Clinical skills assessment exams using Standardized patients (SPs) are an established component of medical school education, including the current USLME Step 2 CS exam™. The authors have developed a novel method for conducting SP encounters using web-based chat technology (e.g. Google® chat). “Remote Live Standardized Patient” (RLSP) interviews are conducted entirely online. The interview requires active learner participation focused on clinical skills, and represents a unique solution to teaching specific skills and affecting behavior. We are not aware of other educators using chat for this purpose. We have been pilot testing chat-based OSCE-style exams1,2 since 2007. In 2009 we have begun using RLSPs to teach skills, as well as evaluate them. The instructional RLSP key components include an interactive SP actor, an EMR like interface, and a “Hats Off” mode, which allows the student learner to “ask a preceptor” or research information during the encounter. Each learner’s performance is evaluated by standardized measures and by the RLSP actor feedback. This interactive, responsive web environment allows the RLSP interview to simulate a broad spectrum of learner/patient encounters, from initial screening through diagnosis and treatment.

Advantages include 1) decreased SP training cost and time commitment, 2) more flexible SP scheduling and recruiting since all encounters occur online, 3) elimination of face-to-face constraints of verisimilitude errors and correlation of actor physical appearance compared to the “patient”, and 4) instant availability of chat conversation transcripts for review and learner feedback. Potential limitations include missing the “whole person” experience afforded by face-to-face encounters, including the ability to assess body language and demonstrate physical exam skills. Since face-to-face SP encounters also suffer from realism limitations (i.e. the actor does not typically have the “patient's” presenting symptoms), we feel that the advantages of an RLSP balance and actually outweigh the drawbacks.

Use of web-based chat or its equivalent may have significant appeal to the current generation of Internet-savvy medical students. The RLSP experience appears to be a viable alternative to the traditional face-to-face SP interview, allows cost savings, and prepares students for Step 2 CS-style exams.

Background: With support from NIAAA (#4R44AA016724-02) we are developing an online curriculum to educate and enhance clinical skill development in Year 2 to 4 medical students on at risk drinking and alcohol use disorders. Objective: Medical students were surveyed to understand learning preferences regarding the topics covered and the case-based learning environment. Program Description: Recruited through a convenience sampling approach, medical students (n=17) completed an on-line survey regarding their interests and perceived needs. Quantitative analyses of responses to multiple choice and 1-5 point Likert scale questions guided development of a case-based online curriculum. Program Evaluation Outcome: Students felt inadequately prepared [1=not prepared, 5=fully prepared] to address the following: ability to treat alcohol use disorders in patients with other addictions (1.65), ability to treat alcohol use disorders (1.76), ability to treat alcohol use in patients at risk for alcohol use disorders (1.76), ability to triage alcohol use disorder patients to appropriate treatment areas (2.00), recognition and treatment/proper referral of relapse to alcohol use disorders (1.88). Students were most interested in learning more about [1=uninterested, 5=very interested]: brief interventions (3.94), co-morbidities (3.94) and case studies representing a variety of patient experiences (4.41). Students would likely use an optional live remote Standardized Patient learning experience [1=strongly disagree, 5=strongly agree] (3.41) and would like to have the option available to them (3.53). A Web-based case interface (4.12) and online chat discussion with the patient (3.94) were preferred. Students preferred to learn clinical skills in multiple short cases compared to one long case (77%). Conclusions: Medical students identify many deficits in their knowledge and skills especially those skills that would be essential in any practice. They express interest in an experience using a live remote standardized patient which would focus on alcohol intervention skills training.

With support from NIAAA (#4R44AA016724-02) we are developing an online curriculum to educate and further clinical skill development in Year 2 to 4 medical students on at risk drinking and alcohol disorders. Through a convenience sampling approach, fifteen medical school faculty took an on-line survey to obtain preference information regarding case-based instruction. Almost all of the faculty (n=14) preferred multiple short cases to cover one topic, rather than one long case in a module. In a course with both didactic and case information, half of the faculty (n=7) preferred three cases per one hour course. When presenting the case to students, 66.7% (n=10) preferred that information be general. To enhance clinical skill development, we queried respondents as to their preferences for using a remote live Standardized Patient (SP) interview within the learning experience. Fourteen out of fifteen (93%) felt that an online SP experience would be an interesting way to teach skills and 87% (13/15) would be willing to use the online SP with their students. Faculty preferred that students receive basic patient case information online through the website (80%; 12/15) and an Internet chat (i.e. Google or Skype) was rated high for conversing with the live SP. We queried about potential topics. Respondents showed a clear interest in supplementing their teachings with materials on assessment and screening (80%, n=12), providing brief interventions (87%, n=13), common co-morbidities of alcohol use disorders (80%, n=12), and referring patients for treatment (87%, n=13). Based on their experience with medical students, the respondents felt that medical students would be interested in learning more about the biology behind addiction (80%, n=12), co-morbid diseases associated with long-term alcohol use (67%, n=10), and recognizing abuse in health case professions (80%, n=12). Support for the planned curriculum including the method of providing online learning was high.

Objective: We completed a needs and preference analysis of primary care providers to guide development of a live remote (offsite) Standardized Patient experience that would be used for skills training. We specifically wanted to understand enthusiasm for the concept of remote (Internet-based) SP-based learning that would occur via live chat or other real-time communication technology. We also sought preferences regarding such an experience, so the experience could be designed efficiently and be consistent with the target audience s wishes. We specifically sought input regarding an SP experience involving interviewing skills related to recognizing addiction and the risk of potential misuse of controlled substances.

Method: We performed online surveys of convenience samples of 3 groups of practicing physicians (total n=27), residents (n=9), nurse practitioners (n=9), and addiction specialist physicians (n=8) regarding their preference in terms of a remote Standardized Patient experience. Total number of respondents surveyed was 53.

Results or Conclusions: Enthusiasm for learning via a live remote SP experience was strong and consistent across different experience levels of physicians as well as for nurse practitioners. In all groups, 77% or more of respondents expressed willingness to take an online continuation education course or earn CME credits based on a remote Standardized Patient experience. The majority of respondents (50-85%) preferred that Internet-based text chat be used for the remote experience instead of video, telephone, or an asynchronous bboard. Most (55 to 78%) preferred to be able to use a specific time window for the experience compared to setting aside a specific time. The majority also expressed a willingness to be observed by other learners and to observe other learners themselves (50 to 77%). Further investigation of this aspect of live remote SP learning is warranted, since respondents were interested having or serving as an observer. Health care providers are interested and willing to utilize a remote SP experience for clinical skills training. Their needs and preferences can be accommodated efficiently.

Idea: For medical students in the pre-clinical years, Standardized Patients (SPs) can help the learner integrate medical science knowledge into a clinical framework. A remote SP experience, where the encounter occurs via the Internet in comparison to traditional “face-to-face” encounters, could offer many advantages.

Why the Idea was Necessary: A pool of remote SPs could be potentially less expensive, and more available. Also, the remoteness may offer an opportunity for more variety in patients and the anonymity may offer other benefits. Although there is an abundance of experience with the utilization of SPs in a live context, the concept of utilizing remote SPs is novel. There are few standards to guide educators interested in utilizing SPs remotely.

What Needs to be Done: We seek to determine the parameters that would define a successful remote SP encounter. We seek to reach consensus regarding the implementation of a remote SP experience from leaders in medical education innovation.

Evaluation Plan: A modified Delphi approach will be used to gather feedback. After explaining the theory behind the “remote” SP encounter, we will then use iterative rounds of discussion to create the framework on which to build our “remote” SP experience. As an example, we will reach consensus on learner-patient interaction technology as follows: Round 1 will present options for modes of delivery (chat, video, discussion boards, or other technology) and elicit further suggestions. Based on responses, we will ask participants to rate the importance of the mode of delivery in Round 2. Discussions will continue until a general consensus is reached on the optimal mode of delivery of the proposed remote SP experience. Additional consensus will be sought in terms of how to integrate remote SPs into other educational approaches (such as TBL), the value of being able to engage a diverse population of SPs, and the value and potential of anonymity.

Future Development: Once the framework of the remote SP program is developed, we will create, integrate, and evaluate the use of remote SP to impart knowledge and clinical skills training in medical school education via our NIAAA funded project.