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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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template for providing feedback to trainees regarding their
success in meeting education or clinical objectives. Rating
scales can be used to provide feedback regarding a student’s
communication and interpersonal skills or humanistic or
professional behaviors and may be combined with narrative
comments from SPs that provide specific critical or
reinforcing feedback. Scores from the clinical interview,
patient note, or other activities associated with individual
patient encounters may be combined to obtain a final score
that best meets the purpose of the educational assessment or
exercise.
If the purpose is primarily to support learning, then the
assessment data collected should enable high-quality, timely,
and individualized feedback to guide student learning. It
may be useful to support learning with faculty observers,
scheduled opportunities for video review, inclusion of
“timeouts” for immediate input, and postsession coaching to
identify subsequent learning goals. If the purpose is
summative in scope, the focus of data collection should be on
ensuring adequate reliability (consistency of assessment
results) and valid inferences about the clinical skill(s) being
assessed (i.e., the assessment measures what it intends to
measure).
Implications for summative OSCE designs include a lesser
emphasis on feedback, the need for a larger number of cases,
oversight for SP and faculty training, and greater attention to
examination security, among other considerations. While a
well-designed approach to score reporting could yield
valuable and actionable information from high-stakes
assessments, combining the roles of an assessment of and for
learning is problematic for learners who are less able to
engage effectively in reflection and goal setting when the
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assessment is perceived as high stakes.
85,86
In addition, when
determining clinical competency, the OSCE data should be
assembled along with adequate additional sources of
assessment data and reviewed by a competency committee to
enable informed decisions regarding progression.
The use of SP assessments for summative purposes is
shifting with the USMLE decision to discontinue the Step 2
CS examination. While numerous studies conducted by both
medical schools and licensing or certification bodies over the
past 50 years have provided evidence that, with sufficient
numbers of simulation encounters, properly sampled from
the practice domain, reliable and valid assessment decisions
could be made,87 these examinations are expensive and
complex to administer and maintain.11 In addition, while
some data exist from individual institutions, it has been
challenging to demonstrate the predictive validity of SP
assessments for clinical performance in the next stage of
training or practice.49 Many medical schools have developed
mandatory SP-based clinical skills assessments required for
graduation88 and designed to prepare learners for highstakes licensing examinations. Without licensing
examinations in place to certify clinical competence, the
responsibility for this final high-stakes decision lies with the
institution and makes the responsibility all the greater for the
development of high-quality summative SP-based
exams.
12,89–91
Developing Standardized PatientBased Assessments
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Examination Content and Blueprinting
Once the purpose of the SP assessment is clearly delineated,
the content of the assessment can be defined (see Fig. 6.1).
Sometimes SPs will be employed for a session regarding one
particular topic such as breaking difficult news or practicing
a trauma-informed physical exam. Often, however, multiple
SP stations are compiled into an OSCE format to assess a
broader range of skills that students may have acquired over
the course of a block or clerkship. Regardless of whether the
assessment focuses on one specific topic or a range of skills, it
is essential to start with the learning objectives for the course
of study and then to blueprint the content of the OSCE based
on those objectives.92 Blueprinting has been defined as “the
process by which content experts ensure that constructs of
interest are adequately represented.”
38,93
Learners should be
familiar with the learning objectives so that they know what
is expected of them in the assessment. When learners are
aware of the educational objectives and understand that
these objectives will be tested, they are motivated to focus on
the content that is most important.
Like all assessments, SP-based assessments are not able to
test every possible disease in every possible patient in every
possible clinical context. Instead, OSCEs employ systematic
sampling across a range of patients and content areas to test a
range of skills in a range of contexts.
33,38
One technique for
blueprinting an OSCE involves mapping patient
characteristics against diseases or clinical topics,
40,94
as
shown in Table 6.1. For a more comprehensive OSCE, the
blueprint may be built off both relevant content areas and
common patient presentations. For example, an OSCE for a
surgery clerkship may include a case from each subspecialty
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including general surgery, orthopedics, urology, and thoracic
surgery. In addition, cases could be based on common chief
concerns including abdominal pain, leg pain, flank pain, and
trauma. Referencing local, regional, or national statistics on
the prevalence of diseases and the primary reasons for
presenting to medical attention will support the validity of
the blueprinting.
95
In addition to topic areas, it may be
important to sample across multiple contexts and patient
characteristics. For example, an OSCE may include a range of
clinical settings from the emergency department to the
ambulatory clinic to the intensive care unit. Developers will
also want to be mindful to include a diverse range of patients
based on age, race, ethnicity, gender, socioeconomic status,
and other characteristics.
Table 6.1
Blueprint for a Standardized Patient-Based Assessment
Chief
Concern
Cardiovascular/Respiratory Gastrointestinal/Genitourinary
Age:
at least
2 >64
2 = 40–64
2 = 15–39
Gender:
at least
3 men
3 women
1
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nonbinary
Acuity:
at least
2 acute
2 subacute
2 chronic
Physical
Exam:
at least
1 system
and
1
abnormality
per case
Alternatively, a blueprint could be generated by identifying
competencies of interest such as communication and
interpersonal skills, history taking, physical examination,
counseling, clinical reasoning, oral presentations, and patient
notes. In the end, a comprehensive blueprint will likely
include a multidimensional matrix that selects content using
several of these techniques. Regardless of the method,
purposeful blueprinting reflecting important educational
goals and objectives is essential for providing validity
evidence for an SP-based assessment.
38
,92
A common pitfall
of SP-based assessments is to choose cases based on
convenience, such as the availability of SPs, or to create cases
based on the expertise of the lead faculty instead of sampling
learning objectives in an intentional way. Obviously, the
extent of the blueprint must also be balanced with the
feasibility and cost of developing and administering the
assessment.
Components of a Typical Standardized
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Patient Encounter
While the format of an SP encounter has great flexibility and
is wide open to innovation, a typical session often includes
the components as described in the following subsections.
The learner and SP have separate tasks before and after their
encounter, as shown in Fig. 6.2
.
FIG. 6.2 Flow of a typical standardized patient encounter.
OSCE, Objective structured clinical examination SP,
standardized patient.
Orientation
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Before the exercise, learners should be oriented to the format
and goals of the session. Students are typically instructed to
interact with SPs in the same way they would interact with
real patients with the acknowledgment that this requires a
“willing suspension of disbelief.”96 The process whereby all
participants agree to behave as if they are acting in real life is
known as the “fiction contract.”96 Instructions must be clear
about any circumstances where the encounter would deviate
from actual clinical practice such as: “Do not perform a
breast, genital, or rectal exam. If you feel any of these exams
are warranted based on the clinical scenario, please note it in
your postencounter write-up.” The orientation may include
information about time limitations, personal protective and
other equipment available, and how to handle student
questions that might arise during the encounter. It should be
clear to learners whether the exercise is formative or
summative, whether the encounter will be video recorded,
and who will have access to viewing the encounter and the
data generated from it.97 In the case of summative
assessments that will be administered to other learners at a
different time, participants should be reminded of
expectations of professional behavior and keeping case
content confidential.
Introduction to the Patient Scenario
The introduction to the patient scenario is called the stem. It
often includes details that would be available when seeing a
patient in a clinical encounter, such as the patient’s name and
basic demographic information, the setting for the encounter,
the reason for the patient’s visit, and the task assigned to the
learner98 (see Box 6.1).
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6.1.
The Stem: Example of the Introduction to
the Patient Scenario
Name>: Julia Aguilar
Age>: 58 years old
Gender/pronouns>: Woman, she/her/hers
Setting>: Urgent care clinic
Presenting concern>: Shortness of breath
Your task>: Elicit a focused history, perform a focused
physical exam, and share your initial impression and
initial plan with the patient.
The amount of detail provided in the introduction depends
on the level of the learner and the goal of the exercise. For
example, for novice students, the task may specifically list the
physical exam maneuvers to be performed, whereas a more
advanced student may be expected to identify which
portions of the physical exam are relevant based on the
clinical situation. As a practical matter, it is often easiest to
create a scenario where the learner is meeting the patient for
the first time so that the need for extensive background
information is minimized.
98
Standardized Patient Encounter
The encounter between the learner and SP will vary widely
depending on the learning objectives. Students may be asked
to elicit a history, perform a physical exam, and share
information, all while conveying empathy and respect for the
patient and family. A case may be focused on one particular
topic such as eliciting a sexual history, performing a
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neurologic exam, or working with an interpreter. The SP may
simulate physical exam findings such as tenderness or
weakness, and moulage makeup or prosthetics may be used
to simulate wounds or other physical findings. The case may
include a standardized question from the SP such as “Can I
get a refill on my sleeping pill?” to evaluate the learner’s
communication skills and clinical judgment. The scope of the
encounter will be tailored to the skills being assessed.
Postencounter Activities (Interstation Exercises)
Often the SP encounter will be followed by a postencounter
activity such as writing a clinical note or answering questions
about the case. If there are multiple SP cases back-to-back, as
in an OSCE, these postencounter activities are often referred
to as interstations. Again, the format and tasks for the
postencounter exercise will be based on the goals of the
session and provide an additional opportunity to assess a
wide array of clinical skills. Learners may be asked to list and
justify a differential diagnosis, develop a diagnostic plan, or
use a literature search to answer a clinical question related to
the case. There is room for a great deal of creativity when
developing interstations, but they should be carefully crafted
to fit into the overall program of assessment described
previously. From a logistical standpoint, the time while
learners are completing an interstation exercise also allows
time for the SP to score the student’s performance and
provide written feedback before moving on to the next
student, as shown in Fig. 6.2
.
Case Development
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Scripting a Case
Writing SP cases often requires close collaboration between
clinicians who are the content experts and professional SP
educators who have an in-depth understanding of the case
formats that are most useful for SPs.
40,99
While clinicians
usually have a clear idea of how a patient with a particular
disease presents, they often do not have experience
converting that mental image into a script that can be used by
a layperson to portray a patient scenario. Furthermore,
including patients, who may sometimes be the SPs
themselves, in case development can ensure incorporation of
the patient’s perspective into the case.19 Some clinicians like
to base SP cases on real patients they have cared for, which
can increase the authenticity of the case. Basing an SP case on
a real patient, however, can sometimes lead to superfluous or
idiosyncratic detail that can distract from the main goals of
the case, or increase the cognitive load for the SP. In some
circumstances, it may be more important to create a
representative “textbook” case, particularly for high-stakes
exams or novice learners.
100
MedEdPORTAL is an openaccess journal of peer-reviewed medical education modules
that includes many excellent SP cases that may be used as
examples when constructing a new SP case.
101
SP educators are essential in helping faculty translate a
patient presentation into a written SP case. Having a
standard template for a case will ensure that all important
information is captured in a way that makes it easy for SPs to
understand and recall.
40,102
Even though these cases are
standardized, it is advisable to include only a very few direct
quotes that the SP will recite verbatim. Including too many
scripted lines can make the interaction stilted and unrealistic
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