Physicians' emotion awareness and emotion regulation training during medical education: a systematic scoping review protocol.

INTRODUCTION: The objective of this systematic scoping review is to identify what approaches have been implemented in medical education programmes to teach medical students the skills to identify and manage emotions that may be elicited in them during physician-patient interactions and in the clinical environment. Emotions of all involved in the clinical encounter are central to the process of clinical care. However, a gap remains addressing and teaching medical students about recognising and dealing with their own emotions. METHODS AND ANALYSIS: This scoping review will follow the updated JBI (The Johanna Briggs Institute) methodology guidance for the conduct and reporting of systematic scoping reviews, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. A search strategy was developed and applied to five databases. Terms used included medical education, medical curriculum, medical students, emotion (regulation), psychological well-being and mental health. Additionally, a grey literature and reference list search will be conducted. Two independent reviewers will first screen titles and abstracts followed by a second, full-text screening phase. Publications to be included will contain information and data about teaching approaches such as lectures, and other teaching material on physicians' emotion awareness and emotion regulation training in medical education. ETHICS AND DISSEMINATION: This study will review existing literature on emotion awareness and emotion regulation training in medical education, and a systematic scoping review does not require ethical approval. The results of this scoping review will be submitted for publication to relevant peer-reviewed journals and will be used to inform the development and implementation of training programmes and research studies aimed at preparing medical students to identify and manage their own emotions in the clinical environment.

Swiss medical schools' experiences with online teaching during the COVID-19 pandemic in light of international experiences.

BACKGROUND: During the pandemic, all universities had to switch to digital learning and teaching (DLT), the experiences were diverse. The advantages and obstacles of DLT are well reported in research. To ensure a sustainable DLT implementation, the requirements of institutions, educators and students should be aligned. OBJECTIVE: This paper aims at identifying and describing the experiences made at the Swiss medical schools after having to switch from on-site to on-line teaching; in particular, the experienced issues, requirements, and solutions were investigated and compared to international literature. METHODS: We conducted a literature review to derive themes and subthemes regarding the central aspects of the transition from on-site to on-line teaching. Also, we conducted semi-structured interviews with people responsible for the medical curricula at the Swiss Medical Schools. We used a purposive sampling method and invited eleven curriculum managers at the seven Swiss Medical Schools. The interviews were conducted in English, audio-recorded and transcribed. Subsequently the data was analysed with the software NVivo. We used a qualitative, deductive, content analysis to explore faculty experiences. RESULTS: Twenty-four articles met the eligibility criteria and were included for full text screening. Of the included articles, 15 reported on DLT in general and nine articles reported on DLT during the Pandemic. The thematic analysis of the interviews resulted in four overall themes, requirements, obstacles, facilitators and advantages. Curriculum managers reported that institutions were relatively unprepared for the quick transition from onsite to online at the onset of the pandemic. CONCLUSIONS: Our research reports a lack of institutional structures, communication, digital competences and literacy, teaching strategies, as well as a theoretical foundation for DLT implementation. A conceptual framework for DLT adapted to the Swiss universities beyond the current situation is needed.

Taxonomy of teaching methods and their use in health professions education: a scoping review protocol.

INTRODUCTION: Applying the lens of social constructivist theory, teaching methods facilitate the process of learning and may be used differently across settings to align learning goals. Teaching methods are used across disciplines, occupations and learning settings, yet terminology, descriptions and application for use vary widely. This scoping review will identify eligible literature of reported teaching methods with documented descriptions across disciplines with a focus of how teaching methods are applied to health professions education. A literary description of a teaching method was used as a basis from which to select eligible articles based on two criteria, a specified method and delivery of that teaching by a teacher figure. METHODS AND ANALYSIS: Using the extension of the Joanna Briggs Institute methodology aligned to Arksey and O'Malley's six-stage framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, this scoping review will systematically search ERIC, Embase, Web of Science and PubMed databases. The search strategy was supported by an information specialist. Eligible studies will be identified in a two-stage screening process with four researchers. To complement eligible peer-reviewed literature, we will also search out relevant grey literature including University Websites, Conference Programmes and handsearched reference lists. Data extraction will be performed using a developed data extraction tool. A narrative summary will accompany charted results and describe the results aligned to the study objectives. ETHICS AND DISSEMINATION: As no intervention or patient recruitment is required for this research, ethics board approval is not required. Results will be disseminated via publication in a peer-reviewed journal, conference presentations and where feasible reaching out to those organisations and universities with published glossaries of terms for teaching.

Artificial Intelligence in Scientific Writing: A Deuteragonistic Role?

In this article, we reflect on the pros and cons of artificial intelligence (AI)-augmented scientific writing for more comprehensible research towards society to gain trust for science-led policy. For this purpose, we integrated our thoughts into the Factors of Perceived Trustworthiness from Mayer, Davis, and Schoorman's Model of Trust and made propositions to define AI's role in trustful scholarly communication.

From threat to challenge-Improving medical students' stress response and communication skills performance through the combination of stress arousal reappraisal and preparatory worked example-based learning when breaking bad news to simulated patients: study protocol for a randomized controlled trial.

BACKGROUND: Breaking bad news (BBN; e.g., delivering a cancer diagnosis) is perceived as one of the most demanding communication tasks in the medical field and associated with high levels of stress. Physicians' increased stress in BBN encounters can negatively impact their communication performance, and in the long term, patient-related health outcomes. Although a growing body of literature acknowledges the stressful nature of BBN, little has been done to address this issue. Therefore, there is a need for appropriate tools to help physicians cope with their stress response, so that they can perform BBN at their best. In the present study, we implement the biopsychosocial model of challenge and threat as theoretical framework. According to this model, the balance between perceived situational demands and perceived coping resources determines whether a stressful performance situation, such as BBN, is experienced as challenge (resources > demands) or threat (resources < demands). Using two interventions, we aim to support medical students in shifting towards challenge-oriented stress responses and improved communication performance: (1) stress arousal reappraisal (SAR), which guides individuals to reinterpret their stress arousal as an adaptive and beneficial response for task performance; (2) worked examples (WE), which demonstrate how to BBN in a step-by-step manner, offering structure and promoting skill acquisition. METHODS: In a randomized controlled trial with a 2 (SAR vs. control) x 2 (WE vs. control) between-subjects design, we will determine the effects of both interventions on stress response and BBN skills performance in N = 200 third-year medical students during a simulated BBN encounter. To identify students' stress responses, we will assess their perceived coping resources and task demands, record their cardiovascular activity, and measure salivary parameters before, during, and after BBN encounters. Three trained raters will independently score students' BBN skills performances. DISCUSSION: Findings will provide unique insights into the psychophysiology of medical students who are tasked with BBN. Parameters can be understood more comprehensively from the challenge and threat perspective and linked to performance outcomes. If proven effective, the evaluated interventions could be incorporated into the curriculum of medical students and facilitate BBN skills acquisition. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05037318), September 8, 2021.

A Changing Landscape for Lifelong Learning in Health Globally.

On 25 July 2022, the Continuing Professional Development (CPD) Special Interest Group of the Association for Medical Education in Europe came together to open up discussions during a live webinar on 'Exploring the Evolution of CPD'. The objective was to bring together global medical educators to consider perspectives of CPD from the role of global lifelong learners, the role of educators and the role of education providers and health regulators. The landscape of CPD is evolving, and the roles of each key player must include specific actions for facilitated change. Delivering competency outcomes-based learning, fit for purpose, to lifelong learners in health will require (1) learner agency, (2) leadership from educators and (3) providers of lifelong learning to come together to improve delivery of CPD that leads to meaningful change in practice care delivery.

Essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss federal licensing examination for human medicine.

Purpose: This report describes the essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss Federal Licensing Examination for Human Medicine (FLE) and the insights gained since its introduction in 2011. Methods: Based on existing scientific evidence, international expertise, and experience gained from previous examinations, the FLE is developed by experts from all five medical faculties in Switzerland with the support of the Institute for Medical Education and is held simultaneously at five locations. The exam organisers document and review every examination held and continuously optimise the processes; they have summarised the results in this report. Results: The essential steps comprise the development, revision and translation of questions; construction of the exam and production of materials; candidate preparation; implementation and analysis. The quality assurance measures consist of guideline coherence in the development of the questions and implementation of the exam, revision processes, construction of the exam based on the national blueprint, multiphase review of the translations and exam material, and statistical analysis of the exam and the comments from candidates. The intensive collaboration, especially on the part of representatives from all the participating faculties and a central coordination unit, which provides methodological support throughout and oversees the analysis of the exam, has proven successful. Successfully completed examinations and reliable results in the eleven examinations so far implemented represent the outcomes of the quality assurance measures. Significant insights in recent years are the importance of appreciating the work of those involved and the central organisation of exam development, thus ensuring the long-term success of the process. Conclusion: Common guidelines and workshops, quality assurance measures accompanied by the continuous improvement of all processes, and appreciation of everyone involved, are essential to carrying out such an examination at a high-quality level in the long term.

Investigating acceptability of a training programme in precision medicine for frontline healthcare professionals: a mixed methods study.

BACKGROUND: Precision Medicine offers tailored prevention, diagnosis, treatment and management to patients that considers genomics, lifestyle and environmental factors. If implementation of Precision Medicine is to advance, effective, focused upskilling of frontline healthcare professionals through quality continuing professional development is needed. This study reports on an evidence-based approach to needs assessment to investigate the current level of knowledge of Precision Medicine, acceptable content for training, the perceived potential of a more precision approach to patient care and motivation to participate in a training programme among pharmacists, advanced practice nurses and general practitioners. Investigating perceived needs can avoid a top-down approach and support a design that is fit for purpose to targeted professions. METHODS: This study reports on 2 focus groups (n = 12) delivered in French and German with equal professional participation of the targeted professions. The research objectives were investigated in two phases. During the first phase, a literature review and expert consultations were conducted to develop a definition of PM, patient cases and content for training. In a second phase, these investigations were further explored using focus groups to investigate acceptable learning objectives, the potential of PM to relevant professions and motivation of participants. Quantitative investigations using rating scales and visual analogues were incorporated. The focus groups were audio recorded, transcribed by intelligent verbatim and translated to English. NVivo was used for data analysis and interpretation following a hybrid approach using the Framework Method and thematic analysis. The analytical framework, Implementation Science, was applied to organise and present research data. RESULTS: Precision Medicine is considered a new topic area, largely unfamiliar to frontline healthcare professionals.. There was acceptance of a more precision approach to care among all participants with perceived positive implications for patients. Valuable insight was gathered on acceptable content and form for training. All participants expressed concerns on readiness within their professions which included an insufficient system infrastructure, a lack of time to attend needed training, a lack of clarity for use in practice and the time needed to build a support network. CONCLUSIONS: A precision approach to patient care is on the horizon for health care professionals not only in hospital settings but also at the community level. Our results conclude that an adaptable and flexible training programme in PM is timely, contextually relevant and conducive to the needs of targeted health professions for successful implementation. A training programme in PM will require support across sectors and stakeholders, supporting insurance models, educated patients and integrated care supported by innovative technology. Implementation Science outcomes are a useful strategy towards design of an effective training programme that can have measurable impact in practice.

Usability and preference of electronic vs. paper and pencil OSCE checklists by examiners and influence of checklist type on missed ratings in the Swiss Federal Licensing Exam.

Background: Only a few studies with small sample sizes have compared electronic Objective Structured Clinical Examination (OSCE) rating checklists with traditional paper-based OSCE rating checklists. In this study, the examiner-perceived usability and preference for type of OSCE checklist (electronic vs. paper based) were compared, and the influence of OSCE checklist type on missed ratings was determined, for the Swiss Federal Licensing Examination in clinical skills for human medicine. Methods: All examiners in the Swiss Federal Licensing Examination in clinical skills for human medicine were invited over two subsequent years to evaluate the OSCE checklist type they had worked with during the examination. This was based on a questionnaire with 14 closed questions (i.e., demographic, checklist-type experience, perceived usability, checklist type preference). Furthermore, the numbers of missed ratings for the paper-based checklist were recorded. Results: The data from these examiners (n=377) with experience of both OSCE checklist types were analyzed. The electronic OSCE checklist was rated significantly higher on all usability aspects (i.e., ease of use, candidate rating and error correction, clarity, distraction using the checklist, overall satisfaction), except for the speed of registering comments (no significant difference). The majority of the examiners in both years (2014: 54.5%, n=60, 2015: 89.8%, n=230) reported preference for working with the electronic OSCE checklist in the future. Missed ratings were seen for 14.2% of the paper-based OSCE checklists, which were prevented with the electronic OSCE checklists. Conclusions: Electronic OSCE checklists were rated significantly more user-friendly and were preferred over paper-based OSCE checklists by a broad national sample of examiners, supporting previous results from faculty-level examinations. Furthermore, missed ratings were prevented with the electronic OSCE checklists. Overall, the use of electronic OSCE checklists is therefore advisable.

Trajectories of learning approaches during a full medical curriculum: impact on clinical learning outcomes.

BACKGROUND: No consensus exists on whether medical students develop towards more deep (DA) or surface learning approaches (SA) during medical training and how this impacts learning outcomes. We investigated whether subgroups with different trajectories of learning approaches in a medical students' population show different long-term learning outcomes. METHODS: Person-oriented growth curve analyses on a prospective cohort of 269 medical students (Mage=21years, 59 % females) traced subgroups according to their longitudinal DA/SA profile across academic years 1, 2, 3 and 5. Post-hoc analyses tested differences in academic performance between subgroups throughout the 6-year curriculum until the national high-stakes licensing exam certifying the undergraduate medical training. RESULTS: Two longitudinal trajectories emerged: surface-oriented (n = 157; 58 %), with higher and increasing levels of SA and lower and decreasing levels of DA; and deep-oriented (n = 112; 42 %), with lower and stable levels of SA and higher but slightly decreasing levels of DA. Post hoc analyses showed that from the beginning of clinical training, deep-oriented students diverged towards better learning outcomes in comparison with surface-oriented students. CONCLUSIONS: Medical students follow different trajectories of learning approaches during a 6-year medical curriculum. Deep-oriented students are likely to achieve better clinical learning outcomes than surface-oriented students.

An overview of and approach to selecting appropriate patient representations in teaching and summative assessment in medical education.

Medical education has a long tradition of using various patient representations in teaching and assessment. With this literature review we aim, first, to provide an overview of the most important patient representations used to teach and assess clinical skills, considering in particular “summative exams” that have a pass or fail outcome; second, to provide arguments for choosing certain patient representations; and third, to show the advantages and limitations of different patient representations, especially simulated patients (SPs) and real patients (RPs). Typical patient representations include case narratives, anatomical models, simulators and mannequins, as well as SPs and RPs. The literature indicates that there are multiple ways of using various patient representations in teaching and that the intended didactical purpose informs the choice of representation. Early in the educational programme, even low-fidelity patient representations can be a good fit for assessment purposes if chosen to match the educational level. The use of RPs in summative, high-stakes assessments (exams with particularly important consequences for the examinee) is limited for methodological and ethical reasons. The methodological implementation of summative exams also entails specific challenges, such as ensuring measurement reliability and fairness towards the examinees. Carefully prepared, SPs can perform their roles with a sufficient degree of authenticity, making summative exams more manageable, and imposing no strain or risk on RPs. The ongoing debate concerning the use of SPs and RPs in summative assessment highlights perceived limitations of SPs in relation to RPs that are often not supported by research. Evidence shows that SPs, in combination with additional simulation modalities as needed, represent the first choice for summative clinical assessment. We also consider the strengths and limitations of this review and reflect on the applicability of our findings. We conclude that in order to select the right patient representations in clinical teaching and/or assessment, a number of perspectives must be considered: (i) the learning goals, aligned with the stage of study, (ii) the corresponding requirements of the clinical task itself (e.g., performing a phlebotomy or a communication task), (iii) the level of authenticity required and (iv) the resources needed, taking patient safety and feasibility into consideration.

The introduction of a standardised national licensing exam as a driver of change in medical education: A qualitative study from Switzerland.

INTRODUCTION: Only a few studies have described the impacts, strengths and needs for further development of national licensing exams (NLE). To gain such insights regarding the Swiss NLE, which includes a multiple-choice and a standardised clinical skills exam, we explored the perceptions of involved experts and stakeholders. METHODS: We explored participants' perceptions in four focus group discussions. The interviews were recorded, transcribed verbatim and qualitatively analysed using a thematic analysis approach. RESULTS: The analysis resulted in five perceived impacts, two strengths and two needs for further developments of the NLE. Perceived impacts were (1) steering students' learning behaviour, (2) supporting teachers and assessors to align teaching to competencies, (3) elevating the importance of the Swiss Catalogue of Learning Objectives, (4) setting incentives for the further development of curricula, and (5) fostering the collaboration between the faculties of medicine. Perceived strengths were the blend of assessment formats, including their competency-based orientation, and the collaborative development approach. Perceived needs lay in the NLE's further development to sustain its fit for purpose and in incentives for people involved. CONCLUSION: According to our study, this NLE had, and has, notable impacts on medical education in Switzerland. Our insights can be useful for others planning a similar undertaking.

Measurement precision at the cut score in medical multiple choice exams: Theory matters.

INTRODUCTION: In high-stakes assessment, the measurement precision of pass-fail decisions is of great importance. A concept for analyzing the measurement precision at the cut score is conditional reliability, which describes measurement precision for every score achieved in an exam. We compared conditional reliabilities in Classical Test Theory (CTT) and Item Response Theory (IRT) with a special focus on the cut score and potential factors influencing conditional reliability at the cut score. METHODS: We analyzed 32 multiple-choice exams from three Swiss medical schools comparing conditional reliability at the cut score in IRT and CCT. Additionally, we analyzed potential influencing factors such as the range of examinees' performance, year of study, and number of items using multiple regression. RESULTS: In CTT, conditional reliability was highest for very low and very high scores, whereas examinees with medium scores showed low conditional reliabilities. In IRT, the maximum conditional reliability was in the middle of the scale. Therefore, conditional reliability at the cut score was significantly higher in IRT compared with CTT. It was influenced by the range of examinees' performance and number of items. This influence was more pronounced in CTT. DISCUSSION: We found that conditional reliability shows inverse distributions and conclusions regarding the measurement precision at the cut score depending on the theory used. As the use of IRT seems to be more appropriate for criterion-oriented standard setting in the framework of competency-based medical education, our findings might have practical implications for the design and quality assurance of medical education assessments.

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials.

OBJECTIVES: Video-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples. METHODS: One-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented. RESULTS: Only a main effect of 'hints' was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups. CONCLUSIONS: Independent of their presentation format, worked examples with hints best foster students' BBN skills learning. PRACTICE IMPLICATIONS: In addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.

Cognitive load in internal medicine: What every clinical teacher should know about cognitive load theory.

Internal medicine is an appropriate example of specialties in which to teach learners clinical reasoning skills, decision-making, and analytical thinking, as well as evidence-based, patient-oriented medicine. During daily clinical work, general internists always encounter a multitude of situations that lend themselves to educating medical trainees in ambulatory and inpatient settings. Application of existing learning theories to teaching has been shown to optimize teaching ability and to maximize the efficiency of teaching efforts. Cognitive Load Theory explains learning according to three important aspects: the types of memory (working and long-term memory), the learning process and the forms of cognitive load that affect our learning. The aim of this paper is to show the main perspectives and implications of the Cognitive Load Theory on clinical educational practices. It is important to give the right amount of information in the most effective way to learners, thereby making this information more useful. This article presents a concise overview of the basis of the Cognitive Load Theory in its first part, and, in its second part, it exposes the practical applications of this theory with examples. This learning theory will encourage clinical teachers to reflect on how to foster learning in medical trainees in the more effective way.

The learning effects of different presentations of worked examples on medical students' breaking-bad-news skills: A randomized and blinded field trial.

OBJECTIVES: Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication. METHODS: Sixty-seven fourth-year medical students attending a mandatory communication course participated in this randomized field trial. Prior to the course, they worked through an e-learning module that introduced the SPIKES protocol for delivering bad news to patients. In this module, a single worked example was presented to one group of students in a text version, to a second group in a video version, and to a third group in a video version enriched with text hints denoting the SPIKES steps. RESULTS: The video-with-hints group broke bad news to SPs significantly more appropriately than either of the other groups. Although no further condition-related effects were revealed, students who learned from the text version most frequently (although non-significantly) ignored unpleasant emotions (standardised emotional cues and concerns) expressed by the SPs. CONCLUSIONS: The learning effect was strongest when the video-based worked example was accompanied by hints. PRACTICE IMPLICATIONS: Video-related learning approaches that embed attention-guiding hints can effectively prepare undergraduates for SP encounters.

Multiple true-false items: a comparison of scoring algorithms.

Multiple true-false (MTF) items are a widely used supplement to the commonly used single-best answer (Type A) multiple choice format. However, an optimal scoring algorithm for MTF items has not yet been established, as existing studies yielded conflicting results. Therefore, this study analyzes two questions: What is the optimal scoring algorithm for MTF items regarding reliability, difficulty index and item discrimination? How do the psychometric characteristics of different scoring algorithms compare to those of Type A questions used in the same exams? We used data from 37 medical exams conducted in 2015 (998 MTF and 2163 Type A items overall). Using repeated measures analyses of variance (rANOVA), we compared reliability, difficulty and item discrimination of different scoring algorithms for MTF with four answer options and Type A. Scoring algorithms for MTF were dichotomous scoring (DS) and two partial credit scoring algorithms, PS50 where examinees receive half a point if more than half of true/false ratings were marked correctly and one point if all were marked correctly, and PS1/n where examinees receive a quarter of a point for every correct true/false rating. The two partial scoring algorithms showed significantly higher reliabilities (αPS1/n = 0.75; αPS50 = 0.75; αDS = 0.70, αA = 0.72), which corresponds to fewer items needed for a reliability of 0.8 (nPS1/n = 74; nPS50 = 75; nDS = 103, nA = 87), and higher discrimination indices (rPS1/n = 0.33; rPS50 = 0.33; rDS = 0.30; rA = 0.28) than dichotomous scoring and Type A. Items scored with DS tend to be difficult (pDS = 0.50), whereas items scored with PS1/n become easy (pPS1/n = 0.82). PS50 and Type A cover the whole range, from easy to difficult items (pPS50 = 0.66; pA = 0.73). Partial credit scoring leads to better psychometric results than dichotomous scoring. PS50 covers the range from easy to difficult items better than PS1/n. Therefore, for scoring MTF, we suggest using PS50.

Learning communication from erroneous video-based examples: A double-blind randomised controlled trial.

OBJECTIVE: Appropriate training strategies are required to equip undergraduate healthcare students to benefit from communication training with simulated patients. This study examines the learning effects of different formats of video-based worked examples on initial communication skills. METHODS: First-year nursing students (N=36) were randomly assigned to one of two experimental groups (correct v. erroneous examples) or to the control group (no examples). All the groups were provided an identical introduction to learning materials on breaking bad news; the experimental groups also received a set of video-based worked examples. Each example was accompanied by a self-explanation prompt (considering the example's correctness) and elaborated feedback (the true explanation). RESULTS: Participants presented with erroneous examples broke bad news to a simulated patient significantly more appropriately than students in the control group. Additionally, they tended to outperform participants who had correct examples, while participants presented with correct examples tended to outperform the control group. CONCLUSION: The worked example effect was successfully adapted for learning in the provider-patient communication domain. PRACTICE IMPLICATIONS: Implementing video-based worked examples with self-explanation prompts and feedback can be an effective strategy to prepare students for their training with simulated patients, especially when examples are erroneous.