1. Using a Simulated Patient Education Encounter to Assess Medical Students’ Ability to Provide Appropriate Patient Education “The Asthma Case” Thomas Roe, MD

2. An OSCE Case Focused on the Learner’s Ability to Provide Patient Education Why should we be concerned about this competency? How can we best assess the achievement of this competency?

3. Why should we be concerned about this competency? 1.The ability of physicians to provide appropriate patient education is identified as desirable by authorities in the health professions.  Specifically, in the management of asthma, experts feel that the evidence supports the provision of patient education by physicians as a means of improving outcomes in patients with asthma Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002. NIH Publication No. 02-5074. Bethesda, MD 2003

4. Why should we be concerned about this competency? 2.The ACGME in its General Competencies identifies the provision of education to patients as a critical skill that must be demonstrated by residents as an outcome of their training.  ACGME Patient Care Competency 1.Skill — “counsel and educate patients and their families” 2.Skill — “provide health care services aimed at preventing health problems or maintaining health”

5. Why should we be concerned about this competency?  ACGME Interpersonal and Communication Skills Competency 1.Skill — “use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills” ACGME Outcome Project—General Competencies 1999.

6. Why should we be concerned about this competency? 3.Patients indicate a desire for education about their health and medical conditions  People with asthma recognize the need for greater patient education – In a survey of 2,509 asthmatics, 71% believed there is a strong need for patient education about asthma Asthma in America Survey—Executive Summary, Schulman, Ronca, and Bucuvalas, Inc. for GlaxoWellcome, 1998. Accessed at www.asthmainamerica.com. www.asthmainamerica.com

7. How can we best assess the achievement of this competency?

8. “The Asthma Case” 1.Patient Education is an important part of patient-centered asthma management 2.Key Course Concepts, specifically Patient Education topics and skills related to asthma are taught to all students in both the Family Medicine and Pediatric Clerkships 3.Additional General Competencies need to be assessed in an ongoing fashion

9. General Protocol for OSCE Station Development and Evaluation of Student Performance Key Course Concepts &  Case Creation  Observation of Evaluating the &  Case Creation  Observation of Evaluating the General Student-Patient  Encounter Competencies Encounters a) Content (H & P Items) --History Taking skills b) Technique (Communication --History Taking skills b) Technique (Communication --Communication Skills and Physical Exam Skills) --Communication Skills and Physical Exam Skills) --Physical Exam Skills --Physical Exam Skills ↓ Student Creates Evaluating the Student Creates Evaluating the Post-Encounter  Student Note Post-Encounter  Student Note Note a) Content (History Items, Note a) Content (History Items, Physical Exam Items, Physical Exam Items, Assessment, & Plan) Assessment, & Plan) b) Technique (Organization & b) Technique (Organization & Legibility) Legibility)

10. “The Asthma Case” Key Course Concepts 1.Patient Education Skills a.Mechanism of disease b.Nature of medications c.Correct use of medications d.Self-monitoring e.Additional appropriate health advice General Competencies 1.History Taking Skills 2.Communication Skills

11. The Asthma Case Scenario and Instructions Clinical Scenario  You are asked to evaluate Matthew Procter an 18-year-old male who presents to your 1°care office with complaints of cough and shortness of breath. He is your partner’s patient, but he has not been to the office, nor seen any other physician, in over two years.  Family History –No significant illnesses in the family  Social History –Smokes ½ pack per day for the past year –Alcohol—Had 1 beer at cousin’s wedding last year—otherwise doesn’t drink –Has never used recreational drugs –Diet—Regular, well-rounded –Exercise—Plays tennis 3-4 times/week and is on his high school varsity tennis team. Feels recent symptoms have impaired his play –Employed part-time as a Junior Tennis Instructor at the local YMCA –Senior in high school—doing well academically—going away to college next fall. Currently lives with both parents and 15-year-old sister in a relatively new suburban home with no unusual environmental exposures –Has never been sexually active with a partner

12. The Asthma Case Scenario and Instructions  Review of Systems –Unremarkable other than for the symptoms reported in History of Present Illness  Physical Examination –Well developed, well nourished young adult male who appears in no distress –T=98.8, P-64, R=18, BP=104/60, Ht=60 inches, Wt=168# –HEENT-Pale, mildly congested nasal mucosa, otherwise normal –Neck-No lymphadenopathy, masses, or JVD –Chest/lungs-No deformities, masses, or tenderness. No use of the accessory muscles of respiration. No dullness to percussion. Auscultation-moderate expiratory wheezing in all lung fields. No rales or rhonchi. Fair air exchange. –Heart-RRR. No murmurs, rub, or gallop. –Extremities-No edema, clubbing, or cyanosis –3 Peak Expiratory Flow Rates (PEF’s) done by the Medical Assistant are all about 445 liters/minute, which is approximately 75% of predicted for his age & height

13. The Asthma Case Scenario and Instructions Instructions 1.Please obtain a History of the Present Illness, Past Medical History, and any other additional history specifically relevant to the patient’s complaint (Focused History). 2.You do not need to repeat the vital signs nor perform any additional physical examination. Assume that the observations noted above are the only pertinent findings on examination of the patient. 3.Based upon your assessment of the patient’s history (both the information provided above and elicited by you) and the objective information given above, provide the patient with pertinent information/education about his/her condition and its management.

14. The Asthma Case Observer Rating Form

16. The Asthma Case Results—General Trends  Students did well eliciting CC and HPI except for inquiring about region and severity of symptoms as well as the patient’s attribution.  In the PMH few students inquired about prior surgeries, hospitalizations, trauma, childhood illnesses/immunization status.  Students performed well in educating the patient about medications and their correct use except for only fair performance in providing instruction on the proper inhaler technique.  Students did well on advising patients to discontinue smoking, fair in explaining the mechanism of the disease, and poorly in providing additional pertinent health advice (vaccinations and follow-up).

17. Implications/Discussion 1.The ability of a physician to effectively provide patient education is an important skill 2.An OSCE station, systematically developed and validated, can be used to assess medical students’ competency in providing appropriate patient education

18. Implications/Discussion 3.Other General Competencies can be assessed concurrently in a Patient Education OSCE station 4.Areas of consistent weakness in student performance in the realm of patient education can be identified and curricular changes can be undertaken to address these deficiencies

20. Please feel free to contact us  Tom Roe troe@med.wayne.edu  Maurice Kavanagh mkavanag@med.wayne.edu