Four Approaches to Using Patients to Teach and Evaluate Clinical Skills of Residents, Interns, and Students" Journal of the American Osteopathic Association (1992): 1433-1436. This Article is brought to you for free and open access by the Sociology and Interdisciplinary Social Sciences at SJSU ScholarWorks. It has been accepted for inclusion in Faculty Publications, Sociology by an authorized administrator of SJSU ScholarWorks. For more information, please contact scholarworks@sjsu.edu. Four approaches to using patients to teach and evaluate clinical skills of residents, interns, and students FRANKLIN J. MEDIO, PhD STEPHEN J. MOREWITZ, PhD As osteopathic medical educa­tors look for ways to enhance their training programs in a fiscally responsible manner, pre­viously underused training methods deserve a second look. This article presents four ways that patients can serve as teachers and eval­uators of residents' and students' clinical skills. (Key words: Osteopathic medical educa­tion, graduate medical education, patient participation, patient education) Traditionally, patients have played a limit­~ut central-role in the education of osteopathic medical students, interns, and residents. Specif­ically, the patients' role has been passive; they are "objects" of study, rather than active partici­pants in the teaching process. But their role can­and should-change. Four ways that patients can serve as teachers and evaluators of residents', interns', and students' clinical skills are outlined herein. All of these approaches can be imple­mented at minimal costs to osteopathic medical colleges and residency programs. At the time that this article was written, Dr Medio was director of educational resources at the University of Med­icine and Dentistry-School of Osteopathic Medicine, Strat­ford, NJ. Cmrently, he is project manager, Department of Outcomes Research and Development, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill. Dr Morewitz is an assistant professor, Depmt­ment of Family Practice, College of Medicine, University of Illinois at Chicago. Reprint requests to Franklin J. Medio, PhD, Joint Com­mission on Accreditation ofHeaJthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, IL 60181. Bedside teaching rounds At the turn of the century, William Osler, MD, stated, "It is truly at the bedside that the young physician learns not only how to solve the patient's problem, but also how to relate to the patient."1 Unfortunately, studies show that the amount of bedside teaching has declined significantly despite the educational benefits derived during the bed­side encounter.2-5 Bedside teaching allows resi­dents, interns, and students to question the patient directly; to demonstrate their skills in interviewing and performing a physical examination; to man­age the patient's treatment course; and to recog­nize the patient's psychosocial state. To be an effective learning experience, bed­side teaching must include patient feedback. This feedback gives information on how the patient responds to a physical examination; the patient's perception of the residents', interns', and stu­dents' interviewing and interpersonal skills; and how the patient feels physically and psychologi­cally. It is important to note, however, that several potential barriers can inhibit teaching and learn­ing in this situation, and they should be avoid­ed. These potential barriers include: Bedside visits as 'maintenance checks' Bedside visits that are primarily "maintenance checks" or "updates" do not promote learning. A bedside visit needs to be a structured opportuni­ty for teaching and learning that follows a set of already established educational objectives. The attending physician should identifY specific learn­ing objectives, focused on one or two key teaching points. Medical education/Progra m director's notebook • Medio and Morewitz JAOA •Vol92 • Noll • Nove mber 1992 • 1433 Poor communication Once these educational objectives are established, the next step is to avoid communication prob­lems that may impede learning during bedside teaching rounds. These communication difficul­ties not only reduce the effectiveness of teaching rounds, but they may also seriously impair assess­ment, treatment, and relations between the patient and the physician. Sometimes, a patient may appear reticent to discuss his or her health problems. Likewise, res­idents, interns, or students themselves may be hesitant in discussing the patient's problem. Rather than attributing this communication dif­ficulty to "patient resistance," physicians-in-train­ing would do well to explore with the patient the reason(s) why he or she is reluctant to reveal per­sonal information. As part of their educational training, the residents, interns, and students might discuss with each other-as well as their trainers-the difficulties they face when they encounter such uncommunicative patients, in addition to any communication problems that may arise with patients who have specific ill­nesses. Too often, physicians-in-training avoid such situations because they feel uncomfortable, but these situations provide many opportunities for learning. Patients and their family members may feel left out of the discussion during these bedside visits; they feel "exploited" by the teaching process. Some patients have reported feeling like a "spec­imen" when the attending physician, residents, and students are standing by their bedside talk­ing about their illness witlwut making eye contact with the patient or family members. Further­more, using the third person in the patient's pres­ence (''The patient has an acute case of ...") makes the patient feel "used." Likewise, patients feel uncomfortable when hospital personnel address them by their first name or by using an endearing term, such as "dear." Rather than fostering a personal rela­tionship, such appellations are perceived as unpro­fessional and as unwanted intrusions into the patient's privacy. By their behavior~liciting direct feedback from patients and making a conscious effort to avoid the aforementioned communication pit­falls-clinicians can teach good bedside skills and serve as role models for physicians-in-train­ing. Another way to enhance communication and 1434• JAOA •Vol 92 • No 11 • November 1992 to make the patient feel at ease and in control of the situation is to invite questions. Depend­ing on their nature, these questions provide a teaching opportunity for the residents, interns, and students. Such questions also recognize the patient's right to participate in his or her own care. Round-table seminar As a complement to bedside teaching, a round-table seminar format offers residents, interns, and stu­dents the opportunity to discuss skills that can improve communication during stressful patient encounters. Participants can learn the social and emotional status ofpatients who have terminal illnesses, who have lost a limb, or who have expe­rienced some other traumatic event. In addition, family members of patients who have recently died may be the guest speaker. This format allows residents, interns, and students to deal candidly and openly with stress­ful situations, without the pressure of the clini­cal environment. In a more relaxed setting such as that surrounding the round-table seminar, participants get a chance to ask patients a wide range of questions. 6 A current or former patient who is willing and able to tell participants what it is like to be a patient can be invited to speak at a round-table seminar. However, patients who may be trau­matized by recounting their experiences should not be selected. A "unique" speaker is a physi­cian who was hospitalized as a patient. This per­son sees the experience "from both sides of the fence"-as patient and physician. The program director or designated faculty member must select and invite the patient to participate in the round-table seminar. Ground rules need to be set in advance. First, the program director or selected faculty member should mod­erate the discussion. The moderator should intro­duce the patient, the topic, and the issues. This individual should also provide a brief synopsis of the clinical scenario, including the patient's background information. Second, the moderator should inform the patient that he or she has the right to refuse to answer any question. Third, the moderator should focus the discussion on the patient's experiences, emphasizing the psychosocial aspects. Partici­pants should try to understand the patient's per­spective and feelings while refraining from mak­ing any moral or social judgments. Medical education/Program director's notebook • Medio a nd Morewitz Finally, enlisting other specialists (medical and nonmedical) as codiscussants can provide residents, interns, and students with key infor­mation concerning other healthcare providers' role in caring for patients. Standardized patients The standardized patient is an innovation in medical education pioneered by Drs Harold Bar­rows, Paula Stillman, and David Kretchmar.7-9 A recent survey of 136 US medical schools10 found that 70% of them reported using standardized patients for medical student education and res­ident training. Either symptomatic or asympto­matic, standardized patients can portray a par­ticular patient scenario. They are also trained as teachers in that they can provide focused feed­back on clinical skills, such as interviewing tech­niques and physical diagnostic skills. The director of medical education (DME) may hire an experienced PhD or physician-consultant to train these patients. Another option is to send such patients to a university-affiliated training cen­ter. If so inclined, the DME may personally train these patients. In a sample scenario, a standardized patient with a history of headaches is examined by the residents, interns, or students. In another sce­nario, residents may learn the appropriate tech­niques for examining the lungs and distinguish­ing among the various pulmonary sounds present in a standardized patient with chronic obstructive pulmonary disease. They may also describe the pertinent positive findings of such an examina­tion. In both scenarios, the standardized patient provides constructive, detailed feedback con­cerning the residents' skills in taking a history and performing an examination. Various investigatorsll,12 have reported that standardized patients can offer reliable, valid evaluations ofresidents' and students' skills. As long as these patients are well-trained, such cri­tiques are possible with minimal supervision by the program director or faculty member. Resi­dents, interns, and students report having posi­tive experiences with standardized patients because they know that these patients are actu­ally instructors. Thus, residents, interns, and students are not intimidated or embarrassed by their mistakes.13,14 Likewise, these patients have expressed a great deal of satisfaction with their participation in these programs. Medical education/Program director's notebook • Media and Morewitz Objective structured clinical examination A standardized method to assess clinical skills in a performance-based format , the objective structured clinical examination (OSCE) is designed using "stations" similar to those in a pathology practicum.15,16 At each station, both clinical knowl­edge and skills are measured using standardized patients or computer simulations. The OSCE approach makes it possible for program direc­tors to evaluate how well residents, interns, and students perform. Such performance skills are difficult to measure using standardized written examinations. However, part of the OSCE station can include written examination questions to evaluate prob­lem-solving skills. For example, one OSCE station can be used to evaluate the skills necessary to take a cardiac history and to conduct a cardiac exam­ination. Direct observation of the standardized patient interacting with the participants can be recorded using a detailed evaluation form. A different station may feature another eval­uation method, such as Folstein's Mini-Mental Status Examination or the CAGE questionnaire. The program director or selected faculty mem­ber should design the OSCE station, including the problem-solving activities, clinical skills, and the standardized patient. Comments The key to successfully incorporating any of the four methods outlined herein is to make patients an integral part of the educational program. Patients can be used effectively in training osteo­pathic medical students, interns, and residents. They provide a perspective on the healthcare experience that is often overlooked. As such, their involvement provides important learning oppor­tunities for physicians-in-training and empow­ers patients with a greater sense of control over their own healthcare. Furthermore, these impor­tant contributions to osteopathic medical educa­tion can be made with only minimal financial expenditures. References 1. Osler W: On the need of a radical reform in our methods of teach­ing senior students.Medical News 1903; 82:49-63. 2. PaysonHE, Barchas JD: A time study ofmedical teaching rmmd~. N Engl J Med 1965; 273:1468-1471. 3. Collins GF, Cassie JM, Daggett, GJ: The roleofthe attending physi­cian in clinical training.J Med Educ 1978;53:429-431. 4. Linsfors EW,Neelon FA: Thecasefor bedside rounds. N E ngl J Med 1980;303:1230-1233. 5. Media FJ, Wilkerson L , Maxwell JA, et al: Improving teaching JAOA •Vol 92 • Noll • November 1992 • 1435 rounds : Action r esearch in medical education. Proc Ann Con( Res Med Educ 1984;23:283-288. 6. Medio F.J: The patient as teacher. J Med Educ 1985;60:63-65 . 7. Barrows HS, Abrahamson S: The programm ed patient: A tech­nique for a pprai sing student performance in clinical neurology . J Med Educ 1964;39:802-805. 8. Stillman PL, Ruggill JS, Rutal a PJ, et al: P atient instructors as teachers and eval uators . J Med Educ 1980;55:186-193. 9. Kretzschma r R: E val uation of the gynecology teaching associ­ate: An educational specialist. Am J Obstet Gynecol 1978;131:367­373. 10. Stillman P, Regan MB, Phil bin M, Hal ey HL: Results of a sur­vey on the use of standardized patients to teach and eval uate clin­ical skill s . Acad Med 1990;65 :288-292. ll. Still man P, Swanson DB: Ensuring the clinical competence of medical school graduates throug h standa rdi zed patients. Arch Intern Med 1987 ; 147 :1049-1052. 12. Ba rrows H, Williams R, Moy R: A comprehensive pelformance­based assessment of fourth-ye ar medical students' clinical skills. J Med Educ 1987 ;62:805-809. 13. Stillman PL, Sabers D, Redfi eld D: Use of paraprofessionals to teach interviewi ng skill s . Pediatrics 1976;57:769-774 . 14. StiUman PL, Regan MB , Swanso n DB, et al: An assessment of the clinical skills of fowth year students at fow· New England med­ical schools . Acad Med 1990;65:320-326. 15. Ha rt I: The objective structw·ed clinical examination, in Lloyd J , Langsley D (eds): How to E valuate Resicknts. Chicago, Til, Amer­ican Board of Medical Specialties, 1980. 16. Kowlowitz V, Moole AJ, Sloane P: Impl ementing the objective structured clinical examination in a traditional medical school. Acad Med 1990;65:345-347 . 1436 • JAOA • Vol92 • No 11 • November 1992 Medical education/Program director 's notebook • Medio and Morewi t z 

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Four Approaches to Using Patients to Teach and Evaluate Clinical Skills of Residents, Interns, and Students

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