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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
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while preventing the SP from responding in a natural way to
conversation with the learner. Scripted lines are often used
only for the opening line, such as “I’ve been having this
terrible headache, and I’m really getting worried,” or for
standardized questions asked of the learner, such as “Can we
postpone some of these vaccines for my baby?” Cases may
also need to include information about the patient’s inner life,
such as what emotions the patient is experiencing and what
the patient’s goals are for the encounter.
98,99
As outlined in the Medical Council of Canada Guidelines
for the Development of Objective Structured Clinical
Examination (OSCE) Cases, an SP script will commonly
include the content listed in Box 6.2.98 For low-stakes
assessments, SPs may be asked to use a simplified version of
their own family or social history. When asked nonpertinent
questions about the past medical history, social history, or
family history, the standard reply can be either “No” or “I
don’t know,” as appropriate.
6.2.
Components of a Standardized Patient
Script from the Medical Council of
Canada Guidelines for the Development
of Objective Structured Clinical
Examination (OSCE) Cases
•. Room setup and props
•. Demographic data: age, gender
•. Standardized patient starting position: sitting, lying
on a gurney, etc.
•. Appearance: dress, hair, make-up/moulage
•. Behavior, affect, and mannerisms
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•. Opening statement
•. Questions the standardized patient must ask
•. Physical findings
•. History of presenting problem
•. Relevant past medical history
•. Relevant social history
•. Relevant family history
•. Critical review of systems
Case Tasks
As noted earlier, the case stem includes the patient
information that is provided to the learner at the start of the
SP encounter along with a description of the task to be
performed. Even when the task is general, such as “Elicit a
focused history and perform a focused physical exam,” it
must be clearly stated.38 SP cases typically have a time limit
that can range from as short as 5 minutes for a specific skill
such as examining the cranial nerves, to 20 minutes or longer
for cases that include a history, physical exam, and sharing a
diagnosis or diagnostic plan with the patient.98 A committee
of both content experts and educational experts should
participate in the development of SP cases to ensure that
there is sufficient time to perform the required tasks and that
the level of difficulty is appropriate for the learners38 (see Fig.
6.1).
Pilot Testing
Pilot testing is extremely helpful since it can be difficult to
estimate both the time required for a case and how students
will respond to case material. Providing insufficient time
may encourage inappropriate test-taking behaviors, such as
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rapid-fire questioning, which may not support the overall
goals of the assessment.
103
Finding representative learners to
participate in a pilot can be a challenge since educators often
do not want to allow students to see case materials ahead of
an assessment. In this situation, slightly more advanced
students can be used as proxies for pilot testing. For example,
fourth-year medical students could be asked to try out cases
that will be used in an OSCE created for third-year students.
Alternatively, for high-stakes exams, new cases can be
incorporated in an established OSCE but not included in the
final scores to pilot-test the cases. This technique was utilized
for the USMLE-Step 2 CS exam.
104
Checklists and Rating Scales
The most common means of evaluating performance during
SP-based assessments is via the use of checklists and rating
scales. Checklists are used for skills that can be scored
categorically and often dichotomously such as “yes/no” or
“done/not done.” Rating scales are used for skills that have a
more continuous and wider range of performance such as
communication skills, which may be scored using a tiered
scale and may also include behavioral anchors. Many cases
include a combination of checklists and rating scales as
described in more detail later in the chapter.
Content-based checklists are used to record whether
specific actions are taken by the examinee and are commonly
used to score history taking and the physical exam.
10
Examinee actions are scored in a categorical fashion such as
“Elicited smoking history: done/not done.” While many
checklist items are dichotomous, they may also be
polytomous.
105
In the preceding example, a student who asks
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the SP if they have a history of smoking but does not inquire
further about the duration and intensity of smoking may be
marked as “partially done.” This example also illustrates the
importance of clearly defining the criteria for “done,”
“partially done,” and “not done,” particularly in a highstakes assessment. Physical exam maneuvers are often scored
as “done/done incorrectly/not done.” With this scoring
system, a learner who at least attempts a maneuver (such as
auscultating the heart for a patient with shortness of breath)
but does it incorrectly (perhaps by listening over the gown)
may still be awarded partial credit if deemed appropriate.
History and physical examination checklists are typically
created during the initial case development and must be
consistent with the learning objectives being assessed.
Checklists are often developed by content experts through
panels or written protocols.
106
Alternatively, checklists may
be developed by having experts participate in the case, and
then using the behaviors that the experts employ—such as
which history questions they ask and which physical exam
maneuvers they perform—to create a checklist.
107
When
possible, checklists should include evidence-based, clinically
discriminating items.
108,109
Clinically discriminating items are
those that help distinguish one diagnosis from another. For
example, examining jugular venous pressure will help
distinguish heart failure from pneumonia for a patient with
shortness of breath. Discriminating items stand in contrast to
checklist items, which are included for the sake of
thoroughness.
109
Case writers should be careful to avoid the
natural tendency to include too many checklist items, which
can negatively impact the reliability of the scores since the
cognitive load for the SPs becomes excessive.
110,111
In
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addition given relatively frequent changes in clinical practice,
checklists must be regularly reviewed and updated since
checklist items considered important today may not be as
relevant in the future.
112
The content of the checklist will also depend on the
experience and needs of the learner. If the goal is to assess the
physical exam skills of a novice student in an introductory
clinical skills curriculum, then the checklist may include
specific items for inspection, palpation, percussion, and
auscultation and may perhaps include several checklist items
under each of those categories. This sort of detailed checklist
will allow course directors to explicitly define and
communicate the proper steps and techniques for each skill
to the students. More experienced physicians, however, score
less well on checklists that emphasize thoroughness.
113
For
higher-level learners, or when making high-stakes decisions,
checklists should instead reflect only the most essential
actions or maneuvers required for an appropriate evaluation
of a patient with a particular clinical presentation. More
advanced examinees can use heuristics, or mental shortcuts,
which minimizes the amount of analytic data they need to
collect to formulate a reasonable differential diagnosis.
114
Therefore the case development team should be attentive to
the potential for rewarding thoroughness or inappropriate
test-taking behaviors rather than true clinical competence.
That is, more capable examinees that arrive at the
appropriate diagnostic or management decision via a more
efficient, or alternative, data gathering approach should not
be penalized.
Typically, the SP will complete a checklist immediately
after the encounter, which sets practical limits on the lengths
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of checklists due to the cognitive load placed on the SPs.
111
Checklists longer than 15 to 20 items can exceed the ability of
most SPs to accurately recall specific elements of examinee
performance,
115
and raters have been shown to fatigue over
the course of an exam.
116
On the other hand, in specific
circumstances well-trained SPs have been shown to have
acceptable accuracy on much longer checklists such as a
head-to-toe physical exam.
117
Other strategies include
checklist scoring by an observer either in the room or
watching remotely from a control room, or scoring
asynchronously by watching a video recording later on,
118,119
although these approaches require additional human
resources.
In addition, faculty should work with SP educators to
ensure that individual checklist items represent specific,
observable behaviors that are amenable to categorical
scoring. Broad or complex checklist items that require SPs to
interpret examinee intentions or recall multiple actions are
more likely to result in inaccurate scoring.
115
For example,
instead of “The student asked about factors that precipitated
my chest pain,” the checklist should include several separate
items such as:
The student asked if physical exertion caused my chest
pain: Y/N
The student asked if taking a deep breath caused my
chest pain: Y/N
The student asked if lying down caused my chest pain:
Y/N
Additional methods for scoring SP-based encounters
employ various types of rating scales.
120
Rating scales are
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often used when the skill or behavior being assessed requires
some multifaceted judgment of examinee performance that is
not amenable to dichotomous scoring. Rating scales are
commonly used for measuring communication and
interpersonal skills and for assessing humanistic or
professional behaviors.
121,122
Rating scales may assess
specific behaviors such as eye contact, or may be more global
assessments of a student’s performance.
123
For example, a
global rating scale may ask an SP to rate the student’s overall
interpersonal skills as poor, below average, average, above
average, or excellent. These sorts of global ratings may result
in similar scores as more specific behaviorally anchored
ratings and may correlate with assessments of actual clinical
performance.
124
In contrast, rating scales may be used to
assess multiple specific communication tasks, such as “Make
a personal connection during visit (e.g., go beyond medical
issues)” and “Explain rationale for diagnostic procedures
(e.g., exam, tests),” which are from Makoul’s SEGUE
Framework.
125
A number of these communication
frameworks are available in the literature.
126–133
These sorts
of frameworks can then be further defined with a
behaviorally anchored rating scale (BARS) as described in
Chapter 4. A BARS assessment includes specific descriptions
of the behaviors that define each point along the scale. See
Appendix 6.1 for an example of a communication skills
checklist that uses a BARS. The BARS format is particularly
well suited to CBME since the criteria for meeting
competence can be spelled out in the anchors.
When developing both checklists and rating scales, faculty
often consider weighting the most important items more
heavily. Many history and physical exam checklist items,
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however, are interdependent, and it can be difficult to
determine the relative importance of various items. In the
end, weighting of items does not have a significant impact on
reliability or pass/fail determinations.
134
Therefore items
should typically only be weighted to signal the relative
importance of certain skills when assessment is used for
learning as described earlier.
Standardized Patient Selection and
Training
SPs come from a very wide range of backgrounds. Recruiting
a diverse group of SPs is essential to the success of the overall
SP program and should take into account as many
characteristics as possible including age, gender, race,
ethnicity, size, disability, and others. SPs should be
motivated to contribute to the educational mission of the
institution. SPs who are hostile or bitter toward the medical
profession, or have a strong personal agenda, will often not
create the best educational experiences for learners.40 SPs are
usually asked about scars or other observable physical
findings that may influence their portrayal of a case. A
clinician should also examine the SP to uncover any
previously unknown physical examination findings that may
impact a case, such as a thyroid nodule or a heart murmur.
Training SPs is a profession unto itself, and whenever
possible SP educators should be employed to ensure that SPs
are trained in a clear and consistent way. The Association of
SP Educators (ASPE) is a tremendous resource for
information on training SPs, particularly through the ASPE
Center for SP Methodology.
135
Numerous strategies are used
to train SPs including written scripts, videos of real patients
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with the target condition, videos of SPs portraying the same
case, and virtual and in-person role-play. With careful
training and feedback, multiple SPs can portray and score the
same case with accuracy and consistency.
136
While most of
the training can be accomplished by SP educators, clinical
staff and faculty must observe and provide feedback to SPs to
ensure a realistic portrayal of the clinical scenario. Clinician
expertise is also required to provide training on proper
physical exam technique. The intensity of training and the
degree of standardization required depends on the stakes
and the purpose of the assessment. For low-stakes formative
assessments, training may be brief and SPs may be asked to
ad lib or use some of their personal history—for instance, a
general family history, which will be easier for the SP to
remember than a fictional family history. For high-stakes
summative assessments, the degree of standardization may
be quite detailed, such as counting the number of seconds the
student takes to wash their hands or counting the number of
times the student says “um” or “ah.”
SPs are also frequently trained to provide narrative
feedback to learners—either verbally or in writing—
particularly regarding communication and interpersonal
skills.
137
,138
One great advantage of working with SPs is that
they can provide honest, individualized feedback to learners
in a way that real patients typically cannot (except perhaps
anonymously online) due to power dynamics and cultural
expectations. SPs should be trained to follow the general
principles of providing high-quality feedback, including
referring to specific details that focus on behaviors and not
on personal characteristics, and being clear that the feedback
is based on the SP’s own point of view. SPs have been found
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to provide a different perspective from physicians when
providing feedback on communication skills, and this
complementary viewpoint is often considered a strength of
working with SPs.
139
Not surprisingly, while not all studies are concordant, there
is concern that SP biases based on race, ethnicity, and gender
may influence the way SPs assess students’ clinical
skills.
43,44,140
SPs should routinely be included in the same
implicit bias and cultural humility training that is required of
all staff members at the institution where the SPs are
working. Moreover, recruiting a wide diversity of SPs can
greatly enhance the feedback provided to learners. Instead of
trying to standardize the feedback SPs provide to learners,
embracing a variety of opinions is likely to be of even greater
benefit to the student and may also help the student
recognize some of their own implicit biases.
92,141
When used
for higher-stakes assessments, reliability can be improved by
employing multiple observations from multiple examiners.
92
Curriculum developers should also be keenly aware of the
potential impact of case portrayal on SPs. In particular, SPs
who are members of historically marginalized groups may be
subject to stereotyping or tokenism. Cases must be
developed, trained, and utilized in a way that attends to
psychological safety for both the learner and the SP.
141,142
Rater Training
Rater training is necessary to produce accurate and reliable
scores.
143
With proper training and effective quality
assurance procedures, SPs and other assessors can be trained
to provide reproducible scores that are similar to the scores
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