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Use of Standardized Patients to Enhance a Psychiatry Clerkship

Hall, Molly J. MD; Adamo, Graceanne MA, CMA; McCurry, Lisa MD; Lacy, Timothy MD; Waits, Wendi MD; Chow, Jennifer MD; Rawn, Lisa MA; Ursano, Robert J. MD

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Author Information

Dr. Hall is associate professor and assistant chair, Dr. McCurry and Dr. Lacy are assistant professors, and Dr. Ursano is chairman, Department of Psychiatry, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland; Ms. Adamo is assistant professor and director of clinical skills teaching and assessment and Ms. Rawn is a standardized patient specialist, National Capital Area Medical Simulation Center, USUHS; Dr. Waits is a psychiatry resident, National Consortium Psychiatry Residency Program, Washington, D.C.; Dr. Chow is a psychiatry resident at the Wilford Hall Psychiatry Residency Program, San Antonio, Texas.

Correspondence and requests for reprints should be addressed to Dr. Hall, Department of Psychiatry, Uniform Services University, 4301 Jones Bridge Road, Bethesda, MD 20814; e-mail: 〈mhall@usuhs.mil〉.

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Abstract

Changes in psychiatric health care delivery driven by such major shifts as deinstitutionalization, community-based care, and managed care have greatly altered the educational milieu for third-year psychiatry clerkships. Students may be assigned exclusively to alcohol and substance abuse treatment units, consultation-liaison services, or outpatient clinics, and may not have as broad an exposure as is desirable to patients with a variety of psychiatric illnesses. The authors describe a pilot course they developed in 2001, Clinical Psychiatric Assessment and Diagnosis, for third-year medical students at the Uniformed Services University of the Health Sciences medical school. The course uses standardized patients (SPs) to help students gain broader clinical experience. In psychiatry, a growing body of literature supports the acceptability, reliability, and validity of objective structured clinical examination assessment using SPs for medical students. Only a few articles report the use of SPs to primarily teach psychiatry instead of evaluating student proficiency in clinical psychiatry. Since this course was developed, the National Board of Medical Examiners announced that all medical students will be required to pass a clinical skills test in order to practice medicine, beginning with the class of 2005. The examination will use SPs modeling different clinical scenarios. In light of this change, many medical schools may have to reevaluate and possibly revamp their curriculums to insure sufficient acquisition of clinical skills in different specialties. The use of SPs in psychiatry could provide an effective, primary clinical teaching experience to address this new requirement as well.

In this article, the authors describe their experience developing and implementing a pilot course in clinical psychiatric assessment and diagnosis for third-year medical students using standardized patients (SPs). The course was created to amplify and enhance learning opportunities in the third-year clerkship that now occur in clinical settings, which have a variety of patient populations and treatment missions and thus sometimes do not expose students to a sufficient array of conditions and treatments.

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Introduction

The third-year psychiatry clerkship is the core of the psychiatry curriculum for medical students. For most physicians it will be their single most concentrated learning opportunity in psychiatry. Beginning in the 1970s, when the Liaison Committee on Medical Education mandated psychiatry clerkships, departments of psychiatry established inpatient-based experiences.1 Students had ample time to study readily-available patients across a span of serious mental illnesses, which exposed them to fundamental mental status elements, psychopathology, risk assessment, differential diagnosis, and treatment strategies.

The changes in psychiatric health care delivery driven by such major shifts as deinstitutionalization, community-based care, and managed care have greatly altered the educational milieu for third-year psychiatry clerkships. Treatment for most patients, even severely ill patients, is largely outpatient focused. The number of inpatient beds is greatly reduced and inpatient care is brief and aimed at stabilization; only the most refractory, chronically ill patients are hospitalized for any appreciable length of time. Even though psychiatry practice has shifted to ambulatory settings, clerkships in psychiatry remain largely inpatient based.1

Increasingly, the Liaison Committee on Medical Education requires comparable and sufficient patient exposure at all sites. For the reasons explained previously, ensuring comparability across all sites is a problem for all clerkships, including psychiatry clerkships. Many other specialties in the 1980s and 1990s (e.g., family practice, internal medicine, pediatrics) successfully undertook a transition to include integrated outpatient experiences in their required clerkships.2,3 There is recent interest in developing and enlarging outpatient experiences for all students in the psychiatry clerkship. However, initiating such a fundamental change in a clerkship structure requires enormous time and resources. To achieve a broader clinical exposure, outpatient rotations in psychiatry will have to be added to experiences on partial and inpatient units.

SPs may offer a way to address some of these difficulties. There is ample literature regarding the validity of using SPs in medical education for both assessment and instruction.4–6 SPs are individuals who have been trained to present specific clinical material in a consistent, reliable manner, although they may be trained to improvise some material, particularly that which emphasizes affect and may also use their own medical history or experiences for teaching purposes. They have been increasingly used in the teaching and evaluation of medical students since the 1960s.7 Use of SPs permits assessment of processes of care such as history taking or physical examination,8 as well as mastery of more complex medicosocial issues such as evaluation of domestic violence, delivering bad news, end-of-life decisions, and other areas of clinical ethics.9,10 In addition, there is extensive literature documenting the fidelity and reproducibility of SPs’ performance.11

In psychiatry, a growing body of literature supports the acceptability, reliability, and validity of objective structured clinical examination assessment using SPs for medical students.12,13 Psychosocial interviewing skills have been taught in pediatric clerkships using SPs,14 but there are only a few articles that report the use of SPs to teach primarily psychiatry instead of evaluating student proficiency in clinical psychiatry.15,16 In this article, we describe our experience developing and implementing a pilot course, entitled Clinical Psychiatric Assessment and Diagnosis, for third-year medical students at the National Capital Area Medical Simulation Center in Bethesda, Maryland. The course was created in 2001 to amplify and enhance learning opportunities in our medical school’s third-year clerkship that now occurs in clinical settings with a variety of patient populations and treatment missions. Specifically, the third-year clerkship in psychiatry at our school (the Uniformed Services University of the Health Sciences) is conducted at five geographical sites in a number of treatment settings (general psychiatry inpatient, partial hospitalization units, outpatient clinic, consultation liaison service, and alcohol and substance abuse partial hospitalization unit). Each student is assigned exclusively to one treatment setting at one site. Clinical exposure is limited to the type of patients appropriate to that site, in addition to three overnight calls covering inpatient psychiatry, urgent consultations, and emergency room evaluations. At their clinical sites, students may or may not see patients with the range of clinical signs and symptoms considered a necessary part of a clinical clerkship in psychiatry.

The primary objective of the pilot course is to teach core psychopathology, with secondary goals of teaching psychiatric interviewing techniques and interpersonal effectiveness. The educational method uses active, experiential learning with immediate individual verbal and written feedback from an SP and faculty for each student in conjunction with more traditional faculty-led seminars.

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Course Development

Five SP cases, modeled after actual cases, were developed for patients with the following conditions: postpartum depression, mania, alcohol abuse, paranoid schizophrenia, and early dementia. The class, lasting two hours, is given once a week for six weeks. All students have an opportunity to individually conduct a 20-minute interview with an SP presenting the clinical case of the day. There are sufficient numbers of SPs trained in each case that all students interview an SP during the class. The students interview the SPs in individual examination rooms and all activities are videotaped. Faculty are able to observe the interviews in an observation studio. After the interview, the students leave the examination room and spend ten minutes completing a self-assessment checklist covering core areas of clinical inquiry and the communication and interpersonal skills that they used in this specific encounter. During this time, the SP completes a checklist that mirrors the content and sequence of the questions in the student checklist and develops notes for succinct, structured verbal feedback. Each student and his or her SP then meet for a five-minute discussion about the interview. The SP leads the student to reflect on the interview process—what went well, what didn’t—and in turn delivers limited, behaviorally anchored feedback that focuses on the patient’s perspective. All feedback sessions are videotaped. Students then meet as a small group (six to nine students) with faculty to review the interview experience, their checklists, and critical assessment elements (such as dangerousness of patient to self and others), and to present their formulation of a differential diagnosis and treatment and intervention plans. At the conclusion of the entire two-hour experience, students evaluate the SP interview and the faculty-led class by filling out a questionnaire. On the sixth and last class, students select one of their tapes and review it with a faculty member.

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Preliminary Findings

We have offered this course to 16 rotations of more than 300 medical students. In addition, the full-time psychiatry faculty all participated in interviewing an SP from one of the cases in the same format as used by the students, and they completed the same paperwork. All interviews and feedback have been videotaped and archived. Data from the SP checklist, student self-assessment checklist, and course critiques have been entered into databases for future analysis.

As explained earlier, one of our justifications for building this educational experience was to offer students an experience of core psychopathology in the psychiatry clerkship that they might not be exposed to at a variety of diverse clinical sites. Review of 156 students’ patient logs to date confirmed that students often do not see core psychiatric diagnoses at their clinical sites. For example, 42% of students assigned to an outpatient site evaluated a patient with bipolar illness, 25% saw a patient with schizophrenia, and 15% evaluated a patient with dementia. These numbers included patients that the students had evaluated on their three nights on call. Data trends from the weekly class critiques also support this disturbing finding. Up to 80% of students reported that the depression case modeled by the SP is similar to others they have observed at their clinical sites, whereas 40% to 50% of students indicated that they had not encountered a similar case of bipolar or schizophrenic illness.

Students overwhelmingly report that the course is enjoyable and a first-rate learning experience, that the written self-assessment checklists are excellent learning tools, and that the feedback from the SP is valuable. These observations are based on written comments from the course critiques, statements from the end of clerkship evaluation form and comments made to faculty. All 112 students taking the course in 2001–02 ranked their SP experience as one of the most useful learning experiences in the clerkship. The course was ranked as highly or higher than other valued clerkship elements such as the preceptor relationship. Students highlighted the exposure to different patients as valuable as often as they mentioned the opportunity to become more comfortable interviewing, receive feedback from the SPs, and watch their videotapes with faculty. Full-time faculty completing the interview experience also evaluated feedback from the SP as highly valuable.

An unintended outcome of this course was the ability to identify students having difficulty early in the clerkship. Sometimes this was evident to faculty observing ongoing interviews; however not all interviews are observed, and only portions of an interview are watched during any class. The interpersonal and communication skills checklists filled out by the SPs tended to identify students who were awkward or less effective interacting with patients. There were four questions in particular that were associated with poor performance: (1) a global assessment of the SP’s confidence in the student, (2) likelihood of the SP’s compliance with the student’s recommendations, (3) likelihood of the SP’s return for a follow-up visit with the student, and (4) the SP’s overall satisfaction with the encounter. The only students who received a D or an F as a final clerkship grade had done poorly on these interpersonal and communications skills checklist items on two or more interviews. However, not all students with difficulty on these items did poorly in the clerkship as a whole. Interesting questions raised included whether the on-site clinical staff were aware of any difficulties these students were having or whether the simulation course format was uniquely able to reveal concerns in students’ interaction with patients that needed attention.

In summary, our experience to date supports the use of SPs to augment clinical exposure to psychopathology and suggests that this learning experience is valued by the students. Future directions include the analysis of student’s evaluation of multiple educational experiences and their relevance to academic performance, as well as an examination of the unique teaching opportunities provided in this format

Since this course was developed, the National Board of Medical Examiners announced that all medical students will be required to pass a clinical skills test in order to practice medicine, beginning with the class of 2005. The examination will use SPs modeling different clinical scenarios. In light of this change, many medical schools may have to reevaluate and possibly revamp their curriculums to ensure sufficient acquisition of clinical skills in different specialty areas. The use of SPs in psychiatry could provide an effective, primary clinical teaching experience that will address this new requirement as well.

The authors gratefully acknowledge Kiera Jones, research assistant, Department of Psychiatry, Uniformed Services University of the Health Sciences (USUHS), for inputting data from over 300 medical student–SP interviews, and also thank Richard Hawkins, MD, medical director, National Capital Area Medical Simulation Center, USUHS, for reviewing early drafts of this article and offering helpful suggestions to improve it.

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References

1.Pessar LF. Ambulatory care teaching and the psychiatric clerkship. Acad Psychiatry. 2000;24:61–7.

2.Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70:890–931.

3.Grum CM, Richards PJN, Woolliscroft JO. Consequences of shifting medical student education to the outpatient setting: effects on performances and experiences. Acad Med. 1996;71(1 suppl):S99–S101.

4.van der Vleuten CPM, Swanson DB. Assessment of clinical skills with standardized patients: state of the art. Teach Learn Med. 1990;2:58–76.

5.Ainsworth MA, Rogers LP, Markus JF, Dorsey NK, Blackwell TA, Petrusa ER. Standardized patient encounters a method for teaching and evaluation. JAMA. 1991;266:1390–6.

6.Hodges B, Turnbull J, Cohen R, Bienenstock, Norman G. Evaluating communication skills in the objective structured clinical examination format: reliability and generalizability. Med Educ. 1996;30:38–43.

7.Barrows HS, Abrahamson S. The programmed patient: a technique for appraising student performance in clinical neurology. J Med Educ. 1964;39:802–5.

8.Colliver JA, Swartz MH. Assessing clinical performance with standardized patients. JAMA. 1997;278:790–1.

9.Kahn MJ, Sherer K, Alper AB, et al. Using standardized patients to teach end-of-life skills to clinical clerks. J Cancer Educ. 2001;16(3):163–5.

10.Edinger W, Robertson J, Skeel J, Schoonmaker J. Using standardized patients to teach clinical ethics. Med Educ Online. 1999;4:4.

11.Badger LW, deGruy F, Hartman J, et al. Stability of standardized patients’ performance in a study of clinical decision making. Fam Med. 1995;27:126–31.

12.Hodges B, Regehr G, Hanson M, et al. An objective structured clinical examination for evaluating psychiatric clinical clerks. Acad Med. 1997;72:715–21.

13.Hodges B, Regehr G, Hanson M, et al. Validation of an objective structured clinical examination in psychiatry. Acad Med. 1998;910–2.

14.Blake K, Mann KV, Kaufman DM, Kappelman M. Learning adolescent psychosocial interviewing using simulated patients. Acad Med. 2000;75(10 suppl):S56–S58.

15.Coyle B, Miller M, McGowen KR. Using standardized patients to teach and learn psychotherapy. Acad Med. 1998;73(5):591–2.

16.Krahn LE, Bostwick JM, Sutor B, Olsen MW. The challenge of empathy: a pilot study of the use of standardized patients to teach introductory psychopathology to medical students. Acad Psychiatry. 2002;26:1.

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© 2004 Association of American Medical Colleges

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