Using first-year students as standardized patients for an objective structured clinical exam for third-year pharmacy students
Significant changes in the clinical context of health professional education and an impressive body of research on the measurement of clinical competence support the use of the Objective Structured Clinical Exam (OSCE) as the preferred means of performance-based assessment and the use of standardized patients as an adjunct to current teaching and evaluation methods. While there is research to support the use of standardized actors (SPs) as patients, using students as patients and raters has been little studied across disciplines and not in the profession of pharmacy. This work investigates the impact of using first– year pharmacy students as standardized patients. It examines the reliability, validity, feasibility and acceptability of using first-year, SP and faculty raters to evaluate performance in a third-year candidate self-medication OSCE. The major findings indicate that using freshman students is reliable and valid, is cost effective and provides learning benefits to participants.
At the Faculty of Pharmacy, University of Toronto, the author coordinates two sequential courses in non-prescription medications for large classes of undergraduate pharmacy students. A previous manuscript described the first three years of implementation and evolution including course design, teaching methodology, reinforcing and enabling strategies, case preparation, assessment tools, evaluations and examinations. Experiences were presented in managing issues and peer teaching, while fostering an interactive, motivating environment(1). One of the goals is to prepare the student to assume the role of a pharmacist who will accept accountability for community patient care by identifying, preventing and resolving problems relating to self-medication. This involves daily communication with patients, requiring accurate and concise evaluation of their global needs. A high level of skill in oral dialogue, interpersonal interactions and assessment is required to competently implement this professional responsibility. During these dialogues, the pharmacist is expected to efficiently process the analysis, synthesis and evaluation of relevant information, based on recall, understanding and application of cumulative knowledge. Whether that outcome has been achieved should be reflected in the type of evaluation at the conclusion of the two courses. In order to credibly evaluate each student’s proficiency in the achievement of course objectives, a final, cumulative oral clinical skills examination was developed and implemented, using standardized patients. The development of this examination was reviewed in a second paper. (AACP Innovations in Teaching Award, 1998)(2).
Since that time, the examination has undergone several years of modification in terms of student preparation and participation and in the use of first-year students as standardized patients. These improvements, described in this paper, help to bridge the gap between the classroom and practice and together with another project,(3) were the basis of the AACP Innovations in Teaching Award, 2001.
PROBLEM-BASED ASSESSMEN IN HEALTH CARE EDUCATION
PBA: Educational measurement has been enhanced in recent years through performance-based assessment (PBA). This was first described as evaluation methods that require “the examinee to demonstrate specific skills and competencies… to apply the skills and knowledge that have been mastered…the examinee’s task is to construct an original response, which the examiner observes and evaluates”(5). Forms of PBA include four basic components: a reason for assessment, a specific performance to be evaluated, exercises which elicit that performance, and systematic rating procedures.
The popularity and acceptance of problem-based assessments in the arena of public education stems from their ability to measure the higher order critical thinking skills such as analysis, synthesis and evaluation, described in Bloom’s taxonomy(6), and emphasize proficiency in processing skills: problem solving, comprehension, reasoning and meta-cognitive processes(7). This is represented schematically by this author in Figures 1 and 2.
The objective structured clinical examination (OSCE) has become the preferred form of PBA used in clinical competency assessment as it typically tests greater numbers of tasks, using greater numbers of examiners, thereby minimizing task and examiner related variance components.
The OSCE: The objective structured clinical examination (OSCE), first described by Harden et al.(8) has become an accepted format for evaluating clinical performance in the health care arena, as it is considered one of the most valid and reliable approaches, especially for a large group of candidates(9). It is widely used in undergraduate curricula and for high stakes licensing and certification bodies in North America(10).
While OSCE structure may be varied, three key components are present: a highly structured format of task stations, objective scoring systems, and use of standardized patients (SPs) to portray the clinical problems in a consistent manner. Generally candidates must rotate through a series of timed stations chosen to reflect important components of clinical competence. The stations may require the examiner to use a checklist, which records behavior. Alternatively, global rating scales are used alone or with checklists to interpret clinical competence.
Use of Standardized Patients: For patient stations, either actual patients with stable physical findings, or standardized patients have been used(11). The standardized patient (SP), first proposed by Barrows and Abrahamson(12) is a normal individual who is taught to simulate every aspect of a patient’s illness in a totally consistent manner so accurately that the simulation cannot be detected by a skilled clinician(13). Often, professional actors are used. The term ‘standardized’ patient has replaced the term ‘simulated’ patient because it underlines the major advantage of this technique: to provide a patient problem that will not vary from student to student. Standardized patients are trained to complete checklists and rating forms at the end of encounters.
Raters: An important consideration in test design is the determination of who should rate candidate performance. Adequate inter-rater agreement can be achieved through use of either SPs or faculty raters. Faculty raters are especially skilled at rating content-related tasks. SPs have been found to give more positive evaluations of communications skills of students than faculty, reflecting differences in perception in the role of observer and patient, and proposing that the patient, as the ultimate participant, is a more appropriate assessor of interpersonal skills(14).
RATIONALE FOR USING FIRST-YEAR STUDENTS AS PATIENTS AND RATERS
No study has examined the use of first-year students as standardized patients for senior student examinations. As subjects, first-year students who have not studied diagnosis or therapeutics, closely represent the unknowledgeable patient. As raters, such students, having taken a communication course, may have a heightened awareness of desirable communication skills. As learners, they may perceive a benefit in terms of application to performance in senior years.
BACKGROUND INFORMATION AND EVOLUTION OF THE EXAM
The format of the examination evolved with changes over the first four years.
Year One (1997): In year one, feasibility was tested in a pilot project wherein each student had a single ten-minute interview with a simulated patient portrayed by a pharmacist. Both the role-playing pharmacist and an observing pharmacist rated the candidate. One practice was held prior to the exam between the candidate and a pharmacist teaching assistant (TA). Students requested a more realistic portrayal of the patient and an opportunity for more than one test interview.
Year Two (1998): In year two, each candidate had two interviews, and the patient role was played by a professional actor. The actor and the observing pharmacist rated the candidate. The practice format was changed to a small group interaction where the candidate experienced self, peer and instructor evaluation. The focus of the sessions was contemplation, discussion and rehearsal. Emphasis concentrated on behavioral skills, using the reflective student-centered approach espoused by Boud(15). Student feedback indicated the value and need for additional practices.
Year Three (1999): In year three, in addition to these group practices, thirty volunteer first-year first-year students were recruited to role-play a patient in an interview with a senior student, immediately following each class in second and third year. First-year students were selected in the hopes that their lack of therapeutic training would provide insights more closely parallel to the experience of the average consumer, and to increase their awareness and skills as future candidates. The overwhelmingly positive feedback from all students involved, who generated and unanimously signed a petition, was instrumental in allowing this initiative to be mandatory for future classes.
Year Four (2000): In year four, the first-year class of 120 students was divided into four cohorts. Two were assigned to the role-playing class practices with the second and third year students. A third cohort conducted individual private practices with a candidate (SR) prior to the exam, where the focus was feedback from the first-year students about organization and communication, rather than content. The fourth cohort underwent standardized training to achieve consistency in both role– portrayal and use of the assessment tool. They were then added to the oral examination patient pool, to enable each candidate to have four interviews with a standardized patient: two with a first-year student and two with a professional actor. This background evolution of the structure of the oral examination and the formative practices led to the innovative OSCE which is the basis of this paper (see Table I).
Purpose of Innovation
The purpose of this innovation is to use first-year first– year students as standardized patients in the third year self– medication OSCE at the University of Toronto, Faculty of Pharmacy. The impact of this work has been investigated by examining the psychometric properties of reliability and validity of using first-year student, SP and faculty raters to evaluate performance, and through qualitative surveys of candidates and first-year students, over two years of implementation (2000, 2001)
Reliability: Using first-years students vs SPs as patients,
Is there an effect on the faculty, shown by the scores they generate?
Is there an effect on candidate performance, shown by the scores achieved?
Validity: Using first-years students vs SPs as patients,
Is there a difference in the scores generated by patient raters vs TA raters?
Is the OSCE a valid measure compared with other assessments of performance?
How do the exam candidates and first-year students who participated regard the project as a learning experience?
Format of the OSCE
The OSCE is designed to measure competencies acquired by candidates during completion of two sequential self-medication courses taught during second and third year. The cumulative exit OSCE occurs in March, 10 weeks after completion of the second course. The examination is administered over two successive days and tests approximately 120 candidates. Each day, the candidate completes two ten-minute interviews followed by a five-minute post encounter assessment period. There is an interval between stations of 45 to 60 minutes. To facilitate the process, five parallel circuits are administered in three consecutive sessions on each day. The first day and second day interviews are scheduled for each candidate at the same times on each day, so that a 24-hour time lapse occurred for each. Table II illustrates the OSCE circuits for the first day of the OSCE.
The first-year of the project (2000), a standardized actor (SP) from the University of Toronto Standardized Patient Program played the patient on day one and a first-year pharmacy student played the patient on day two. This sequencing was reversed the following year, in response to student feedback. The performance of candidates at each station is observed and rated by a practicing pharmacist (TA) who is a teaching assistant or professor at the Faculty. Table III outlines the patients and raters for the OSCE for March, 2000.
Quality Control of Consistency in Role Delivery
For each examination day, all patients and TA raters who participate in the same case watch a preliminary enactment of the role to establish consistency in role-delivery. The course instructor rotates through each set of five rooms assigned per case to observe and comment on consistency in role-delivery and consistency in use of the assessment tool.
Description of Data Collection
During the encounter, the TA observer completes a casespecific five item task-specific checklist, which relates to problem identification and treatment. Following the encounter, the candidate leaves the room. The TA, the patient and the candidate, complete a global rating scale, which is the same for all stations. Patient and TA raters are carefully cautioned to resist the inclination to compare impressions. Their scores are included in data analysis.
Candidate self-assessments are not included in data analysis. They are carried out in order to give the candidate an opportunity to reflect upon and evaluate their performance after each interview. It is an opportunity to garner insights in preparation for the next test interview. At the completion of the four-station OSCE, each candidate completes a survey to collect data regarding their impressions of the OSCE.
Method for Recording Incidents
Each interview is audio-taped by the TA observer. They note on the schedule any untoward events, the candidate involved and the tape number and time for future review and scrutiny. In their self-assessments, the candidates also have the opportunity to record any untoward events and their impressions of the incident for future evaluation.
A total of twelve cases are written for the OSCE. Six are used each day in pairs over three administered sessions. Each sessional pairing is designed to be similar in terms of complexity of the content, and complexity of the patient. However, to ensure content validity, the clinical scenarios present as wide a range of situations as a self-medication advisor would be expected to handle. The sampling is twelve of thirty curriculum topics or 40 percent. Each case is an interaction between a simulated patient and the candidate, who assumes the role of a practicing pharmacist. The cases are designed to address the course objectives in terms of content, processing the delivery of pharmaceutical care, and interpersonal skills, in addition to assisting patients with special needs. Cases are structured to test performance in four separate areas of professional competency which the candidate is expected to identify and solve. These include:
a communication challenge;
a special need, such as a social, emotional or cognitive issue;
a key component in history-taking relating to medical conditions, family history, allergies or medications;
the identification, prevention or resolution one or two drug-related problems.
These key points are summarized in a short, five point checklist of task-specific items that is required of the candidates relating to problem identification and treatment. Integration of this knowledge with skills is required to pass the interview and is reflected in the scoring of the assessment tool in the domain that addresses overall impression (knowledge and skills).
The candidate is expected to dialogue with the patient effectively. The scope of the material is cumulative over the two courses. The cases are reflective of realistic patients in pharmacy practice. This content validity is assured since they are real patient situations encountered by the course instructor in her pharmacy practice as an advisor for self-medication. In that practice site, the instructor has no other tasks except dialoguing with patients in the over-the-counter (OTC) sections in a community pharmacy and typically will advise 120-130 patients during each shift. The cases are written by the case instructor and reviewed by another instructor for content and level of difficulty.
Description of the OSCE Practices
Candidates are provided with extensive information about the purpose and format of the testing in advance of the OSCE. This is to prevent candidate misconceptions about level and quality of performance expected by the test design, and to allow formative feedback to enhance performance skills. At the commencement of the second year course, a training session introduces students to the global rating scale. The purpose, use and interpretation are outlined using videotapes of student interviews.
Three types of formative practices are experienced by candidates prior to the OSCE. First, after each hour case-based class on a self-medication topic in both second and third year, they observe or participate as a pharmacist in ten-minute practice interviews conducted in front of the entire class. The patient is a first-year student and the case, an applied version of the same topic, is written by a class team. The global rating scale is scored by the first-year student, the pharmacist and the team who writes the case. Feedback comments are elicited from each of the raters and a class discussion is generated. Secondly, a formal practice of ten-minute interviews is conducted as part of the third-year Pharmacy Practice laboratory, in teams of six students with a TA. The students role-play patients for each other in turn and the cases are written by the course instructor for self-medication. The global rating scale is used by each observer which generates discussion and suggestions for improvement. Lastly, each candidate has a private ten– minute practice interview with a first-year student prior to the OSCE. The cases are written by the self-medication course instructor. The first-year student rates the candidate using the global rating scale and gives immediate oral feedback regarding their feelings as a patient during the dialogue; and the organization, focus, and communication skills of the candidate. Each first-year student repeats the role-portrayal with two or three candidates.
Description of the First-Year Students
The first-year students are recruited from a pharmacy social science course, which examines the perspective of the patient. These students complete a full semester course in communication skills. Sixty students who score highest on their entrance to pharmacy test of oral and written communications skills are selected for participation in the exam. A total of six patient roles are delivered by first-year students. They receive their roles, but no description of content checklist items, ten days in advance. First-year students are then trained by the self-medication instructor both for consistency in using the global rating scale, using videotapes of student interviews, and in standardizing their roles. Each first-year student repeats the assigned role for no more than four ten-minute interviews on the examination day, in order to utilize all sixty students, and to protect against fatigue in these inexperienced role-players.
The remaining students of the first-year class are sorted into sections for participation in either the class practices (one per student) or the private individual interviews (two to three per student). Participation in the OSCE or the practices are part of their curriculum cross-course requirements. After each experience, first-year students complete a survey to collect data regarding their impressions.
Prior to the examination, each candidate and each first– year student are required to read the code of conduct governing test security for examinations at the University. They sign a confidentiality agreement, which prohibits discussion of the nature of the patient roles or stations until the examination is completed. A literature review of test security using SPs reveals little or no problem with test security, especially when the SP application is measuring process rather than the ability to recall content and produce answers. Security should be monitored, but the issues should not restrict use(16). It is hoped that operationally, an element of uncertainty among the candidates is present as to the identity of the cases, and the use of 12 different cases and stringent efforts to enforce security will discourage any dissemination of confidential checklist items by first-year students.
During the examination, candidates are sequestered in separate rooms with invigilators for each parallel stream to ensure there is no verbal contact. Incoming candidates are sequestered before outgoing candidates leave the building. Each candidate and first-year student are required to disclose in advance, any close relationship with a student in the other year, and the pairings are scheduled to avoid combining first-year students and candidates who may know one another.
CHALLENGES IN IMPLEMENTATION
There are issues which require more careful planning in using of students vs actors. Although students are accessible, careful scheduling around their timetable is needed to make training available at times which are convenient and reasonable in duration, yet close enough in proximity to the examination date to afford a measure of test security. In consideration of their workload, the investigator is careful to schedule the examination date on a day which does not conflict too significantly with workload or examinations in other first-year courses, and this is a weekend day. Students are not reimbursed for their participation and have to provide their own transportation which is problematic for some since the OSCE is not held during regular classes. Finally, in order to affect a high degree of realism in role-delivery, all first-year student cases are written to portray patients of this age group, whereas greater age variability is possible with SPs. However, since the first-year student cohort is multi-cultural, it is possible to direct a variety of ethnicities into their roles, and this is not possible with the SPs, who are a much smaller cohort.
Initially, SPs were used on day one (Saturday) and first-years students were used on day two (Sunday). Feedback from first– year student was useful in suggesting reversing this order, giving them an opportunity to use Sunday for relaxing, work or study for the coming week. Candidates made a similar suggestion, since they reported being more at ease with the first-year students than the SPs during the interviews, and felt it would lessen their anxiety for SP interviews if they began with first– year. This suggestion made scheduling easier for the instructor and was implemented the following year.
Description of Assessment Tool: a Global Rating Scale
The assessment tool used to gather data for analysis is a global rating scale, which is the same for all stations and used by all the raters for the exam. It was designed by a rhetorician in consultation with clinical educators from several health care disciplines to test processing skills which reflect competence. The scale consists of four domains, which assess empathy, coherence (organization/focus), verbal skills and non-verbal skills on a five-point scale. A fifth domain is the overall impression of the integration of knowledge and skills in the performance, also on a five-point scale.
The five-point scale can be interpreted in terms of the five levels of learning described by Collis and Biggs as the Structure of the Observed Learning Outcome (SOLO) taxonomy(17). This scheme is well-designed to reflect the quality of learning of a complex set of skills such as process analysis and discriminates between performance levels described as prestructural (novice), uni-structural (beginner), multi-structural (competent), relational (proficient) and extended abstract (expert or insightful). This author has represented the hierarchy schematically in Figure 3.
Formal evaluation has shown that this instrument has quite acceptable psychometric properties(18) and rewards efficiency and mastery rather than thoroughness. Appendix C is the global rating scale used for the OSCE.
Description of Student Feedback
Student perceptions (both candidate and first-year student) of the examination project are determined by surveys. Quantitative survey questions are graded using a Likert scale with the response “Strongly Agree” = 5 and the response “Strongly Disagree” = 1. Students are asked to complete this survey anonymously. All first-year students are also asked to complete a free response feedback survey after participating in either the practices or the examination. The author designed this form to capture the learning cycles described by Kolb(19). The four-part form directs the student to describe their experience, reflect on their feelings during the encounter, analyze why this was so, and suggest modifications for future administrations to improve the program. In this way, each iterative experience expands the cycle of learning about the project into a widening cone of knowledge that increases the breadth and depth of understanding. This knowledge is a balanced assessment, since it is based on both deductive or objective and inductive or empathic reasoning. See Figures 4, 5 and 6.
EVALUATION AND RESULTS
First-year of Innovation (2000): One hundred and eight candidates were examined. The overall examination score was 73.1 percent with a standard deviation of 6.7 and a range from 53.3 percent to 86.5 percent. Four students failed (3.7 percent) and 15 (14 percent) received honor-status marks.
Acknowledgements. The author gratefully acknowledges the assistance and support of the following people in contributing to this project: Dr. Cleo Boyd, who developed the global rating scale used as the measurement instrument in the study; Dr. Heather Boon, professor of the first-year pharmacy social administration course, for enthusiastic collegial support and prompt and organized assistance in the sorting of first-year students; and the classes of first-year students for their participation. In willingly giving their time, energy, enthusiasm and insights to this project, they too learned from this experience.
1This article is based on a portfolio which was submitted to the AACP Council of Faculties and presented during the innovation in Teaching Awards special session, AACP Annual Meeting, Toronto, July 10, 2001. The title of the portfolio was “Innovative Enabling Strategies which Bridge the Gap from Learning to Practice.”
Am. J. Pharm. Educ., 65, 404-412(2001) received 8/9/01.
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