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Simulation Program for Clinical Performance Improvement

Improving clinical care and patient safety through simulation

Baylor College of Medicine's Simulation Program for Clinical Performance Improvement trains qualified
individuals to teach and evaluate medical students, residents, and others in a simulation lab setting. It can
be used for teaching and testing a variety of skills for not only students but residents, practicing
physicians, nurses, etc... Our Standardized Patients, or SPs, go through a rigorous training process that
prepares them for "performances," which we call their scripted interactions with the students.

What is a Standardized Patient?

An SP is a person who has been carefully trained to simulate an

actual patient so accurately the simulation cannot be detected by a
skilled clinician. While performing a simulation the SP portrays the
role of a patient. This is done through the knowledge of history
content, body language, physical finding, as well as emotional and
personality characteristics. All components are vital but they are not
always portrayed for each simulation. Training is determined by the
type of exam performed and can vary.

Types of Projects
Standardized patients at Baylor College of Medicine participate in a
variety of projects, the most frequent of which are listed below:

Objective Structured Clinical Examinations

OSCEs are used for teaching and evaluating the clinical skills of medical students before they begin their
clinical rotations. The testing situation consists of a number of stations (examination rooms) where
standardized patients present a variety of common, yet important patient problems. The medical students
rotate through the stations at timed intervals, and the patients evaluate the students’ performance. This
examination is administered to first-year students in May/June.

Clinical Performance Examinations

CPXs are used for teaching and evaluating the clinical skills of medical students. The testing situation is
much like the OSCE described above. However, this examination is somewhat less lengthy and is
administered to second- and third-year medical students. This exam occurs once a month on Wednesday
evenings.

Classroom Demonstrations

These demonstrations utilize standardized patients to illustrate specific history-taking and physical
examination techniques. Demonstrations may be given for groups of eight to 200 first-year students. The
number of SP demonstrations varies from month to month.

Practice Sessions
Practice sessions provide students with an opportunity to practice their history-taking skills or components
of the physical exam on an SP before performing them on real patients in a clinical setting. Practice
sessions may be attended by individuals or small groups. The number of sessions varies from month to
month.

Project Coordination
Departments or institutions that are interested in developing standardized patient projects should contact
us. We can help departments design their own standardized patient projects as well as provide and train
the standardized patients to participate in them.

For instance, we have assisted departments in developing clinical practice exams, teaching practice
scenarios, and clinical skills demonstrations. We have even recruited standardized patients to serve as
actors in training videos. Consulting availability and costs vary according to project needs.

Britta Thompson, Ph.D.

Director, Standardized Patient Program
Phone: 713-798-7975
Fax: 713-798-8522
E-mail: Brittat@bcm.edu

Eugenia Greenfield
Project Coordinator
Phone: 713-798-7952
Fax: 713-798-8472
E-mail: eugeniag@bcm.edu

Become a Standardized Patient

Are you bright, punctual, conscientious, and interested in role-playing and teaching medical students? If
you live in the Houston area, have a flexible schedule, and would like to participate in one of our projects,
fill out a Standardized Patient Program Application. For additional details, call 713-798-7952 or e-mail
eugeniag@bcm.edu. You can also request that an application packet be mailed to you.

Application

To become a participate in the program, you will need to fill out

an application and answer questions about your physical
characteristics and medical history. Your application will be
added to a database of patient roles. When a "casting call"
comes in, we search our application pool for matches. We
cannot, for instance, ask an SP who has delivered children by
cesarean section to realistically play the role of a woman who
has never had children. Her abdominal scars would take away
from the realism of the case. All application information is kept
confidential.

The selection process may take up to six months or more,

depending on the program needs. Please note that, if selected,
you will be considered a consultant, not an employee of Baylor
College of Medicine. Therefore, you will not be eligible for
medical or other benefits.
Pay and Compensation

Generally BCM pays Standardized Patients $20 an hour.

Training Sessions
Script

We provide the standardized patient with a "script" that details all of the information they will need to
realistically portray an actual patient. Often, the script is accompanied by the patient chart. The script
provides such information as the patient’s chief complaint and the sequence of events of the illness. The
chart provides the patient's lab/test results and medication record. Standardized patients must become
completely familiar with this information. The time it takes to learn the material varies among SPs, but as
they gain experience, they need less time to review.

Cases

Scripts are developed from cases. Each case illustrates a particular problem or issue such as:

 Physical Complaint
 Prevention and/or Patient Education
 Chronic Illness
 Psychosocial Problems
 Sexual Concerns
 A Combination of Problems
Physical Exams

Those comfortable portraying cases that include a physical exam receive written physical examination
materials to familiarize them with the type of examination and the sequence of procedures performed.
Then, a certified professional will teach SPs the examination procedures. Standardized patients must
become completely familiar with the procedures to properly evaluate the students. Standardized patients
evaluate students by completing evaluation forms, which are essentially checklists of skills.

Feedback

Studies show that some feedback techniques are more helpful than others. To make sure students
receive helpful, accurate responses to their history and/or physical exam skills, we train Standardized
Patients in a particular method of giving feedback. The feedback sessions are generally incorporated into
the specific case training sessions.

Evaluation

SPs also receive feedback on their performance. The feedback may occur during a project when the
trainer or a faculty member asks the SP to modify certain behaviors, or the trainer may give the SP written
feedback after viewing a videotape of the encounter. In addition, students are often asked to evaluate
how realistically the SP portrayed the case and the usefulness of the SP's feedback. SPs are asked to
consider all forms of the feedback as additional training to improve their skills.
Checklist Reliability

Sometimes, SP are asked to attend special checklist reliability sessions. These training sessions are
designed to verify that SPs are interpreting grading criteria in the same way. A group of SPs are asked to
watch a videotape of an encounter and fill out a checklist. If they are reliable graders, they will all fill out
the checklist in the same way. Discrepancies in checklist answers indicate the areas where additional
training is needed.

View a typical Standardized Patient script and sample evaluation form.

Standardized Patient Script Example

Back Pain Script
(Nancy Owens, Age 44)

Chief Complaint: "I’ve had some back and leg pain and want help for it."

Identifying Data: College-educated accountant; workload stressful at times; married, one child, good
home life.

Scenario: Your low back/left leg pain began about three months ago. You had a similar problem during
the last few months of your pregnancy (your child was born seven years ago), but then none until three
months ago. You consider yourself an athlete and can’t run due to pain and intermittent numbness and
tingling (pins and needles feeling) in left leg.

Patient Profile: Concerned/anxious about this problem. You are in pain during the interview, but it is
tolerable. Sitting is very uncomfortable, so shift around after several minutes. Bend forward slightly when
sitting (put hands under knees—having knees higher than pelvis feels better). When walking, do so slowly
with pelvis tilted forward. You have slow movements with some stiffness in your back. Standing tolerance
is 10-15 minutes. You bend over and rotate slowly. If asked to lie down: bring your knees up and flatten
your back for comfort

History of Present Illness:

 When did it start? Three months ago.

 How did it come on? It gradually started over a few days, on and off.
 Did you have any injury to bring this on? No
 How frequent is the pain? It was every few days, but now it’s almost daily.
 How long does it last? At least a day; sometimes now longer than a day.
 Where is the pain? Lower back, especially left side and left leg, along back and side of leg into
side of foot.
 If probed further: Currently have back and leg pain together, but can have back pain without
leg pain.
 Describe the pain. Dull and achy.
 How bad is the pain? On a scale of 1-10 (10 as the worst), it ranges from 3-; now it’s at 5.
  Does it interfere with your life? After an hour at your desk you get stiff. Haven’t been able to do
your usual exercise. Can’t bend over to pick things up. Housework is painful (like doing
laundry). Shifting painful when driving.
 Relieving factors? Lie on side and sit with feet up.
 Aggravating factors? Exercise, standing, bending over, and stress
 Back/leg pain during pregnancy? Yes. It was like this, but it went away gradually after the child
was born.
 Any other symptoms beside pain? Intermittent numbness and tingling in left leg , and left leg
feels weak.
 Where is the numbness? The same area as the pain.
 How often does numbness occur? Up to once a week lately; less often than the pain.
 How long does numbness last? A few hours at a time.
 Does the numbness accompany the pain? Sometimes have numbness without pain.

Past Medical History:

Answer NO to the following: allergies, surgery, tobacco, intravenous or recreational drugs

 Medications? None now. Tried a non-steroidal anti-inflammatory (Motrin, over-the-counter),

Hasn’t really helped much so just take it on an off.
 Alcohol? Socially, one or two glasses of wine a week
 Hospitalizations? Childbirth, seven years ago.
 Exercise? I usually swim, walk, and run - mile a day before the pain. Haven’t been able to
because of the pain.

Family History:

Live with spouse and 1 child; parents-living; one sibling – an older sister. No history of hypertension,
cancer or coronary artery disease in family; father and sister have allergies-hay fever.

Questions to Ask:

1. What do you think I have?

2. Is this a herniated disc?
3. Will I need surgery?

Script covers all problems/abnormalities. If asked about any other problems, everything is normal.

Evaluation Form - History

Following a "performance," the standardized patient completes a history evaluation form. Below is a
sample history evaluation form.

Patient-Centered Process
( ) Yes ( ) No Appropriate introduction/greeting

( ) Yes ( ) No Began with and used other open-ended questions

( ) Yes ( ) No Used closed-ended questions for clarification

( ) Yes ( ) No Avoided complex or leading questions

( ) Yes ( ) No Avoided multiple questions

Facilitating Skills

( ) Yes ( ) No Speech clear

( ) Yes ( ) No Language clear (no jargon)

( ) Yes ( ) No Avoided disruptive Note-taking

( ) Yes ( ) No Attended to patient’s non-verbal communication

( ) Yes ( ) No Used silence and nonverbal encouragement

( ) Yes ( ) No Used facilitative techniques (echoing, reflection, neutral utterances, paraphrasing)

( ) Yes ( ) No Used emotion-handling skills during interview (understanding/legitimation,

respecting/praising, supporting/partnership)

History of Present Illness

( ) Yes ( ) No Chief complaint in patient’s own words

Symptoms patient experiencing

( ) Yes ( ) No Location

( ) Yes ( ) No Radiation

( ) Yes ( ) No Character

( ) Yes ( ) No Severity

( ) Yes ( ) No Associated Symptoms

( ) Yes ( ) No Onset

( ) Yes ( ) No Duration

( ) Yes ( ) No Aggravating factors

( ) Yes ( ) No Relieving factors

( ) Yes ( ) No Impact of illness on patient and others

( ) Yes ( ) No Patient’s concerns about illness

( ) Yes ( ) No Health issues (ethical-social-spiritual, functional, health promotion, health hazards)

Past Medical History

( ) Yes ( ) No Hospitalizations

( ) Yes ( ) No Other medical problems

( ) Yes ( ) No Major diseases

( ) Yes ( ) No Medications

( ) Yes ( ) No Allergies

( ) Yes ( ) No Menstrual/OB history

Personal/Social History

( ) Yes ( ) No Current personal situation

( ) Yes ( ) No Other personal factors (smoking, alcohol)

Family History

( ) Yes ( ) No Family history of present illness

( ) Yes ( ) No Specific diseases (diabetes, hypertension, high cholesterol)

Review of Systems

( ) Yes ( ) No Review of systems (questions related to the function of relevant systems)

Transition to Physical Exam

( ) Yes ( ) No Summarized history

( ) Yes ( ) No Asked patient if she/he had any questions

( ) Yes ( ) No Answered patient’s questions clearly

( ) Yes ( ) No Appropriate transition to physical exam

Global Assessment

Overall, how satisfied were you with this student’s history taking skills?

( ) extremely dissatisfied
( ) very dissatisfied
( ) dissatisfied
( ) satisfied
( ) very satisfied
( ) extremely satisfied

Following a "performance," the standardized patient completes a history evaluation form.Following a

"performance," the standardized patient completes a history evaluation form.

Evaluation Form - Physical

Following a "performance," the standardized patients complete a physican evaluation form. Below is a
sample physical evaluation form.

Process

( ) Yes ( ) No Wash hands

( ) Yes ( ) No Note general appearance

( ) Yes ( ) No Pay attention to patient's comfort

Cardiovascular Exam

( ) Yes ( ) No Inspect neck veins

( ) Yes ( ) No Palpate carotid pulse

( ) Yes ( ) No Auscultate carotid artery

( ) Yes ( ) No Inspect and examine chest with patient supine

( ) Yes ( ) No Feel for PMI below nipple

( ) Yes ( ) No Use both diaphragm and bell of stethoscope

( ) Yes ( ) No Listen to apex (mitral value)

( ) Yes ( ) No Listen to left lower sternal border (tricuspid valve)

( ) Yes ( ) No Listen to left second intercostal space (pulmonary valve)

( ) Yes ( ) No Listen to right second intercostal space (aortic valve)

( ) Yes ( ) No Listen to first and second heart sounds

( ) Yes ( ) No Listen for physiological split second sound (pulmonic area)

( ) Yes ( ) No Inspect skin

( ) Yes ( ) No Inspect nail beds

( ) Yes ( ) No Palpate peripheral pulses

( ) Yes ( ) No Palpate for pedal edema

Vital Signs

( ) Yes ( ) No Place cuff on arm, tubing forward over brachial artery

( ) Yes ( ) No Support patient's arm so it is relaxed

( ) Yes ( ) No Measure patient BP

( ) Yes ( ) No Check radial pulse at least 15 seconds

( ) Yes ( ) No Check respiratory rate at least 15 seconds

Lung Exam

( ) Yes ( ) No Stand on right side of patient

( ) Yes ( ) No Assess rate and rhythm of respiration

( ) Yes ( ) No Examine symmetry of chest excursion

( ) Yes ( ) No Percuss alternate sides of lung fields (bilaterally at 3 levels)

( ) Yes ( ) No Auscultate alternate sides of posterior lung fields (bilaterally at 3 levels)

( ) Yes ( ) No Auscultate alternate sides of anterior lung fields (bilaterally at 3 levels)

Global Assessment

Overall, how satisfied were you with this student’s physical examination skills?

( ) extremely dissatisfied
( ) very dissatisfied
( ) dissatisfied
( ) satisfied
( ) very satisfied
( ) extremely satisfied

Following a "performance," the standardized patients complete a physican evaluation form.Following a

"performance," the standardized patients complete a physican evaluation form.

Claire Huckins Clinical Performance and Simulation Lab

Baylor College of Medicine has expanded its lab from six rooms to 14 rooms designed to look and
function like a real medical clinic. Each room is equipped with computers, wall-mounted exam equipment,
and video cameras.

Students are tested in these exam rooms to experience a realistic patient-doctor encounter. The lab
prepares students to start their residency with confidence.

Lab Examination Room Photos

Frequently Asked Questions for Standardized Patients

Q: What is a standardized patient?

A: The "SP" is a person who has been carefully coached to simulate an actual patient so accurately that
the simulation cannot be detected by a skilled clinician.

Q: How are standardized patients trained?

A: We provide the SP with a script that details all of the information they will need to realistically portray
an actual patient. The SPs also attend mandatory training sessions where they learn their role in more
detail.

Q: Do you need any special education?

A: No, our SPs come from various backgrounds, and we will teach you everything you need to know
about your assigned role.

Q: What type of physical exams would an SP be required to do?

A: The exams vary depending on the role portrayed.

Q: Can an SP pass on a role?

A: Yes, an SP can pass on a role they do not want to portray.

Q: How often does an SP work?

A: It depends on the particular exam, but it can range from 1 day to several days a week.

Q: What is the pay rate?

A: SPs are paid about $20 an hour.