DENISE/DENNIS JONES STANDARDIZED PATIENT

Ayesha Siddiqua, MD

Josephine Albritton, MD

Denise Noseworthy, Certified Peer Specialist (CPS)

Adriana Foster, MD

Standardized Patient Case Materials as Educational Scholarship

Purpose of materials: Why was the case developed?

Encounters with simulated patients, followed by feedback,are an important tool to transfer communication skills from classroom to clinical environment [1]. A standardized patient (SP) intervention in the psychiatry clerkship can be beneficial in enriching medical students’ history taking and suicide risk assessment skills and can raise trainees’ confidence in screening and assessment of patient with suicidal thoughts beyond the level achieved with classroom-type teaching [2]. In addition, seniormedical students believe that suicide risk assessment is one of the most important skills to acquire in medical school and particularly in the psychiatry clerkship [3]. We developed the SP “DENISE/DENNIS Jones” to address these concerns.

Description of development process: including how and by whom: Who developed the case and related materials? What steps were taken in the development process?

The SP case was written by one of the authors, a psychiatrist with extensive experience in treating people with bipolar disorder and a peer support specialist who introduced elements of her own experience in the scenario. To create the scenario, we went through the following steps:

  1. We created the learning objectives;
  2. We drafted the case;
  3. The peer specialist and the psychiatrist acted the scenario as a patient and respectively interviewer, to assess its fluidity and time requirements; the scenario was then edited to fit a short, 15 min interaction, to fit within the time constraints of a USMLE –style examination.
  4. The scenario was further edited and the SP instructions were further detailed after testing by experienced standardized patients (SPs) from the Clinical Skills Center of a large university.

Information pertaining to how the materials have been used: In what way has the case been used (for training, assessment, both)?

The SP case was used in a research study to test suicide risk assessment proficiency in 2nd year medical students after they had been exposed to either a virtual patient or a video intervention designed to teach students basic suicide risk assessment [4].The authors believe that any group of 1st or 2nd year medical students who have been exposed to mental health curriculum (lecture, problem-based , team-based or other type of case-based learning) may benefit from interacting with our SP for deliberate practice of history taking skills in a patient with a mood disorder and basic suicide risk assessment.

Methods used for training: How have the SPs been trained to portray the case? How have they been trained to evaluate performance and/or provide feedback (if applicable)?

The authors trained senior SPs(already experienced in portraying various roles and completing symptom and communication checklists in the clinical skills center) to portray DENISE/DENNIS Jones’ role. The SPs were trained and tested by the team psychiatrists (AF and JA) and clinical skills staff center prior to portraying DENISE/DENNIS in the study as follows:

  1. The scenario was provided prior to the initial meeting with the authors;the clinical skills center team and the SPs were asked to familiarize themselves with the scenario.
  2. The authors, the SPs and two experienced staff members went over the scenario, to answer questions and clarify content as needed.
  3. The SPs were then invited to learn the revised scenario and a testing date was established.
  4. Each SP was then tested in a 15 minute interaction by a team physician and separately, by a psychiatrist who did not belong to the research team, while Clinical Skills Center staff watched the interactions and took notes. The SPs completed the checklists for the test interactions
  5. Each SP met with the center staffand research team separately, watched the videotaped interactionsand incorporated suggestions. The checklists were reviewed during the same meetings.

Data to support the content of the materials. Was research literature referenced when developing the case? Were content experts engaged in the development process?

An academic psychiatrist with 20 years of experience in treating people mental illness with special interest in bipolar disorder and a certified peer support specialist created the scenario. The symptoms of manic and depressive episode as outlined in DSM IV TR [5] were used to guide the checklist. Existing practice guidelines [6]and communication objectives for various levels of training [7, 8] were used to guide the case as well.A similar case published on MedEdPORTAL was also consulted in the development process [9]. Our case adds to the published SP pool in several ways: 1) while our SP shows inflated self-esteem and expansive mood, she/he does not emphasize grandiosity and lacks delusional content leading to the recognition of more subtle symptoms of mania; 2) by emphasizing the history of depressed episodes (a significant contributor to disability in bipolar disorder), we bring up the need to perform a basic suicide risk assessment in each patient with bipolar disorder.

Data to support the reliability of any related checklists or rating scales: What data is available to support the inter-rater agreement or internal consistency or generalizability of the materials?

At the end of each SP-student interaction, the SPs completed a 25-item checklist, each of them rated as yes or no. The checklist items consisted in symptoms of a manic episode: including mood—elevated, irritable or depressed - in the past; inflated self-esteem or grandiosity, decreased need for sleep; rapid, pressured speech; flight of ideas or racing thoughts; distractibility; increase in goal directed activity; excessive involvement in pleasurable activities with painful consequences; delusions and/or hallucinations, depressive symptoms, episode duration, medical, alcohol and drug history [5]. The checklist also included questions related to suicide risk: (1) current thoughts of suicide, (2) suicide plan and intent, (3) access to suicide means, (4) past suicide thoughts and attempt, and (5) family history of suicide and mental illness as well as thoughts of hurting others. For some items, the SP had more than one response option to the same inquiry, thus there are more items on the SP checklist than the items listed in Table 1. For the five suicide items in the SP survey Cronbach’s alpha was 0.7722. To assess their subjective experience with student’s interview, each SP completed a “Communication Checklist” which contains 7 items rating the medical students’ professional appearance, behavior, empathy, and rapport, with each item rated as “Agree” or “Disagree.” For the Communication Checklist items in the Bipolar SP survey the Cronbach’s alpha was 0.9698. Since the symptoms of bipolar disorder were adopted without modification from existing manuals [5], we did not measure internal consistency in those items.

Data to support the accuracy of case portrayal: Are any methods recommended for ensuring accuracy of case portrayal?

The standardized patients who played the role have utilized several strategies to covey the patient’s elevated mood, distractibility and flight of ideas:

  • Paying attention to an object in the exam room and speaking about it, regardless of the interview question;
  • Wearing clothing or jewelry items (for example mismatched earrings) that invite inquiry from the interviewer and thus give the SP an opportunity to display rapid, pressured speech while talking about the respective item.

Any other relevant data from trial or actual use of materials?

The SP interaction occurred during the 2nd year Central Nervous System integrated module, which included lectures and team-based learning activities on topics of psychopathology, taught along with neurology, pharmacology and pathology. Lectures about mood disorders and suicide were included in this module. Prior to the SP interaction, students were exposed to either a virtual patient or a video intervention designed to teach basic suicide risk assessment. Then, student were instructed to interview the SP after reading the information provided in the door note, for no more than 15 minutes. A 5 minute warning was given to students before the interaction ended. In our study, students were not asked to write-up the encounter. The assessment was not graded because only students who volunteered to participate in the study interacted with the SP. The study was advertised by mass emails and classroom announcements according with Institutional Review Board approval. Students who volunteered for the study were informed that the study participation had no impact on their grade.

In Table 1 below we describe the data onhistory taking, suicide risk assessment for our sample of 67 second-year medical students.For some items, the SP had more than one response option to the same inquiry, thus there are more items on the SP checklist than the items listed in Table 1.

Table 1. Number and percentage of students who elicited checklist items for the bipolar SP (N = 67 second year medical students)
Variable / Level / Overall
Trouble Sleeping – n, % / No / 0 (0.0)
Yes / 66 (100.0)
Elevated Mood – n, % / No / 0 (0.0)
Yes / 66 (100.0)
Grandiosity – n, % / No / 18 (26.9)
Yes / 49 (73.1)
Irritable Mood – n, % / No / 24 (35.8)
Yes / 43 (64.2)
Depressive Symptoms – n, % / No / 6 (9.0)
Yes / 61 (91.0)
Duration – n, % / No / 4 (6.0)
Yes / 63 (94.0)
Speech – n, % / No / 14 (20.9)
Yes / 53 (79.1)
Distractibility –n, % / No / 14 (20.9)
Yes / 53 (79.1)
Flight of Ideas – n, % / No / 23 (34.3)
Yes / 44 (65.7)
Goal Behavior – n, % / No / 14 (21.2)
Yes / 52 (78.8)
Excessive Behavior – n, % / No / 7 (10.5)
Yes / 60 (89.5)
Delusions, n, % / No / 22 (32.8)
Yes / 45 (67.2)
Alcohol – n, % / No / 42 (62.7)
Yes / 25 (37.3)
Medical Conditions – n, % / No / 27 (40.9)
Yes / 39 (59.1)
Suicidal– n, % / No / 12 (17.9)
Yes / 55 (82.1)
Suicidal Thoughts– n, % / No / 12 (17.9)
Yes / 55 (82.1)
Suicidal Means– n, % / No / 57 (86.4)
Yes / 9 (13.6)
Past Suicide Attempts– n, % / No / 21 (31.3)
Yes / 46 (68.7)
Family History of Suicide– n, % / No / 40 (60.6)
Yes / 26 (39.4)

General suggestions for using the materials: What have you learned from using the case?

The second-year medical students informally reported that while they were able to elicit the mood symptoms, the interview was difficult because they felt uncomfortable interrupting the patient, due to her pressured speech, and at times could not follow her thoughts. They suggested that interviews with people with mental illness be introduced earlier in their training, perhaps as early as the first semester of medical school. Some students also mentioned that it was difficult to ask questions about alcohol and drug use and questions about suicide risk, even though they viewed a video of an interview with a patient with bipolar disorder which modeled such questions or had the opportunity to practice those questions in an interaction with the virtual patient. Overall the students appreciated the learning experience provided by the interaction with the SP Denise Jones (no male SP was used in our educational study,however the SP allows the use of a male character as it will be detailed in the faculty and SP materials).

The SP training to portray at patient with mania was challenging. The SPs who portrayed the patient had acting experience outside their extensive work in the Clinical Skills Center, viewed video clips of actors portraying mania and developed own strategies to help them display elevated mood, distractibility and flight of ideas as described above. Despite of using these techniques, the SPs noted “acting fatigue’ after 3-4 student interactions. We thus spaced out the SP interactions to adjust to this phenomenon.

Providing more than one response option to the same symptom inquiry, although it raised the number of items on the checklist to 25, per SP report, it helped them to recall with more accuracy whether the student asked about the items in questions.

While we used a short communication checklist to accompany the symptom checklist in this study, the Clinical Skills Centers may want to add questions or use their own checklist as desired.

The authors encourage faculty to include the early and repetitive use of deliberate practice tools on psychiatric interview and suicide risk in medical school curriculum. Doing so allows medical students to feel familiar and comfortable with mental health topics when they enter clinical rotations. Such gain in skills and change in attitudes can potentially change lives by identifying and referring mental illness for care early and preventing self-harm and suicide.

References:

  1. Brown J. Transferring clinical communication skills from the classroom to the clinical environment: perceptions of a group of medical students in the UK. Acad Med. 2010; 85(6):1052–9.
  2. Fiedorowicz J G, Tate J, Miller A C, et al. A medical interviewing curriculum intervention for medical students’ assessment of suicide risk.Academic Psychiatry 37.6 (2013): 398-401.
  3. Oakley C, Oyebode F. Medical students’ views about an undergraduate curriculum in psychiatry before and after clinical placements.BMC Med Educ. 2008;8:26.
  4. Foster A., Chaudhary N., Murphy J., et al, The Use of Simulation to Teach Suicide Risk Assessment to Health Professions Trainees – Rationale, Methodology and a Proof of Concept Demonstration with a Virtual PatientAcad Psychiatry, July 2014, epub ahead or print, DOI 10.1007/s40596-014-0185-9.
  5. DSM-IV-TR: Diagnostic and statistical manual of mental disorders, text revision. American Psychiatric Association, 2000.
  6. American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal behaviors. Am J Psychiatry, 2003; 160(11).
  7. The Psychiatry Milestone Project, A Joint Initiative of The Accreditation Council for Graduate Medical Education and TheAmerican Board of Psychiatry and Neurology, org/acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf. Retrieved on Dec 30, 2013.
  8. Psychiatry Learning Objectives Taskforce 2007. Clinical learning objectives guide for psychiatry education of medical students.Association of Directors of Medical Student Education in Psychiatry (ADMSEP), retrieved on October 25, 2013.
  9. Goldenberg M, Adamo G, Hamaoka D, McCurry L, Rawn L. Standardized Patient Case: John/Joan Marriot, Acute Mania . MedEdPORTAL Publications; 2011. Available from:

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