Petrusa, Emil R., "Taking Standardized Patient-Based Examinations to the Next Level," Teaching and Learning in Medicine, 16(1), 98-110, 2004 Reviewed by David Levine, Morehouse School of Medicine
Petrusa, Emil R., "Taking Standardized Patient-Based Examinations to the Next Level," Teaching and Learning in Medicine, 16(1), 98-110, 2004Reviewed by David Levine, Morehouse School of Medicine
Dr. Petrusa is the Associate Dean for Curriculum Assessment at Duke University School of Medicine. The article reviews the literature and defines the current state of affairs with SP-based examinations, then discusses three important new areas that are being investigated.
The author begins by reviewing some of the literature on SP-based exams and supports the assertion that this modality is the most extensively researched educational innovation in the history of medical education. The article then defines three areas that need further investigation.
The first area of challenge and improvement suggested is "the gap between SP-based assessments and the current clinical curriculum of medical schools." The author documents that learners perform better on simulations that they have had practice in clinical encounters. There are a few solutions to the gap, including trying to make the exam fit the situation - using statistical analysis pass rates are set, checklists generated - but this may not assess the learning of the curriculum. The other is to make the clinical curriculum more appropriate to the cases being tested, a strategy recommended by the author.
The second area focuses on advances in these examinations that correspond to performance at advanced stages of professional development. For example, the subspecialist is able to find a diagnosis in their area of expertise with less information to confirm the diagnosis, but this may not be scored as well on a SP-based examination, since the learner would not document all the steps that the generalist would need to accomplish to make the diagnosis. This area, then, is ready for further development to define what are the expected thought processes and diagnostic reasoning appropriate at each level of medical education. One suggestion is to use nurse practitioners/ physician assistants, or residents as SPs in order to strengthen this role in the exam to help the learner develop diagnostic reasoning at the appropriate level. Clearly, checklists by SPs, written notes, and follow up questions are poor at evaluating the development of clinical reasoning.
The third area of exploration related to SP-based examinations is assessment of multi-person interactions in clinical encounters. More experienced clinicians can use SP-based exams to challenge themselves in cases that feature ambiguous signs and symptoms, challenging emotional states, socioeconomic and cultural differences. Really innovative work will be in the development of structured simulations that allow assessment of multiple persons in complex interactions, such as teamwork. Such simulations already developed include a simulated family where medical students interact with parents, children, and grandparents over a 16-week period. Another example is multidisciplinary scenarios where students from medicine, dentistry, public health, and allied health work on the coordinated care of patients. However, these modalities are used mostly for formative exercises. The challenge will be to define what are the expected roles and responsibilities in order to create a valid assessment tool for summative examinations.
Overall, the article was well written, and at an "intermediate" or "advanced" level for the medical educator. This was a review article, so there was little to critically analyze and the arguments presented were well supported by literature in both medicine and in private industry. Having knowledge of each individual's SP program as well as an awareness of the NBME Clinical Skills Examination would be necessary to be able to fully understand the article. It does point out the three areas of concern and improvement that we have had in discussions at COMSEP and the APA meeting. I would recommend the article to those schools that have formative and summative SP exercises and examinations that are well established, to take their programs to the next level, and to study those advances.
(Do you use SP's as part of the third year pediatric clerkship? Steve Miller)