The Art and Science of Medicine
Volume XXVI Number 1
Objective structured clinical examination in progress.
Photo by Rocky Rothrock, IUSM Office of Visual Media
Photo © 2003 Tyagan Miller
A doctor knocks on the door of the hospital consulting room, then enters to deliver troubling news to a young couple. A routine circumcision procedure has just gone wrong. Their infant son's glans penis and urethra have been slashed. The baby will require corrective surgery and further hospitalization.
The doctor explains how the mishap occurred, accepts the anger of the parents, and gives a full and heartfelt apology for the error. When the couple's shock begins to subside, the doctor explains the necessary corrective procedure and discusses the prognosis for the infant's recovery. After checking that they understand the situation and have no further questions, the doctor offers a final apology and assures the parents that they can reach her any time they need to.
Then the doctor leaves the room and begins to take a quiz. The parents, still in the examining room, pull out a checklist and grade the doctor on empathy, professionalism, and ability to communicate medical facts in layperson's terms. In another room, a physician who watched the entire interaction on a video monitor also grades the doctor.
The 'doctor' is a senior medical student at the Indiana University School of Medicine. The 'parents' are professional actors, and the scenario is just one among many played out in the Medical School's Objective Structured Clinical Examination (OSCE). The OSCE, an evaluative tool, began to be used at the school in the 1990s. Third and fourth-year medical students visit as many as 15 stations during a day of OSCE testing, where they focus on different scientific and clinical knowledge, diagnoses, interpersonal skills, and ethical/moral decision-making.
"After each 15-minute scenario," explains Stephen Leapman, executive associate dean for education affairs and professor of surgery at the School of Medicine, "physician-raters and the actor-patients evaluate the performance of the students. The entire scenario is videotaped, so students can go to the observation room and watch themselves on tape."
A trip to the OSCE facilities, housed in the Clinical Skills Education Center on the second floor of the Methodist Professional Tower near downtown Indianapolis, reveals a U-shaped row of 15 examination rooms. A corridor connecting these rooms conceals a central observation area with 15 corresponding video monitors, each equipped with pan-and-zoom controls, where observing physician-raters watch the exam in real time.
Although the technology at the center is modern, the use of actors as patients in medical education is not new. The first use, more than a century ago, came out of an accidental meeting.
"In the early 1900s," says Leapman, "there was a pickpocket gang that operated in the Bowery. One of their members would fake an epileptic seizure, and while a crowd gathered to watch, the gang members would circulate, picking pockets. A doctor from a medical school in the city was so impressed with the accuracy of the seizure that he hired the man to perform for his students."
So began the first simulations for medical education. For many years, these simulations were done occasionally and were regarded as little more than a novelty in medical education. That began to change about 40 years ago.
"Beginning in the 1960s," Leapman explains, "a neurologist named Howard Barrows developed simulations as a standardized medical tool for evaluation and teaching. He is the grandfather of the OSCE."
Thanks to Barrows, who is now an emeritus professor at Southern Illinois University School of Medicine, simulations have become a regular part of medical training at most medical schools in the United States. But why? If there are plenty of real patients to look at, why go to the trouble of hiring and training actors?
"The key to the OSCE is standardization," Leapman explains. "With the standardized exam, we can be sure that all the students are seeing the same patient with the same symptoms and the same physical examination findings. We can evaluate each student based on his or her handling of the same controlled situation."
There is another advantage: the use of standardized actor-patients in evaluation and training exposes all the students to the medical challenges they will most likely face in the course of a career. "In the regular clinics, if a student happens to miss a series of rounds, they may never deal with an appendicitis case, for example," says Leapman. "This way, we know they deal with it before they graduate."
Beginning in 2005, the National Board for Medical Examination will require all graduating medical school students in the United States to pass an OSCE as part of the U.S. Medical Licensing Examination. Since an OSCE is being added to the national boards, it is only natural that the IU School of Medicine is increasing its emphasis on OSCEs. IU's eight Regional Medical Education Centers in the state are now introducing simulated experiences for teaching and assessment, allowing first- and second-year medical students in the regional centers to gain familiarity with the process.
The OSCE fits well with the Medical School's recent shift to a competency-based curriculum.
"There are three foundations to medical education: knowledge, clinical skills, and attitude," Leapman observes. "Knowledge can be tested with a written test, but clinical skills and attitude are performance-based." The OSCE provides the perfect setting for measuring performance and offers enhanced ways to teach attitudes as well.
Leapman describes the motivation behind the curriculum shift and the OSCE implementation at IU this way: "A student graduating from the IU School of Medicine is more than a technocrat. Our graduates are complete physicians who care about their patients."
The scenarios in an OSCE are designed to include a variety of clinical problems as well as communication and decision-making challenges. The daunting task of writing the scenarios falls on Susan Ballinger, associate professor of clinical pediatrics and director of the Clinical Skills Education Center. She heads a committee of faculty volunteers who put together new scenarios for the yearly exams.
"Most of the committee members are clinicians, but we have a very active member who is a basic scientist and another member who is part of the IUPUI communications faculty," says Ballinger. "As the competency curriculum continues to evolve, we are incorporating things into the examination that have been taught in the curriculum. Communications--giving bad news--is an area that repeats yearly."
The bad-news scenarios test the ability of the doctor to empathize while remaining professional, to apologize, or to handle the requirements of informed consent. In one scenario, a patient must be told that a leg needs to be amputated; in another, a wife is told her husband, who has been in an automobile accident, is brain dead, and the physician must then ask about organ donation. In a third scenario, a woman must be told that her pregnancy has ended in miscarriage. The botched circumcision is yet another example.
Even a small-scale OSCE, with only five or six stations for students to move through, is a considerable administrative undertaking, requiring coordination of the flow and timing of the scenarios and the movement of the students from station to station. Sara Highbaugh, the center's coordinator, has worked with the administrative challenges of OSCE since its inception at IU. Medical students take an OSCE at IU before progressing through their junior year. Also, all 280 senior-year medical students pass through a large-scale OSCE before graduating.
"We get pretty crowded here sometimes," admits Highbaugh from her desk at the coordination center.
Typically, a student taking the exam will get the signal to begin, move to the door of a numbered examining room, and read the patient's chart or a task assignment affixed to the door. Then the student knocks and enters, and the scenario unfolds. Camera and microphone are built into the ceiling of the room, so only a trained observer is aware of their presence. The surroundings, including an examining table, wash sink, medical equipment tray, and glove dispenser, all conform to a real clinical environment. The actor-patients provide a superb level of accuracy in their portrayals, and the verisimilitude keeps the students focused on the task. A full-scale OSCE with many stations may require as many as 20 highly trained actors.
The Clinical Skills Education Center now has a cadre of actors for such roles, recruited by a bit of serendipity. In the early 1990s, a retired IU adjunct professor of biochemistry at Veteran's Hospital, the late Robert Blickenstaff, was an amateur thespian who knew the Indianapolis theater scene well. When he heard that the School of Medicine needed actors for medical simulations, he recruited actors from among the many he knew personally. Blickenstaff, who died in 2002, ended up as the Medical School's first trainer, assuring that the standardized patients performed with accurate symptoms and realistic complaints. Highbaugh now handles the training.
"In addition to Bob Blickenstaff's contribution, we've been fortunate to have a number of other retirees from the medical professions help us with training in one way or another, often as physician raters," Leapman adds.
Leapman first became involved in medical education in the area of surgery, his own specialty. Since then, he has taken on responsibility for coordinating the educational programs of the entire Medical School, and he's enthusiastic about the benefits of OSCE as a training method.
"In an ideal world," Leapman says, "every class in medical, nursing, and allied health schools should use the standardized patient scenarios as a teaching tool, not just as an assessment or evaluation method." He counts out the reasons: OSCE is less threatening than a real clinical situation where a patient's well-being is at risk; if the student doesn't get it right the first time, it can be repeated; and the OSCE scenarios can be manipulated to provide problems that might not be seen regularly in a real clinic.
Although Leapman would like to see OSCE used universally, he is realistic about the chances of that happening soon. "The cost of running OSCE is substantial," he explains. Add together the costs of the technology and administration, of the rooms needed for the testing stations, and of hiring and training the actors, and an OSCE becomes a valuable but very expensive endeavor.
The standardized patient scenario is also used elsewhere in the university hospital system for training and evaluation. Internal medicine residents in the IU system encounter actor-patients in their general medicine and geriatric clinics. The actors, termed "unannounced patients," evaluate the performance of their physicians; the plan is to introduce more standardized patients into the clinics so that each resident has six such encounters. "The resident will never know that the patient is acting a role," says Leapman.
Another idea that may soon be implemented is use of 'chronic' standardized patients. Such patients would be seen by the same resident four or five times in a year, and the patients would evaluate the ongoing treatment given by them by the resident. Ballinger says such "fake" patients are needed in residents' rounds.
"Patients are just not as available to students as in the past," she says. "When I was in medical school and residency, we would have patients in the hospital for months with a variety of illnesses and physical findings--infections of the bone, for example. Now so often these patients can go home for treatments with home health care and are not available for students to work with."
Does the use of OSCE make for better doctors? Leapman ponders the question, then relates the content of an e-mail he received from a recent School of Medicine graduate. "He wrote to tell me that, when in school, he had been less than enthusiastic about the OSCE," says Leapman.
"But as a new resident at a hospital in Wisconsin, he was recently assigned to deliver bad news to a family. He panicked for a moment, and then he remembered he had practiced this at the OSCE." The resident pulled himself together, reviewed what he had learned, and went in and handled the situation.
"He wrote me to affirm that the OSCE has real value," Leapman says. "That's the sort of message I'm gratified to get."
William Rozycki is assistant director of the Indiana Center for Intercultural Communications at IUPUI.