AN EVIDENCE-BASED CURRICULUM at chiropractic colleges is a key component of education for students to become full-fledged doctors of chiropractic (DCs). Part of that training involves use of standardized patients (SPs) — usually trained actors, but they don’t have to be — who help students gain real-world experience prior to treating actual patients. These SPs are trained to portray various conditions that a student may someday see in practice, thereby helping students build clinical expertise in a controlled setting.
According to the University of Western States (UWS) website, using SPs in a simulated environment provides chiropractic students with the opportunity to:
• practice physical examination procedures on a variety of individuals with differing physical features;
• develop doctor-patient communication skills;
• obtain feedback regarding how the examination feels from the patient’s point of view; and
• experience what examination of a relatively healthy individual feels like, which gives students a benchmark from which to compare the examination of patients with abnormal physical findings.
At Texas Chiropractic College (TCC),the state-of-the-art assessment center contains eight simulated treatment rooms holding equipment and furniture typical of a chiropractic physician’s office. But while the facilities are important, SPs are at the program’s center. At TCC, students are exposed to SPs starting in the second trimester and by graduation, the students have been involved in more than 50 SP encounters.
According to Ezra Cohen, DC, assistant dean, chief academic officer and professor of chiropractic medicine at National University of Health Sciences (NUHS), SPs are hired at medical institutions to play the part of patients and sometimes families. He explains that depending on the school, SPs may actually have the condition they are hired to portray. “The students never know the difference and are not entitled to know who actually has what unless it’s an obvious deformity that can’t be disguised,” he says.
NUHS does allow SPs to portray a condition of their own if they are well informed. “Right now we are looking to hire somebody who is deaf,” Dr. Cohen says. “That is not impossible to act, but it is hard to fake, as the SPs have to know sign language and lip reading, etc. We would love to get in patients from the multiple sclerosis support groups, who might be in wheelchairs, and NUHS has used patients in wheelchairs before.”
Use of SPs for Teaching
SPs are used throughout the curriculum at chiropractic colleges in varied ways. At NUHS, a capstone course of the clinical science program (classes are taught in the order of basic science first, clinical science and clinical practice) is advanced diagnosis and problem solving. That class is entirely presented through laboratory exercises wherein the students encounter the SPs.
Dr. Cohen explains that at first students encounter SPs in breakdown drills. For example, the student might take a history or might see an SP to do an examination. “In this class, which is offered right before students get to clinic, they are required to introduce themselves, take the history, do a physical examination and then the report of findings in which they explain everything to the patient and gain informed consent.” At that point the encounter stops, as the students don’t provide treatment.
NUHS requires the new patient encounter. Dr. Cohen explains that if in the report of findings for the new patient, the student says, “We would like to see you three times a week for three weeks and then reassess,” the follow-up visit is that reassessment in three weeks. “We make believe that the SP has been seen in the meantime, so the question then becomes what kind of progress have you made, what kinds of barriers were encountered and where are you going from here?” Then the students gather more history, give a reexamination, provide a full report of findings and renegotiate the treatment plan.
A unique situation provided at NUHS is the medical emergency. The students know it will come at some point during the term, but not when. “During the 9 a.m. lab, all SPs will have the same medical emergency,” says Dr. Cohen. They might all have heart attacks. This requires students to recognize the urgency, stop what they are doing and have one student stay with the patient while the other steps out to call emergency services. “Every step of the way the students must be making a report of findings – whether it’s usual and customary patient care or emergency care – to the clinician.”
Dr. Cohen points out that typically what matters in the allopathic medical schools is how quickly students can find the diagnosis. In the chiropractic school, the concern is how effectively can you provide holistic care? “Our encounters are typically longer, as we expect students to get the diagnosis,” says Dr. Cohen. “But we expect students to go beyond that and talk about lifestyle and health-seeking behaviors and so on.”
A typical clinical class section at NUHS using SPs holds a maximum of 16 students in eight rooms with no more than two students per room; NUHS will have three to four labs with the naturopathic doctor (ND) and DC candidates working together. Students see eight patients during the course. “We try to give them a balance, so sometimes students see a patient alone, sometimes with another student for support; and as they rotate through, they can be with two NDs, two DCs or an ND and DC. It is deliberately mixed,” he says.
Having DC and ND candidates learning together is instructive for integrative care, explains Dr. Cohen, as even if two different professions deliver the same intervention, the students have to decide who will deliver what part of the intervention and who might be best to do so. It is also helpful that in pre-lab at NUHS, one instructor is an ND and one is a DC. (see Box, Integration Opportunities).
Visualization and Communication
“For each of those patient encounters, the students have to produce a complete medical record, and that is how they are scored,” says Dr. Cohen. “All of those encounters are recorded and given to the students so they can go home, watch themselves and they are asked to perform various exercises; for example, listen to yourselves with your eyes closed to understand what your verbal communication is like, or turn off the sound and just watch your body language.”
“The advantage to the SP for us is to be able to give a structured patient encounter for a complex whole-person scenario that students may or may not get in the clinic,” Dr. Cohen says. “Typically the SPs will portray a primary condition, will have family history, may have secondary conditions, and sometimes the secondary condition will turn out to be the primary condition.”
In addition, all SPs have a communication style. “For some, the communication style becomes critical to the case; the challenging patient may not be accepting of what the student is saying or may be deliberately hiding a condition,” Dr. Cohen says. “The student has to pick up on the holes in the narrative and deliberately explore what has been left out.” An example is a patient presenting for a routine physical but hiding a heart condition because he or she is a pilot and simply wants a clean bill of health.
The result is that students next should be able to move into the clinic at an introductory level, but competently and mostly alone, to be able to see patients. “Students don’t see patients alone at that time – they are paired with a senior intern – but they should be able to step into the clinic with a low level of competency in all aspects of patient care., says Dr. Cohen. This is the capstone of clinical science. It is a lot of work for the students, as they have to complete a new patient record and a full patient record.”
The Association of Standardized Patient Educators
The Association of Standardized Patient Educators (ASPE), formed in 2001, is the international organization for professionals in the field of simulated and standardized patient (SP) methodology. ASPE holds an annual conference and NUHS presented research on how standardized patients (SPs) perceive their own conditions relative to playing made-up conditions. For more on ASPE, go to www.aspeducators.org.
The benefits of integration apply to the instructors too. In Northern Illinois there is a consortium of SP educators, the Chicago Simulation Consortium (CSC), whose members from other Chicago health profession institutions meet to share curricula, cases, assessments and research. Ezra Cohen, DC, assistant dean, chief academic officer and professor of chiropractic medicine at National University of Health Sciences (NUHS), in 2013 helped establish the CSC along with educators from other Chicago health profession institutions. CSC holds quarterly meetings to share resources and facilitate collaborative research. There are 12 members so far, including NUHS, an osteopathic college and allopathic medical schools and organizations.