Standardized Vaccine-Hesitant Patients in the Assessment of the Effectiveness of Vaccine Communication Training.

OBJECTIVES: To determine if training residents in a structured communication method elicits specific behaviors in a laboratory model of interaction with vaccine-hesitant parents. STUDY DESIGN: Standardized patients portraying vaccine-hesitant parents were used to assess the effectiveness of training in the Announce, Inquire, Mirror, Secure (AIMS) Method for Healthy Conversations. Blinded pediatric residents were pseudorandomized to receive AIMS or control training and underwent pre- and post-training encounters with blinded standardized patients. Encounters were assessed by blinded raters using a novel tool. Participant confidence and standardized patient evaluations of the participants' general communication skills were assessed. RESULTS: Ratings were available for 27 AIMS and 26 control participants. Statistically significant increases in post-training scores (maximum = 30) were detected in AIMS, but not in control, participants (median, 21.3 [IQR, 19.8-24.8] vs 18.8 [IQR, 16.9-20.9]; P < .001). Elements (maximum score = 6) with significant increases were Inquire (0.67 [IQR, 0-1.76] vs -0.33 [IQR, -0.67 to 0.33]; P < .001); Mirror (1.33 [IQR, 0 to 2] vs -0.33 [IQR, -0.92 to 0]; P < .001) and Secure (0.33 [IQR, 0 to 1.67] vs -0.17 [IQR, -0.67 to 0.33]; P = .017). Self-confidence increased equally in both groups. Standardized patients did not detect a difference in communication skills after training and between groups. Internal consistency and inter-rater reliability of the assessment tool were modest. CONCLUSIONS: Standardized patients proved useful in studying the effectiveness of structured communication training, but may have been limited in their ability to perceive a difference between groups owing to the predetermined encounter outcome of vaccine refusal. AIMS training should be studied in real-world scenarios to determine if it impacts vaccine acceptance.

Epistemic Peerhood as a Model To Improve Gender-Affirming Care in Medical Education.

Issue: Inadequate training around gender-affirming care is a critical gap in health care and medical education that causes disparities and leads to injury for transgender, nonbinary, and other gender-diverse patients. In contrast to this widespread provider knowledge gap, gender-diverse patients bring critical knowledge from their own experiences to health care. Embracing varied epistemologies, or sources of knowledge, within medical education has the potential to enhance gender-affirming care by intentionally placing value on the lived experiences and emphasizing the credibility of gender-diverse patients. Evidence: In this article, the authors endorse a model of epistemic peerhood in which the embodied knowledge of gender-diverse patients and the authoritative knowledge of providers are each valued for their contribution to care. The authors reflect on experiences developing gender-affirming healthcare curricula and how medical education has not yet adequately addressed gender-diverse care without embracing community knowledge. Implications: The authors identify three vital areas to integrate epistemic peerhood in medical training to address gaps in gender-affirming care: (1) collaborative student training methods that reflect embodied knowledge in the absence of, or in addition to, clinical expertise on gender-affirming care; (2) sustainable partnerships between academic programs and gender-diverse communities that foster continuous engagement from collaborators with lived experience; and (3) broad community input about best practices for representing gender diversity in patient simulation. Embracing epistemic peerhood in each of these areas would result in broader gender-diverse community representation and leadership in medical education, which would ultimately strengthen gender-affirming healthcare training.

Perspectives of Transgender and Genderqueer Standardized Patients.

Phenomenon: Disparities in health and healthcare for gender minorities (GMs) such as transgender people are significant, and medical educators have a responsibility to ensure trainees master the clinical skills required to provide them with quality care. We implemented a standardized patient (SP) scenario designed to measure students' ability to provide gender-affirming care and sought to understand the experiences and perceptions of the GMs who served as SPs in this case. Our key research question was: how do GM SPs describe the experience of serving as an SP on a gender-affirming care clinical case? Approach: Semi-structured focus groups were conducted with GM SPs (n = 10) to understand their experiences and gauge their perceptions of portraying a patient seeking gender-affirming care. The patient they portrayed matched their own gender identity. Focus groups were transcribed verbatim and analyzed using inductive thematic analysis. Findings: We developed three primary themes in our analysis: personal connection, gap identification, and insight into medical education. The SPs reported a personal connection to this case, enabling them to give nuanced feedback, confront bias they encountered, and foster connection to their broader community. They were able to identify specific gaps related to communication skills, assumptions, and knowledge about gender identity and gender-affirming care. They gained valuable insight into medical education such as the complexity of learning clinical skills and roadblocks to inclusive simulation. Insights: By sharing the perspectives of GMs in patient simulation, this study demonstrates that GMs can also benefit from engagement with medical education, as the SPs in our study described hope, empowerment, and engagement as positive aspects of participation. This study also shows that GMs' lived experiences seeking medical care were instrumental in their ability to note gaps, which provides valuable insight for other institutions attempting to improve students' GM clinical skills. Further, GM SPs' perspectives are valuable to provide a rationale and guidance to other schools implementing gender-affirming education. Efforts to create and implement gender-affirming care curriculum should include GMs in order to build partnerships and prioritize the voices and agency of GMs.

Compassionate Options for Pediatric EMS (COPE): Addressing Communication Skills.

INTRODUCTION: Each year, 16,000 children suffer cardiopulmonary arrest, and in one urban study, 2% of pediatric EMS calls were attributed to pediatric arrests. This indicates a need for enhanced educational options for prehospital providers that address how to communicate to families in these difficult situations. In response, our team developed a cellular phone digital application (app) designed to assist EMS providers in self-debriefing these events, thereby improving their communication skills. The goal of this study was to pilot the app using a simulation-based investigative methodology. METHODS: Video and didactic app content was generated using themes developed from a series of EMS focus groups and evaluated using volunteer EMS providers assessed during two identical nonaccidental trauma simulations. Intervention groups interacted with the app as a team between assessments, and control groups debriefed during that period as they normally would. Communication performance and gap analyses were measured using the Gap-Kalamazoo Consensus Statement Assessment Form. RESULTS: A total of 148 subjects divided into 38 subject groups (18 intervention groups and 20 control groups) were assessed. Comparison of initial intervention group and control group scores showed no statistically significant difference in performance (2.9/5 vs. 3.0/5; p = 0.33). Comparisons made during the second assessment revealed a statistically significant improvement in the intervention group scores, with a moderate to large effect size (3.1/5 control vs. 4.0/5 intervention; p < 0.001, r = 0.69, absolute value). Gap analysis data showed a similar pattern, with gaps of -0.6 and -0.5 (values suggesting team self-over-appraisal of communication abilities) present in both control and intervention groups (p = 0.515) at the initial assessment. This gap persisted in the control group at the time of the second assessment (-0.8), but was significantly reduced (0.04) in the intervention group (p = 0.013, r = 0.41, absolute value). CONCLUSION: These results suggest that an EMS-centric app containing guiding information regarding compassionate communication skills can be effectively used by EMS providers to self-debrief after difficult events in the absence of a live facilitator, significantly altering their near-term communication patterns. Gap analysis data further imply that engaging with the app in a group context positively impacts the accuracy of each team's self-perception.

Standardized patients in audiology: a proposal for a new method of evaluating clinical competence.

BACKGROUND: While accrediting organizations require AuD programs to provide evidence that their students are able to demonstrate knowledge and competencies in specific content areas, there are no generally accepted mechanisms for the assessment and the measurement of these proficiencies. We propose that AuD programs consider developing standardized patient (SP) cases in order to develop consistent summative assessment programs within and across universities. PURPOSE: The purpose of this article is to provide a framework for establishing SP programs to evaluate competencies in AuD students by detailing the history of SP cases and their use, developing a rationale for this method of assessment, and outlining the steps for writing and implementing SP cases. RESEARCH DESIGN: Literature review. RESULTS: SPs have been used to assess clinical competence in medical students for over 50 yr. The prevalence of SP assessment in allied health professions (e.g., dentistry, psychology, pharmacy) has increased over the last two decades but has only gained a limited following in audiology. SP assessment has been implemented in medical education using the Objective Structured Clinical Examination, a multistation, timed exam that uses fictional cases to assess students' clinical abilities. To date, only one published report has been completed that evaluates the use of SPs to assess clinical abilities in audiology students. This article expands upon the work of English et al (2007) and their efforts to use SPs to evaluate counseling abilities. To this end, we describe the steps necessary to write a case, procedures to determine performance requirements, and the need to develop remediation plans. As an example, we include a case that we have developed in order to evaluate vestibular assessment and patient communication skills. CONCLUSIONS: Utilizing SP assessment in audiology education would provide useful means to evaluate competence in a uniform way. Future research is necessary to develop reliable and valid cases that may be implemented across programs. This article aims to serve as a call to audiology programs to begin developing and reporting these cases. Once these are established we can begin to use SP cases for summative assessment.

Gender-Affirming Care With Transgender and Genderqueer Patients: A Standardized Patient Case.

Introduction: Transgender and gender-diverse (TGD) patients experience health disparities and bias in health care settings. To improve care for TGD patients, medical trainees can practice gender-affirming care skills such as inclusive communication and discussing hormone therapy through patient simulation. Systematically evaluating these simulation outcomes also helps educators improve training on gender-affirming care. Methods: A standardized patient case with a patient establishing primary care was developed for rising third-year medical students. The case featured multiple patient iterations to portray individuals with the same health history but a different gender identity and/or sex assigned at birth. Each student was randomly assigned to one patient encounter. Gender-affirming care skills were assessed through standardized patient checklists, postencounter notes, and preventive care recommendations. Results: Over 2 years, 286 students participated in the simulation. Transgender men and women, cisgender men and women, and genderqueer patients were portrayed. Performance gaps such as misgendering patients and incorrect cancer screening recommendations based on perceived gender identity (rather than sex assigned at birth) were documented. Ninety-eight percent of students agreed that the encounter helped them practice clinical skills needed to see actual patients, and students described the case as challenging but important. Discussion: This case served dual roles for medical training: (1) Students working with TGD patients practiced skills for gender-affirming care, and (2) portraying TGD patients along with cisgender patients allowed educators to identify biased recommendations that necessitated additional training. The outcomes further highlighted the importance of students routinely practicing gender-inclusive communication with all patients during simulation.

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants.

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs. The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Gender Minorities in Simulation: A Mixed Methods Study of Medical School Standardized Patient Programs in the United States and Canada.

PURPOSE: A provider's ability to translate knowledge about transgender health to affirming patient care is key to addressing disparities. However, standardized patient (SP) programs have little published guidance for gender-affirming care or addressing disparities experienced by transgender and nonbinary patients. METHOD: Between 2018 and 2019, we invited all 208 accredited US and Canadian medical schools to participate in a study to determine how gender minorities are represented in SP encounters. Responding programs (n = 59, response rate = 28%) that represented patients with diverse gender identities were invited to complete semistructured interviews about SP case content, impact, and barriers to this work. Discussions were analyzed using a modified grounded theory method. RESULTS: Fifty nine of 208 eligible programs (response rate = 28.3%) completed our survey and 24 completed interviews. More than half of programs used gender minority SPs (n = 35, 59.3%). More than half of the programs also reported portraying gender minority cases (n = 31, 52.5%). Interviewees described how effective SP simulation required purposeful case development, engaging subject matter experts with lived experience, and ensuring psychological safety of gender minority SPs. Barriers included recruitment, fear of disrespecting gender minority communities, and transphobia. Engaging gender minorities throughout case development, training, and implementation of SP encounters was perceived to reduce bias and stereotyping, but respondents unanimously desired guidance on best practices on SP methodology regarding gender identity. CONCLUSIONS: Many programs have established or are developing SP activities that portray gender minority patients. Effective SP simulation hinges on authenticity, but the decisions around case development and casting vary. Specifically, programs lack consensus about who should portray gender minority patients. This research suggests that input from gender minority communities both to inform best practices at the macro level and in an ongoing advisory capacity at the program level will be essential to teach gender-affirming care.

Medical education and human trafficking: using simulation.

Healthcare providers have the potential to play a crucial role in human trafficking prevention, identification, and intervention. However, trafficked patients are often unidentified due to lack of education and preparation available to healthcare professionals at all levels of training and practice. To increase victim identification in healthcare settings, providers need to be educated about the issue of trafficking and its clinical presentations in an interactive format that maximizes learning and ultimately patient-centered outcomes. In 2014, University of Louisville School of Medicine created a simulation-based medical education (SBME) curriculum to prepare students to recognize victims and intervene on their behalf. The authors share the factors that influenced the session's development and incorporation into an already full third year medical curriculum and outline the development process. The process included a needs assessment for the education intervention, development of objectives and corresponding assessment, implementation of the curriculum, and finally the next steps of the module as it develops further. Additional alternatives are provided for other medical educators seeking to implement similar modules at their home institution. It is our hope that the description of this process will help others to create similar interactive educational programs and ultimately help trafficking survivors receive the care they need. ABBREVIATIONS: HCP: Healthcare professional; M-SIGHT: Medical student instruction in global human trafficking; SBME: Simulation-based medical education; SP: Standardized patient; TIC: Trauma-informed care.

Taking Up the Mantle of Human Trafficking Education: Who Should Be Responsible?

Human trafficking is a global human rights issue with long-range health consequences about which physicians are largely uneducated. Medical schools are uniquely positioned to address this gap. All future physicians, regardless of specialty, must learn to identify victims and refer them to trauma-informed treatment. Research and advocacy are needed to address the lack of rigorously evaluated curricula in this area, impact policy, and improve services for victims of this heinous form of exploitation.

The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP).

In this paper, we define the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) for those working with human role players who interact with learners in a wide range of experiential learning and assessment contexts. These human role players are variously described by such terms as standardized/simulated patients or simulated participants (SP or SPs). ASPE is a global organization whose mission is to share advances in SP-based pedagogy, assessment, research, and scholarship as well as support the professional development of its members. The SOBP are intended to be used in conjunction with the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: SimulationSM, which address broader simulation practices. We begin by providing a rationale for the creation of the ASPE SOBP, noting that with the increasing use of simulation in healthcare training, it is incumbent on ASPE to establish SOBP that ensure the growth, integrity, and safe application of SP-based educational endeavors. We then describe the three and a half year process through which these standards were developed by a consensus of international experts in the field. Key terms used throughout the document are defined. Five underlying values inform the SOBP: safety, quality, professionalism, accountability, and collaboration. Finally, we describe five domains of best practice: safe work environment; case development; SP training for role portrayal, feedback, and completion of assessment instruments; program management; and professional development. Each domain is divided into principles with accompanying key practices that provide clear and practical guidelines for achieving desired outcomes and creating simulations that are safe for all stakeholders. Failure to follow the ASPE SOBP could compromise the safety of participants and the effectiveness of a simulation session. Care has been taken to make these guidelines precise yet flexible enough to address the diversity of varying contexts of SP practice. As a living document, these SOBP will be reviewed and modified periodically under the direction of the ASPE Standards of Practice Committee as SP methodology grows and adapts to evolving simulation practices.

The Longitudinal Standardized Patient Project: innovation from necessity.

PROBLEM: Constraints on time and resources prevented first- and second-year medical students from having sufficient time to complete required tasks in standardized patient (SP) communication skills training sessions, and to appreciate the SP character as a "person." Case believability was limited by having each individual SP portray multiple patients in different encounters. APPROACH: In 2010, a series of nine longitudinal SP cases was developed, in which the same SP would portray the same patient with the same student across 19 SP encounters during the two-year preclinical Introduction to Clinical Medicine course at the University of Louisville School of Medicine. Each SP character had a unique health history and illness trajectory that matched the history-taking and communication skill content in the course. OUTCOMES: Students had more time to focus on the communication skill topic for each SP session because they did not need to spend as much time learning about the individual patient and the patient's previous medical history. Students learned more about continuity of care, and documented their progress notes in a longitudinal patient chart. SPs were able to identify performance issues with their continuity students more readily than if they had been seeing students for the first time. NEXT STEPS: Additional case content has been developed as new SPs participate in the program, including versions of some patient cases to represent both genders. Specific outcomes measures need to be developed and researched to assess the overall impact of this program.