Standardized Patient History at University of Kentucky

In the mid to late 1980’s standardized patients (SP) were used to help teach interviewing and communication skills to second-year medical students. Dr. Craig Kaplan was instrumental in the use of lay persons to provide a standardized interviewing experience across small groups of second-year medical students. John S. Thompson, MD Department of Internal Medicine had an interest in further developing a standardized patient program at the University of Kentucky and using such a program to evaluate medical students and residents. Dr. Thompson’s interest in standardized patients was a result of his ten years on the American Board of Internal Medicine (ABIM) and interacting with Paula Stillman, MD through various projects. In the fall of 1988 John Thompson provided financial assistance to send one of the new faculty members in the Department of Internal Medicine, Steven A. Haist, MD to Southern Illinois University to spend several days with the standardized patient program led by Howard S. Barrows, MD. Later he went to the University of Massachusetts where Paula Stillman, MD was the Associate Dean for Education and Director of the Standardized Patient Program. Again, he spent several days with the standardized patient program at that institution. 

In August of 1988, Dr. Haist and Sue Fosson, MA, the Assistant Dean for Student Affairs at that time implemented a Standardized patient examination for 1/4th of the senior medical student class (21 students) at the end of their third-year. The medical students had five focused encounters representing various clinical encounters from five different sub-specialties including internal medicine, surgery, OB/GYN, psychiatry and pediatrics. Despite having a limited number of students in this pilot, there was still a significant correlation seen with the third-year medical students GPA of r=0.44 and with their NBME Step I score of r=0.46. 

In 1989 Dr. Haist used Standardized Patients to teach the breast exam. A pair of SPs were taught to be instructors as well as patients. A pair of medical students would work with a pair of the trained SPs. The medical students were instructed on how to do the examination techniques and then the students would practice performing the examination on one of the SPs. The students would receive feedback from both SPs. 

In the 1980’s the practical for the second-year medical student’s physical diagnosis course included an observed history and observed physical examination. The medical students would perform a physical examination on a hospitalized patient. This physical examination was observed by their preceptor. There was a great deal of difficulty in standardizing a practical examination for the second-year medical students. As clerkship director, Dr. Haist was frustrated with the variability of preceptor evaluations having students of one preceptor all get 100% correct on their practical examinations. An analysis was done that demonstrated 25% of the variance in students’ scores were attributable to their preceptors. It was felt this degree of variance that was inappropriate. 

In 1991-92, Dr. Haist trained nine standardized patients to a 215 item checklist that was a derivation of the checklist used by Paula Stillman, MD at the University of Massachusetts. Her checklist was used in a similar fashion to assess medical students’ physical examination skills. The testing encounter was a patient unknown to the medical student and the students were told to obtain a history of the present illness and either the past medical history, psychosocial history or family history. After the physical examination the standardized patients are given fifteen minutes to complete the 215 item checklist and subjective rating scale. Following completion of the checklist, the medical students would reenter the room and the standardized patient would provide the student with individual feedback regarding items on the physical examination that were performed incorrectly or were omitted. Prior to testing, the standardized patients underwent rigorous reliability testing by Dr. Haist who would perform the history and physical on the standardized patients omitting and performing incorrectly 20-30% of the items. On the history items Dr. Haist and the nine standardized patients had a mean agreement of 93.3 with a range of 88.6 to 96.2 and on the physical examination a mean agreement of 91.9 and a range of 85.1 to 95.0.

The first medical school class that underwent the second-year history and physical standardized patient examination as part of their second-year interviewing and physical diagnosis class had a mean score on the examination of 90.2 with a range of 61.7 to 98.2. 94.1 % of the students strongly agreed or agreed that the standardized patients seemed like a real patient; 92.9% strongly agreed or agreed that the feedback given by the standardized patient was accurate; and 91% agreed or strongly agreed that a standardized patient practical examination should be used to evaluate the physical examination skills of second-year medical students. The program continued; it was noted that the amount of faculty time to train the standardized patients decreased from year 1 to year 2 from 266 hours to 149 hours (a 44% decrease). 

In 1991 the Department of Surgery began using standardized patients to evaluate medical student’s surgical clinical skills. This program was developed and implemented by Phyllis Nash, PhD, Richard Schwartz, MD, and Mike Donnelly, PhD.

With the new curriculum that resulted from The Robert Wood Johnson Grant in 1995, the standardized patient program expanded in both teaching medical students clinical skills as well as assessing clinical skills. In the first year of the new Introduction to Medical Professions course standardized patients were used to teach basic communication and interviewing skills, evaluate basic interviewing skills and evaluate the ability of first-year medical students to perform a comprehensive physical examination. The standardized patients were used to teach advanced communication and interviewing skills to second-year medical students in Introduction to the Medical Profession. The scenarios included an angry patient, breaking bad news and obtaining a sexual history. The standardized patients also were used to teach the second-year medical students the gynecologic and breast examination. The second-year medical students were evaluated using a five station OSCE (Objective Structured Clinical Examination) developed to evaluate history taking and physical examination skills. 

Standardized patients were also used to teach and evaluate specific skills as part of the new medicine/surgery clerkship. In 1993 the Internal Medicine Clerkship, MD-836 used standardized patients to evaluate medical student’s clinical skills as part of a 16-station OSCE. The OSCE format has been used in this clerkship since.

In 1996 the College of Medicine developed a comprehensive Clinical Performance Examination (CPX) administered to third-year medical students at the clinical experiences.  This standard evaluation form for student performance assesses clinical reasoning skills as well as history-taking, physical examination and counseling skills.  Students must pass this 10-12 station OSCE-format Clinical Performance Examination. This examination serves as a summative assessment of students’ clinical skills as well as preparation for the USMLE Step 2 Clinical Skills examination.