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MEDICAL EDUCATION |
From the National Board of Osteopathic Medical Examiners National Center for Clinical Skills Testing (Dr Gimpel, Ms Weidner, and Ms Wilson) in Coshohocken, Pa; from the Foundation for Advancement of International Medical Education and Research (Dr Boulet) in Philadelphia, Pa; and from the New York College of Osteopathic Medicine of New York Institute of Technology (Dr Errichetti) in Old Westbury.
Address correspondence to John R. Gimpel, DO, MEd, National Board of Osteopathic Medical Examiners, 1010 W Elm St, Suite 150, Conshohocken, PA, 19428-2075. E-mail: jgimpel{at}nbome.org
Context: A 2001 survey of 19 colleges of osteopathic medicine (COMs) revealed that standardized patient programs (SPPs) are increasingly used in osteopathic medical education. However, no new data have been published since.
Objectives: To evaluate current SPP and mechanical simulator use at COMs compared with previous survey results.
Methods: In 2005, an electronic survey regarding the use of SPPs (eg, staffing, facilities) and mechanical simulators in the teaching and assessment of students' clinical skills was sent to the deans of the 23 fully accredited COMs and branch campuses.
Results: Responses were received from all 23 COMs for a 100% response rate. According to survey results, 19 COMs (87%) had active SPPs, 2 COMs (9%) reported that SPPs were in development, and the remaining 2 COMs (9%) used students as patients. In comparison, only 12 COMs (63%) in 2001 had active SPPs. Results indicated an increased use of standardized patients for assessment, particularly in physician-patient communication, osteopathic manipulative medicine, and osteopathic manipulative treatment. In addition, 12 COMs (52%) reported using mechanical simulators in the teaching or assessment of clinical skills.
Conclusion: From 2001 to 2005, the use of SPPs and mechanical simulators at COMs increased substantially.
In 2001, the National Board of Osteopathic Medical Examiners (NBOME) surveyed all 19 colleges of osteopathic medicine (COMs) regarding SPPs.5 The NBOME used the results of the survey to proceed with the research and development of the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE). As a result, standardized patients are now used in required examinations for osteopathic medical students.6,7
The implementation of the COMLEX-USA Level 2-PE in 2004 ignited interest in re-examining how osteopathic medical students are being trained. The current survey, in addition to providing an update on SPPs, also sought to investigate the use of new technologies used in students' training and assessment. These technologies included various types of simulators, from endoscopic and part-task trainers to whole body robotic simulators.
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Methods |
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The survey was e-mailed directly to the dean of each school. As with NBOME's 2001 survey,5 the deans were asked to provide the following information:
As described in the 2002 study,5 an SPP was defined as a program having a paid staff consisting of a program administrator, at least one standardized patient trainer, and a core of part-time, paid standardized patients.
Respondents were also asked to describe the use of mechanical simulators in osteopathic medical education. Those COMs who did use mechanical simulators were asked to indicate which types of simulators were used for the training and assessment of clinical procedures and psychomotor skills by selecting from the following list:
Respondents were asked to indicate in which years of under-graduate and graduate school these technologies were used and if they were used for outside contracts. The survey also included questions regarding the number of simulators available, the mechanical simulator facilities available, and the integration of simulators with SPPs.
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Results |
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The departments responsible for administrating the SPP shifted from the dean's office to other areas (Table 2). Whereas the majority of SPPs were administered through the dean's office in 2001, only 1 program was in 2005.
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Use of Standardized Patients
Similar to the 2001 survey results, standardized patients in 2005 were used
primarily during the first 2 years at COMs
(Table 3). However,
unlike the 2001 data, SPPs now are being used by COMs slightly more for the
assessment of clinical skills than for teaching. The only instances in which
standardized patients were used more for teaching than assessment were in
genital and rectal examinations in men and women. Use of standardized patients
to provide assessment of student skills varied by teaching component assessed
and year of medical training (Table
3).
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Staffing of Standardized Patient Programs
The number of standardized patients in the schools' SPPs ranged from 21 to
235. Seventeen (89%) of the 19 COMs with active SPPs reported having access to
culturally diverse standardized patients, both male and female, between the
ages of 18 and 80 years. Although it is unknown whether survey respondents
reported standardized patients' self-identified race or their own general
impressions, nearly half of these schools (47%) reported having access to
Asian, black/African American, and Hispanic/Latino standardized patients. In
addition, though US Census Bureau documents ask survey respondents about race
and Hispanic ethnicity in two separate questions because a person of Hispanic
ethnicity can be of any race, the current survey did not make such a
distinction.
Of the 23 schools surveyed, 21 schools—both the schools with active SPPs and the 2 schools that used students as patients—employed standardized patient trainers. Thirteen COMs (62%) employed full-time trainers, and 12 COMs (57%) employed part-time trainers. Each COM had no more than 5 full-time and 7 part-time trainers. Six COMs (29%) employed both full-time and part-time trainers. In addition, 16 respondents (76%) indicated that faculty physicians were assigned as supervisors for SPPs.
Facilities and Equipment for Standardized Patient Programs
All SPP facilities had simulated examination rooms and separate video
control rooms, and all SPPs had sphygmomanometers available
(Table 4). Since 2001,
more COMs with SPPs reported having observation rooms (67% in 2001 vs 89% in
2005), and separate video control rooms (58% vs 100%) available. Standardized
patients and students are also now more likely to have separate orientation
and rest areas (33% in 2001 vs 95% in 2005). The average number of SPP
examination rooms was 10 (range, 4 to 24). In addition, of the survey
respondents, 11 COMs had built a new facility since 2001, and 6 COMs reported
having plans for a new or updated facility within the next 3 years.
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Mechanical Simulators
Twelve (52%) of the 23 COMs reported using mechanical simulators or
equipment (Table 5).
At the time the survey was conducted, 11 of 12 COMs had three mechanical
simulation rooms; 1 COM was building four rooms to open in 2006. Nine COMs
integrated both standardized patients and mechanical simulators into their
training and assessment programs. Of these COMs, 7 administered both programs
under the same department. All of the COMs that used mechanical simulators had
digital audiovisual technology, 8 COMs had a data capturing system, and 7 had
ambient sounds for SPPs, medical simulators, or both. Some schools allowed
mechanical simulator use for OGME programs and others in the healthcare
professions (eg, emergency medical technicians) on a contract basis.
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Comments |
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The 2001 NBOME survey was a paper document that allowed schools to reply separately whether or not they used SPPs for teaching or assessment of each clinical skill area by academic year. For example, in students' second year of osteopathic medical school, 6 COMs reported using SPPs in the teaching of OMM or OMT, while 2 COMs reported using SPPs in the assessment of OMM or OMT.5 Although these data allowed for an exact comparison of the use of SPPs by teaching or assessment by academic year, they also inflated the total use of SPPs for teaching and assessment (ie, they were counted more than once). By contrast, data from the 2005 survey revealed how many COMs used SPPs by clinical skill and by year (eg, OMM or OMT in year 2), and then teaching and assessment by clinical skill across all 4 years. For example, COMs reported using SPPs to teach or assess OMM or OMT at any point during undergraduate medical education.
Nonetheless, 2001 data revealed that only 5 COMs (42%) used standardized patients in the assessment of OMM or OMT,5 compared with 14 COMs (67%) in 2005. Likewise, the use of SPPs in the assessment of physician-patient communication skills has more than doubled, from 5 COMs (42%) in 2001 to 19 COMs (100%) in 2005. Similar increases are seen in the use of SPPs for the teaching and assessment of patient education, behavioral medicine, and medical ethics. In addition, other than in the areas of genital and rectal examinations, standardized patients are used more for student assessment than teaching. Because of the sensitive nature of these examinations, schools often use trained clinical professionals (eg, nurses, genitourinary teaching associates) for the teaching or assessment of these portions of physical examination.17
Although the difference in the use of standardized patients in teaching versus assessment is not statistically significant (P=.75), the greater use of SPPs in assessment may be a result of schools' desire to further improve the reliability of standardized patient–based clinical skills examinations, including the COMLEX-USA Level 2-PE before graduation. Further study of whether schools use SPPs for formative or summative assessment and how schools remediate students who fail school-based or national high-stakes clinical skills examinations would be of interest.
Survey results also indicated that nearly half of the COMs (47%) employed white, Asian, black/African American, and Hispanic/Latino standardized patients. However, because the survey did not request specific racial data, it is unknown whether the percentage of these patients matches the racial distribution within the United States or the school's geographic location. This distribution should be further studied.
The current study revealed that 12 COMs (52%) use mechanical simulators at their schools. Until recently, simulation-based medical education for most medical schools—both osteopathic and allopathic—had predominantly used "low-tech" simulations (eg, standardized patients).8,9 Now, various simulators are being incorporated into teaching, learning, and assessment programs at almost half of the COMs. As the fidelity, durability, reliability, and affordability of mechanical simulators continue to improve, COMs and OGME programs are expected to expand the use of these simulators in teaching and assessment. It is also expected that mechanical simulators, alone or in combination with standardized patients, will eventually be incorporated into high-stakes assessments of hands-on skills used for licensure and certification.
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Conclusion |
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Submitted March 16, 2006; revision received September 12, 2006; accepted September 19, 2006.
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References |
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2. Yudkowsky R, Alseidi A, Cintron J. Curr Surg. 2004;61:499 -503. Beyond fulfilling the core competencies: an objective structured clinical examination to assess communication and interpersonal skills in a surgical residency.[Medline]
3. Yudkowsky R, Downing SM, Sandlow LJ. Developing an institution-based assessment of resident communication and interpersonal skills. Acad Med.2006; 81:1115 -1122.[Medline]
4. Hauer KE, Hodgson CS, Kerr KM, Teherani A, Irby DM. A national study of medical student clinical skills assessment. Acad Med. 2005;80(suppl 10): S25-S29.[Medline]
5. Errichetti AM, Gimpel JR, Boulet JR. State of the art in standardized patient programs: a survey of osteopathic medical schools. J Am Osteopath Assoc. 2002;102:627-631. Available at: http://www.jaoa.org/cgi/reprint/102/11/627. Accessed November 20, 2007.
6. Commission on Osteopathic College Accreditation. Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures. Chicago, Ill: American Osteopathic Association; 2007. Available at: https://www.do-online.org/pdf/acc_predocomstds.pdf. Accessed November 20, 2007.
7. Rausa MM, Campea M. Osteopathic medical students begin clinical skills test at new testing center to help improve patient care [press release]. September 8, 2004. Available at: https://www.do-online.org/index.cfm?PageID=mc_clinskillstestbeg. Accessed November 30, 2007.
8. Teitelbaum HS. Osteopathic Medical Education in the United States: Improving the Future of Medicine. Washington, DC: American Association of Colleges of Osteopathic Medicine/American Osteopathic Association; 2005. Available at: https://www.do-online.org/pdf/acc_mededstudy05.pdf. Accessed December 6, 2007.
9. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med.2003; 78:783 -788.[Medline]
10. Sensi S, Ben-David MF, Guagnano MT, Merlitti D, Pace-Palitti V, Danieli G, et al. Assessment of clinical competence of medical school graduates in Italy with standardized patients. The opinion of the examinees [in Italian]. Recenti Prog Med.1998; 89:575 -577.[Medline]
11. Liu M, Huang YS, Liu KM. Assessing core clinical competencies required of medical graduates in Taiwan [in Taiwanese]. Kaohsiung J Med Sci. 2006;22:475 -483.[Medline]
12. Stevens A, Hernandez J, Johnsen K, Dickerson R, Raij A, Harrison C, et al. The use of virtual patients to teach medical students history taking and communication skills. Am J Surg.2006; 191:806 -811.[Medline]
13. Institute of Medicine. To Err Is Human: Building a Safer Health system. Washington, DC: National Academies Press;2000 .
14. ACGME Outcomes Project: An Introduction. Accreditation Council for Graduate Medical Education Web site. 2005. Available at: http://www.acgme.org/outcome/project/OPintrorev1_7-05.ppt. Accessed November 20, 2007.
15. Gallagher H, Cummings M, Gilman D, McNerney J, Mogil C, Piccinini R, et al, for the AOA Core Competency Task Force. 2007. Report of the Core Competency Task Force: A Report to the AOA Board of Trustees. Chicago, Ill: American Osteopathic Association; 2003. Available at: http://www.com.msu.edu/scs/cc/docs/AOATaskForceReport.pdf. Accessed December 18, 2007.
16. Gimpel JR, Boulet JR, Errichetti AM. Evaluating the clinical skills of osteopathic medical students. J Am Osteopath Assoc. 2003;103:267-279. Available at: http://www.jaoa.org/cgi/reprint/103/6/267. Accessed December 18, 2007.
17. St John Kelly E. Teaching doctors sensitivity on the most sensitive of exams. New York Times. June2 , 1998.
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