Deep Standard Impact

Deep Standard Impact

The Use of the Standardized Patients in Chiropractic Education

The utilization of the standardized patient (SP) in education enables students to interact in a realistic clinical situation with minimal risk to the patient who is simulating a significant condition. A SP is an individual selected and coached to imitate a designated condition as if they were an actual patient. Quality, accuracy and realism of the performance is portrayed by the SP in such a manner that it would go undetected by a skilled clinician. Instructional goals in case simulations provide students with an opportunity to demonstrate not only their knowledge and practical proficiency, but also their interpersonal skills and attitudes. This paper discusses the preparation of a case, the training of a standardized patient, the interaction with the student, and subsequent assessment procedures.

INTRODUCTION
Conventional chiropractic education has traditionally followed the lecture/lab format of instruction, where practical clinical experience is incorporated later in the educational process. Student interns are suddenly faced with a real patient encounter requiring an immediate application of the knowledge and skills amassed over 3 yr of classroom and lab instruction. Incorporation of problem-based teaching methods are recognized as a tool to provide clinical relevance early in the educational process. SP performances enhance problem based teaching by facilitating the integration of human structure and function into significant case scenarios while still maintaining student interest. The interaction between student and SP bridges the gap between the academic classroom and the practical clinic experience. Standardized patients are instrumental in providing a variety of teaching moments and learning opportunities in large group, small group and one-on-one exercises. As students advance through the curriculum they are periodically monitored to collectively assess the integration of basic science knowledge, the progression of clinical competency and development of interpersonal skills.

CASE SELECTION
The following methods support traditional education and may serve to encourage educators to implement a standardized patient program. The process begins with case development and the acquisition of actual clinical records that are situated into a case template to preserve authenticity. Features of the case are regulated by the template since variability can occur in presentations of the same condition. Consistency in training and performance of standardized patients is also enhanced by this process. A textbook case, flawless as it may be, would not serve the intended purpose.

As an example, patient individuality and the symptoms of an acute disk condition may present with hard neurological findings while a second patient with a similar acute presentation may have different personal attributes and negative test results. Students are challenged to make professional decisions in these real life simulations when patient attributes and findings are more subtle and where there is uncertainty. Potential cases  are acquired from a list compiled from the Significant Conditions Survey of clinical conditions in chiropractic. Selected cases are critiqued by faculty members for academic level of the student, substance, authenticity and reproducibility by the standardized patient. Course directed objectives incorporate diagnostic measures and the various management applications to include, by example, the need for collaborative care, recognition of emergency situations and the ability to deal with difficult patients.

RECRUITMENT AND TRAINING
Recruitment of the SP begins by searching for potential resources offered in the community such as college theater groups and senior citizens by publication of ads in local newspapers. Typecasting of the SP begins with an initial encounter to ascertain the interview qualities of the subject, as well as to establish performance day availability. An example of typecasting would be the selection of an ectomorphic female in a specific age group for a case that included anorexia. A personal history of the subject is an invaluable tool for case assignment.. Training techniques can then be customized to each case allowing SPs to perform a variety of maneuvers and/or tests in an authentic manner. These techniques are designed for simplicity in training and to  focus attention on the symptoms of the case rather than the diagnosis.

Introductory training of the standardized patient requires two sessions. The goal of the first meeting is to coalesce the patients actual life experiences as they are trained to emulate the symptoms of the case. For in stance, if a patient requires increased reflex activity they would be coached to perform a Jendrassik reinforcement at the time the reflex is being checked by the student doctor. Individual attributes and personal experiences are incorporated into the case to render a realistic representation. To insure a comfort level in the SP's role play, an awareness of their sensitive personal life issues needs to be considered. A dry run performance of the history and physical findings is the focal point of the second meeting. On performance day the trainer reviews the special features of the history and examination to develop a mind-set for the SP in the role they are about to play.

DIVERSITY OF APPLICATION
A curriculum can provide a gradual exposure to a number of experiences with the SPs. A large group experience by direct observation, where a clinician interviews the SP, is apropos for the beginning student. This initial contact is usually non-intimidating and a comfortable introduction to the SP interaction. Subsequent small group discussion activities in tutorial settings utilizing "time in, time out" teaching methods give an opportunity to accomplish preset objectives. Faculty spontaneously interrupt simulations by the use of the "time in, time out" technique. Simulations are suspended during the "time out" period to encourage immediate group discussions while fulfilling specific learning objectives. This technique is easily utilized in both large and small group settings.

Following this experience, the progression to small group and one-on-one activities is an easy transition. The one-on-one doctor/patient experience is assessed by fellow students on checklist forms designed specifically for the case. Following encounters, students proceed to an examination room to develop a report of findings. Individual student/patient encounters are videotaped for evaluation and feedback. Small group videotape review sessions are then planned. Videotaped observation provides a personal baseline performance quality for the student and SP. Faculty are directed to encourage a nonthreatening environment during these discussions on the video playback. A positive atmosphere is achieved by utilizing a "sandwich teaching technique." This technique includes a critique of the performance, which is preceded and followed by a complimentary statement. A beginning statement complimenting the overall performances sets an optimistic tone and stimulates participation in the ensuing discussions. This atmosphere allows for a free exchange of information between students and faculty members. The opinion of the SP is furnished to the students by faculty members in a final written SP Interview Report. Videotapes are reviewed in small group sessions and self-assessment of personal strengths and areas of needed improvement are provided by the student doctor in the presence of faculty and followed by peer review. Patient rapport is a fundamental objective that is reinforced during these sessions since chiropractic management depends on patient compliance.

Upon completion of the simulation, as part of the debriefing process, SPs are queried with regard to their experiences and interactions. To avoid retention of any residual characteristics. of the trained behavior, their normal health picture is reaffirmed and confidentiality of the diagnosis is maintained. SPs are also  evaluated by the students, who fill out a checklist on their performance as a determinant of future involvement.

PERFORMANCE EVALUATIONS
The primary goal of the SP program is to reinforce cognitive retention and give students experience and insight into their personal abilities and areas of needed improvement in the most realistic clinical setting. A variety of assessments are designed to more fully evaluate student performance. A complete assessment includes not only didactic, but psychomotor and interpersonal skills. Case driven history and examination checklists are provided to students to evaluate each peer interaction. One phase of performance assessment is accomplished by using a simple checklist form for history and examination. Forms were developed identifying performance items with consideration for ease and grading consistency. Case progression includes a report of findings that is developed into an examination checklist form. This list validates resultant findings, ensures case comprehension and allows students an opportunity to prioritize diagnoses.
Videotape review sessions begin with a discussion by faculty of the collective observations of student performance and a list of objectives as reflected in the case. Students view themselves to recognize both their strengths and areas for needed development. Peer critique provides immediate verbal feedback and validates the student doctors' personal assessment with additional insight which proves to be most beneficial. A Standardized Patient Interview Report regarding conversational ability, professional decor, and an overview of their "bedside manner" is shared with each student doctor. Student response to the challenge of the entire endeavor is met with a positive affirmation. Authenticity of the case stimulates excitement by participants and teaching moments are easily recognized and captured.

QUALITY AND VARIETY OF ENCOUNTERS
Students are exposed through the SP encounters to a potpourri of significant conditions as seen in chiropractic practice. This ensures a variety and mix of opportunities that are not normally available in traditional educational settings. An SP impacts the educational program by reinforcing curricular goals and providing feedback concerning achievement of educational outcomes. The SP's personal insight and natural real life experiences benefit the quality of the existing case. A simple phrase, nuance or opinion can add value to the presentation. An original question phrased by the student, "Why did you choose to see a chiropractor today?", led to a spontaneous response by the SP, "I didn't have a chance to get to my real doctor." An added interpersonal challenge was created by the response that would not otherwise have existed.

SPs are available on call and their performances can be repeated on a number of occasions, adding consistency in teaching. The consistency provides an ease in the evaluation of a large number of students. Case authenticity stimulates excitement for the participants who recognize the ambiguity, variability and inconsistency of a real life case.

UNEXPECTED OUTCOMES
The emotional investment of the SP in case simulations is deep seated and should not go unrecognized. Unlike other teaching aids, the debriefing process is a vital component of the SP encounters. "There are three debriefing objectives: to help the SP get out of the role, provide feedback about the performance, and to provide suggestion about future performances". The importance of the debriefing process has been illustrated on more than one occasion during both the training and performance sessions. An example of an SP's inability to get out of the role occurred at the end of a second training session for a low back condition. Following completion of a "time in, time out" dress rehearsal, the SP asked the trainer, "now what are you going to do about my low back pain?' The SP was immediately returned to the role play and disarmed of the trained behaviors by utilizing a desensitization process through discussion of their normal health characteristics and demonstration of their normal physical findings.

An interesting and unexpected benefit of the program is the reaction of the SPs regarding their involvement in the education of future doctors. An enlightenment of the comprehensive training of a doctor of chiropractic gives them a new perspective of the field and they become proud and enthusiastic contributors to this innovative educational process.

CONCLUSION
The collective literature and personal experience suggest that the use of SPs are a definite benefit to clinical education. This approach provides an improved and more comprehensive assessment of clinical competency than conventional education has offered. Our experience with SP encounters have provided a baseline of assessed performance levels enabling continuous feedback for areas of needed improvement in the clinical competencies. Early in the students' education, their long-term clinical goals become apparent as observed in their evolving attitude toward their future as a doctor. A more serious demeanor is assumed regarding the structure and function of the human body and how it relates to a clinical condition. Exposure to the active learning process heightens students' awareness of their role in patient care.

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