A student clinical practicum has long served as a catalyst for "aha moments"—when students finally grasp the connection between something told to them in class and its clinical relevance. These experiences are critical in developing a clinician who can move from simply absorbing knowledge into one who can apply that knowledge effectively to assess and treat patients.
Despite their best efforts, however, academic programs cannot always assure that students will receive appropriately complex clinical experiences at the most opportune time to reinforce classroom learning. In addition, with the growing cost-containment efforts in health care, it has become more difficult to provide hands-on clinical education that requires student practice and supervisor feedback. And although mistakes can be powerful tools for learning, clinical supervisors obviously are not inclined to allow students to make such mistakes.
A decade ago, Vanderbilt University faculty decided to address this situation by investigating problem-based learning (PBL) to supplement clinical teaching for audiology and speech-language pathology students. This teaching-learning method is designed to develop independent problem-solving skills. PBL has been used successfully in medical schools throughout the world and has warranted consideration as an addition to training programs in communication disorders. PBL can be used to enhance lecture-format classes, or an independent PBL course can be designed to facilitate learning in specific or general areas of study.
This approach emphasizes self-directed learning and learning-by-doing. The student, not the instructor, assumes the responsibility for determining what is already known and what remains to be learned. PBL has gained popularity over the years and has served as a foundation for role-playing, group learning activities, and even computer-based educational programs.
More recently, patient simulation has extended the concept of PBL. By suspending their disbelief while practicing clinical skills, students have the opportunity to hone their diagnostic and counseling skills in a risk-free clinical environment. In contrast, when role-playing in class, students are aware that they are really interacting with their fellow students or the instructor, not with patients.
Planned scenarios using simulated or standardized patients in a clinical environment feel "real" to students, unlike role-playing. These patients are pro re nata (i.e., as needed) employees who are recruited, trained, costumed, and paid to portray patients, family members, and health care team members and to critique students. Programs generally recruit "patients" from the general public through job postings, websites, print media, and referrals from program participants. Most programs recruit individuals with varied backgrounds, including experience in an education or health care setting, theater, as a patient or a caregiver, and a variety of other vocations. At Vanderbilt, the School of Medicine pays the cost of hiring and training these actors. Some institutions might opt to create partnerships with theater departments or campus groups.
With standardized patients, instructors can provide the specific type of patient needed at the exact time required to supplement classroom instruction. Standardized patients also can be used for assessment as well as instructional purposes. The educational focus is typically related to interviewing, physical exam, complex communication, and interpersonal skills.
Partnership for Experiential Learning
The Department of Hearing and Speech Sciences of the Vanderbilt Bill Wilkerson Center has been using patient simulation for several years through a partnership with the Vanderbilt Center for Experiential Learning and Assessment (CELA). CELA is an innovative instructional environment in an 11,000-sq.-ft. facility in the heart of Vanderbilt University Medical Center. CELA consists of 12 fully equipped examination rooms and can create other types of environments as needed. For example, CELA created a school conference room for simulating an Individualized Education Program (IEP) meeting.
Opportunities for this approach are endless. At Vanderbilt, actors portray parents receiving their child's diagnosis of hearing loss. Or, a "parent" might express concern about her child receiving a diagnosis of normal hearing from our "student" audiologist even though the child did not pass a newborn hearing screening. Providing such complex explanations to families requires practice that might not be readily available to all students when needed. Furthermore, communication needs to be appropriate to the patient's level of understanding. For example, explaining test results to parents with advanced degrees in medically related fields will be distinctly different from explaining results to parents who have no such training or who, perhaps, use English as a second language.
During CELA activities, students must think on their feet and make adjustments without having a supervisor standing nearby to coach or correct them. Our students experience counseling in a realistic way and receive constructive critiques after the simulated scenario from the instructor and the standardized patients. Most importantly, this experience occurs prior to counseling "real" families in our clinics.
The process of developing simulated scenarios begins after faculty members agree on the desired learning outcomes. Faculty members write scenarios, which often are based on previous clinical experiences. After the course instructors create the "patient" details—the age, gender, disorder, ethnicity, and other factors required by a project—actors are hired and trained by the CELA staff and learn their scripts. Such scripts are highly flexible because the actors never know what the student might ask or say. However, course instructors are able to predict the students' most likely questions and comments and can prepare the actors accordingly.
Training time for particular roles usually ranges from four to 25 hours; more complex roles may require several weeks. After the actors are trained and learn their scripts, course instructors view rehearsals (using former students) and ensure that actors are portraying their roles as desired. Depending on the complexity of the scenarios and number of students to be scheduled, the process of preparing the scripts, hiring and training the actors, and scheduling the event typically takes three months.
Instructors can observe the simulated sessions in real time and review the recordings with students immediately afterward, or review recordings online at a later time. Students also can review the recordings online as often as desired. Because students watch their own performance, they typically provide a self-evaluation that requires little comment from the instructor. In addition, the course instructor designs a checklist for the standardized patient to complete following the encounter. Checklist items are based on the course objectives and the standardized patient is trained to listen or watch for them throughout the encounter. Examples of rating statements include "The student listened attentively to my concerns (made eye contact, attended to non-verbal cues)" or "I could easily understand what the student was saying (avoided jargon)."
The use of standardized patients provides clinical education opportunities that might not be available through traditional practicum experiences. These opportunities allow students to:
- Practice communication skills with difficult patients or in difficult situations.
- Review their own clinical behavior as often as necessary or desired with the opportunity to self-correct.
- Make mistakes without interruption by supervisors.
Instructors have the benefit of assessing students with equivalent "patient" experience. Although the use of standardized patients will never substitute for a traditional clinical practicum, it can enhance student preparation by providing a safe, risk-free environment for practicing clinical skills. Furthermore, such training might enhance the retention of material learned in the classroom because of the student's emotional investment and direct association with the real world.