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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2823_Библиотеки_им_академика_М_И_Перельмана
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Chapter Outline
Introduction
Overview of SPs in Education and Assessment
Strengths of Standardized Patient-Based
Assessments
Direct Observation of Skills
Standardization and Curricular Alignment
Timely and Meaningful Feedback
High-Stakes Assessment Decisions
Program Evaluation
Challenges of Standardized Patient-Based
Assessments
Expense of Standardized Patient Programs
Logistic Complexity and Indirect Costs
Rater Training and Bias
Limitations of the Simulation Environment
Planning for Standardized Patient-Based
Assessments
Mapping to a Competency Framework
Which Competencies to Assess With Standardized
Patients
Implications of High- and Low-Stakes Assessments
Developing Standardized Patient-Based
Assessments
Examination Content and Blueprinting
Components of a Typical Standardized Patient
Encounter
Case Development
Standardized Patient Selection and Training
Rater Training
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Implementation of Standardized Patient
Assessments
Scoring and Psychometrics
Applying Kane’s Validity Framework
Standard Setting
Evaluation and Quality Assurance
New Directions in Standardized Patient
Assessments
Innovation Highlights
Expansion of Learner Groups
Interprofessional Collaboration
Multifaceted Simulation
Scoring and Automation
Conclusion
Annotated Bibliography
References
Introduction
Direct observation of a learner interacting with patients is
essential for the assessment of clinical competence and may
be accomplished with actual patients in the clinical
environment as described in the preceding chapter or with
simulated patients, commonly referred to as standardized
patients (SPs). SPs are laypeople trained to portray patients,
family members, healthcare professionals, or others in a
realistic way for medical education and/or assessment
purposes. Using SPs for assessment overcomes many of the
challenges faced when working with actual patients,
including providing a consistent, accessible, safe clinical
encounter while still allowing learners to demonstrate the
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way they perform with real people. Through SP-based
assessments, learners can “show” their clinical skills, as
represented by the third level of Miller’s pyramid, in
comparison to the lower levels that focus solely on
knowledge (see Chapter 1
).
The methodology for SP-based assessments has been
refined to the point
1,2
where this strategy is used for high-
stakes decisions regarding promotion of learners to the next
academic level3 and even physician licensure.
4–8
In the
United States, from 2004 to 2020 the National Board of
Medical Examiners (NBME) and the Federation of State
Medical Boards (FSMB) required all medical students to pass
Step 2 Clinical Skills (Step 2 CS) of the United States Medical
Licensing Examination (USMLE) to qualify for licensure in
the United States.
9,10
Since Step 2 CS was officially
discontinued in 2021,11 individual medical schools and
consortia of medical schools are now taking responsibility for
assessing students’ clinical skills, often still using SP-based
assessments.
12
This chapter focuses on assessments that involve SPs,
beginning with an overview of SPs in performance-based
examinations followed by the strengths and challenges of
utilizing SPs in assessment and factors to consider when
incorporating SP-based assessments within an overall
program of assessment. Next, the chapter includes a practical
guide for the development and implementation of SP
assessments from blueprinting to case development, to
training of SPs and raters. Consideration is then given to
scoring and evaluating the psychometric properties of SPbased assessments before concluding with a discussion of the
expansion of opportunities and future directions for the use
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of SPs in health professions education and assessment.
Overview of SPs in Education and
Assessment
The use of SPs in medical education was first described by
Barrows and Abrahamson in the 1960s
13,14
and has now
expanded across the globe to include many disciplines of
health professions education and assessment from podiatry
to pharmacy to traditional East Asian medicine and
beyond.
15–18
Some authors make a distinction between the
term simulated patient, which is a broad term used whenever a
layperson portrays a patient, and the term standardized
patient, where the emphasis is on the consistency of
portrayal.19 Earlier work found that educators in Asia and
Europe tend to use the term simulated patient, while those in
North America more commonly use standardized patient.
19
More recently, the simple abbreviation SP has been used as
an umbrella term, encompassing both “simulated” and
“standardized” patients, as in the Association of SP
Educators.20 SPs come from many backgrounds, and some
programs prefer professionally trained actors while others
employ a wide range of laypeople or even recruit volunteers.
SPs can be used for straightforward tasks such as serving as a
model for a cardiovascular exam, or re-creating complex
clinical behaviors such as a patient with psychosis or
complex neurologic findings. SPs are also frequently trained
to score learners in a consistent way and to provide
individualized feedback on clinical skills including
communication, history taking, physical examination,
procedures, and other clinical tasks.
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Depending on the purpose of the assessment, scenarios
involving SPs may be carried out singly or in a sequence of
several encounters run back-to-back. In 1975, Harden et al.
described the process of linking together multiple stations
assessing clinical skills into an assessment now known as an
objective structured clinical examination (OSCE).21 While
many OSCEs include stations with SPs there are plenty of
OSCE stations—such as suturing using a task trainer—that
do not involve SPs.22 Similarly, not all SP-based assessments
would be considered an OSCE. For example, a single SP
station used as a formative assessment of a comprehensive
physical examination would typically not be referred to as an
OSCE. The opportunities for utilizing SPs in education and
assessment are very broad and wide open for innovation.
Strengths of Standardized PatientBased Assessments
SP-based assessments have several strengths relative to other
assessment modalities, including the ability to anchor the
assessment around the clinical encounter while ensuring the
experience is standardized and aligned with curricular aims.
Assessments with SPs can be designed to enable timely and
meaningful feedback to guide learning or to inform highstakes assessment decisions as part of competency-based
medical education (CBME). In addition, data from SP-based
assessments provide valuable insights as a part of program
evaluation and quality improvement.
Direct Observation of Skills
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First and foremost, the use of SPs for teaching and assessing
clinical skills enables direct observation of the interaction
between the student, or resident, and the SP and focuses the
curriculum, learners, and faculty on the patient encounter.
The well-known influence of assessment on learning results
in renewed interest in clinical medicine and focuses attention
on developing patient-centered skills when SP-based
assessments are introduced.
23–25
Regardless of whether the
observer is a trained SP, faculty member, peer, or other party,
the assessment of skills is not inferred from case
presentations, preceptor sessions, or review of the medical
record. The incorporation of some form of direct observation
in medical education is essential to identify areas for
improvement, target subsequent teaching, and certify
competence at the time of high-stakes assessments. The last
of these is essential to ensure patient safety before skills are
applied in the clinical setting.
26
Standardization and Curricular
Alignment
SP-based assessments additionally allow the program,
course, or clerkship director to control the instructional and
assessment activities and align goals in a manner that is not
possible in clinical care. Encounters with SPs can be
scheduled to coincide with, or complement, other relevant
educational or assessment activities. This is quite different
from education in actual clinical settings where a particular
learning experience depends on patient availability. The SP
exercise can be designed to assess appropriate milestones for
learner level or to serve specific individual or programmatic
needs. For example, a case for an early learner may focus on
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communication skills and hypothesis-driven data collection
for a common syndrome. Adding a patient note as a
postencounter exercise for a later learner then changes the
focus from assessment of data gathering to evaluation of
diagnostic management and documentation (see Chapter 7
).
In addition to modifying SP cases to focus on different
aspects of clinical competence, examination blueprinting (see
“Examination Content and Blueprinting”) ensures that an
appropriate range of clinically relevant syndromes, patient
populations, and levels of acuity are represented within the
program of assessment. Having a centrally coordinated
assessment program that relies on a competency framework
with developmental milestones ensures that SP-based
assessments are used appropriately relative to other
assessment tools
27
,28
(see Chapter 3 and Fig. 6.1).
FIG. 6.1 Development of a standardized patient-based
assessment. CR, Clinical reasoning; Hx, history; IPS,
interpersonal skills; OP, oral presentation; PE, physical exam;
PN, patient note; SES, socioeconomic status.
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Timely and Meaningful Feedback
From the student and resident perspectives, the use of SPs
within curricular sessions or low-stakes assessments allows
learners to practice clinical skills and receive feedback in a
safe environment that also avoids the risk of harm to real
patients. The lower stakes for such exercises make the use of
SPs an ideal method for teaching and assessing difficult or
sensitive communication or physical examination challenges
before students attempt these skills with real patients. In
particular, SPs have proven to be a valuable resource for
teaching and assessment of an examinee’s ability to deliver
bad news to a patient, to discuss preferences for end-of-life
care, to engage in patient counseling or education, and in
teaching and assessing breast, rectal, and genitourinary
examinations.
29–31
The use of SPs for these challenging
communication and examination skills importantly enables
feedback on the patient experience prior to application of
these skills in genuine clinical settings. In addition, allowing
for a “timeout” in which the SP encounter is interrupted to
provide formative feedback allows the trainee to make
adjustments or develop alternative approaches to difficult
clinical situations in real time.
To ensure high-quality feedback, programs should consider
feedback skills in SP recruitment, training, and oversight for
SP performance.
19,32
SPs can provide valuable patient
perspectives regarding trainee skills and behaviors,
commenting on how they felt from the perspective of their
character during various portions of the interaction. For
curricular sessions occurring in small groups, peer observers
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and faculty can also provide immediate feedback to learners,
focusing on discrete skills and behaviors. Alternatively,
videotaped encounters can be rated by faculty, peers, SPs, or
the trainees themselves. Review of videotapes allows
evaluators to gather important diagnostic information such
as when errors of commission or omission occur, and video
review with struggling learners is invaluable during the
development of remediation plans or when there is a need to
build insight regarding areas of challenge (see Chapter 17).
High-Stakes Assessment Decisions
While allowing for flexibility in tailoring instruction and
formative assessment to the level and needs of the learner
and program, SP-based assessments can also be designed to
enable higher-stakes assessment of competence.
33–35
As
discussed in Chapter 1, the shift in educational philosophy
over the past century from cognitive to behaviorist or
outcomes-focused approaches aims to improve our ability to
measure how the learner integrates communication,
knowledge, technical skills, clinical reasoning, emotion,
values, and reflection to demonstrate competence for
practice.
36,37
This complex integration of behaviors is
impossible to assess by any single instrument and almost
certainly will require the thoughtful inclusion of SP-based
assessments. Through standardization of individual cases,
examinees are each exposed to the same clinical problem
presented uniformly, which cannot be replicated in the
workplace. By methods such as exam blueprinting,
increasing the number of SP encounters within a single
assessment, and ensuring interrater reliability, SP
assessments can be designed to provide reliability and
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validity evidence to inform decisions regarding
advancement, promotion, or even graduation.
38
Program Evaluation
The use of SPs, either individually or as part of multiplestation OSCEs, not only allows clerkship and program
directors to obtain valuable feedback concerning individual
trainees but can also be used to evaluate whether the
program as a whole has been successful in achieving
important curricular objectives (see Chapter 18).
39,40
Using
SP-based methods for program evaluation is ideal in that it
identifies the patient encounter as a critical event in which
learning should occur and on which individual assessment
will focus. A poor performance on information sharing in a
case of newly diagnosed diabetes, the omission of questions
about cardiac risk factors in a case of angina, or the lack of
assessment for volume overload in a case of dyspnea
provides both information on individual performance and,
when reviewed as part of program evaluation, on areas in the
curriculum in need of improvement. Since a sound
educational program is dependent upon the alignment of
objectives, curriculum, and assessments, using SP-based
assessment outcomes for evaluation encourages course and
program directors to make improvements that impact patient
care.
Challenges of Standardized
Patient-Based Assessments
Challenges of SP-based assessments should also be
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