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.

Through a convenience sampling approach, we performed 5 detailed needs analysis interviews of PCPs. We also asked interviewees about typical primary care practice to better understand current behavior so that interactive educational materials would be realistic. With respect to typical primary care practice, we found that most of the PCPs screen for current substance abuse, but over half do not screen for past substance abuse. Most participants only ask about substance abuse during the patient interview if the medical history screening question(s) were positive or if there is another red flag. The fact that followup questioning only happens in these situations underscores the need for the medical history questions to be sensitive and evidence-based. Interviewees reviewed the early plans for the website to see if it met their needs and to identify further needs. Interviewees described a strong interest in information on: 1) reimbursement, 2) how to handle resistance from patients, especially when alcohol is the substance, 3) brief intervention, and 4) referral resources. They also noted a lack of a protocol for updating screening info for patients in ongoing care. The planned curriculum is a core course on each of the following: screening, brief intervention, and referral to treatment plus an advanced course addressing variations in patients or settings. The planned educational approach is live, standardized patient interviews via online chat. Support among the interviewees for the planned curriculum including the method of providing online learning was high. All participants said they were likely or very likely to take a course on SBIRT. The need for a curriculum including evidenced-based recommendations and skills training in SBIRT is clear.

Introduction/Statement of the Problem: Successful treatment modalities for patients with co-morbid pain and substance abuse problems have been developed. However, the practice community is ill-equipped to incorporate such evidence-based recommendations or strong clinical consensus opinions due to a lack of knowledge and training in this area. Materials and Methods: Using funding from NIDA, this project is surveying and interviewing primary care physicians (PCPs), primary care residents, and nurse practitioners (NPs), to determine educational needs and learning preferences. We also inquired about interest in an educational experience involving Internet-based Standardized Patients (SPs) to mirror the challenges and variability of interviewing live patients. Exempt research determined by the Clinical Tools' IRB involved opt-in subjects who were contacted by email about participating in online surveys (n=9 for each group).

Results: Each group prioritized training need as follows: 1) treating patients in recovery, 2) treating patients actively using substances, 3) treating patients at risk for substance abuse. With respect to conventional online, case-based educational courses, each group preferred a format using multiple short cases (>75%). They differed slightly in terms of how to best integrate cases and factual content but all preferred interactive questions/answer pairs on every page. The majority of each group expressed interest in learning by interviewing a virtual SP. For the SP experience, a chat-based interview was preferred to a video-based interview. Practicing physicians want very flexible hours and quick response time. Residents and NPs are more willing to wait for a response.

Conclusions: PCPs, residents and NPs identify a need to learn more about co-morbid substance abuse and pain. They are interested in online education solutions, especially those that employ multiple cases as the learning modality and interactive questions. They are willing to engage with virtual SP via chat.

References
Mitchell AM, Dewey CM. Chronic pain in patients with substance abuse disorder: general guidelines and an approach to treatment. Postrgrad Med. 2008;120(1):75-9 [http://www.ncbi.nlm.nih.gov/pubmed/18467812].