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The authors describe their recent experience in using a standardized patient (SP) to illustrate the mental status examination (MSE) to 170 second-year medical students in a large classroom setting. An SP was trained to portray a patient with schizophrenia who was interviewed during the MSE lecture. A six-question survey was distributed to the students to evaluate how the students felt about the learning experience. Results show that the majority of students felt that using an SP in a large classroom setting helped them to understand the material better and was a useful teaching tool. Follow-up studies are under way to objectively measure students' integration and retention of the lecture material.
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Brief Report
The authors describe their recent experience in using a standardized patient (SP) to illustrate the mental status examination (MSE) to 170 second-year medical students in a large classroom setting. An SP was trained to portray a patient with schizophrenia who was interviewed during the MSE lecture. A six-question survey was distributed to the students to evaluate how the students felt about the learning experience. Results show that the majority of students felt that using an SP in a large classroom setting helped them to understand the material better and was a useful teaching tool. Follow-up studies are under way to objectively measure students' integration and retention of the lecture material.
(Academic Psychiatry 2002; 26:180-183)
The mental status examination (MSE), often considered the psychiatric equivalent of the physical examination, is one of the psychiatrist's most important tools. It is often introduced to medical students in the preclinical years and taught in the traditional large classroom setting. Frequently the information is presented in a dry, unexciting manner, listing many complicated technical terms. At Northwestern University, Medical, The Feinberg School of Medicine, a lecture was the standard method of teaching the MSE to the second- year class of 170 medical students. The lecture is a component of the course "Scientific Basis of Medicine" (SBM), given as a series of lectures organized according to organ systems.
The course was modified in April 2001 to include a standardized patient (SP) to allow the students to have a more realistic illustration of the MSE. We hypothesized that using an SP as an educational adjunct would result in a more creative, meaningful educational experience.
A standardized patient is an individual who is trained to portray a patient with a specific condition or illness. During the simulated medical encounter, the SP's history is elicited in a realistic and consistent manner. SPs have been used in medical education since the 1960s, typically in small group or one-onone settings (1-8). However, use of an SP in a live simulation in front of a large group of students has not been well documented in the literature. A review of the literature found two studies employing this method, which showed it to be an effective teaching tool (9,10). This paper describes our recent experience using an SP to teach the MSE in a large group classroom setting and illustrates the potential benefits of using this novel teaching technique. The goal was to improve the students' understanding of the concepts and stimulate a more dynamic discussion for the remainder of the 90-minute lecture.
METHODS
The Clinical Education and Evaluation Center (CEEC) at Northwestern University, The Feinberg School of Medicine, is a facility where standardized patients are used to assist in learning and evaluation of clinical skills among health care professionals. The Assistant Director of the Clinical Education and Evaluation Center (M.E.K.) was contacted by the attending psychiatrist (C.A.B.) to determine the feasibility of using an SP for an MSE demonstration. An SP who recently had been trained to portray a schizophrenic patient agreed to assume this role before the entire second-year class. The SP's training for this lecture was done by the attending psychiatrist (also the lecturer). It consisted of only two additional one-hour training sessions, since the SP was already well prepared to portray this type of patient. The training included helping the SP focus on specific areas of the MSE, such as disorganized thinking and auditory hallucinations.
The SP came to class unshaven, disheveled, and dressed in clothes inappropriate to the season, all typical characteristics of a patient suffering from schizophrenia. The SP was instructed to sit in the front row near the lecturer. After a 20-minute introduction to the terminology of the MSE, all students watched the course lecturer conduct a 20-minute interview with the SP, who accurately portrayed a schizophrenic patient. Although the students were not initially told that the patient was an actor, they were informed immediately after the interview. By not revealing the patient's identity, the lecturer hoped to create a more realistic perception of an actual patient. Also, it was thought that the students would take the educational experience more seriously if they believed the actor to be an actual patient.
A six-question survey was developed to evaluate how the students felt about this learning experience. When the same class met again for another large group lecture, the authors reminded the students of the SP experience and asked that they complete a brief, anonymous survey. The surveys were completed immediately upon distribution and were collected and tabulated.
RESULTS
One hundred and sixteen students out of 140 attendees (82.9%) returned the survey. The survey questions had five response options, ranging from Strongly Disagree to Strongly Agree, with a Neutral option in the middle. Table 1 shows the distribution of responses.
Overall, the students felt positive about using an SP to demonstrate the MSE examination during a large group lecture. The great majority of students agreed or strongly agreed that using an SP to demonstrate the MSE was a useful teaching tool (93.9%) and helped them to understand the material better (89.5%). Regarding the patient portrayal, 75% of the students had believed the SP to be an actual patient, but more than half (59.1%) had felt uncomfortable with the idea that a real patient was being used in a large group lecture setting. On the other hand, about ninety percent felt that the SP was a good alternative to using a real patient (87.8%) and would find it useful to use SPs again in large group lecture settings (90.4%).
DISCUSSION
This teaching technique introduced a shift from the conventional lecture format to a more creative approach, and it seemed to contribute to the interactive discussion with students following the SP demonstration. A large number of students voluntarily participated in this lively discussion, with questions and comments illustrating their integration of the new material. We believe that the level of enthusiasm in the classroom reflected the students' excitement about the material being taught in an innovative fashion.
Although actual patients are often used in academic teaching settings such as hospitals, outpatient offices, and clinics, a large classroom lecture hall did not seem an appropriate venue. Using a real patient in a formal, arranged setting may cause distress or embarrassment to the patient (11). A psychotic patient, for example, may feel paranoid and therefore may not want, or be able, to speak in front of a large audience. In addition, real patients may have unpredictable behavior and not demonstrate all the manifestations and symptoms that would provide students with the most comprehensive illustration.
In this study, the SP's identity was initially and deliberately withheld from the students to create a more realistic patient interview. However, over onehalf of the students reported feeling uncomfortable with the idea that a real patient was being used. Creating such a learning environment during a lecture is not a desirous outcome. In addition, using an "unannounced" SP could raise ethical issues.
In retrospect, it seems unnecessary to withhold the SP's identity, since the literature supports the notion that SP portrayals of patients are realistic and not easily differentiated from the presentations of real patients (1,12-15). Moreover, our survey indicated that the majority of the students had positive feelings about using an SP for MSE demonstration as an alternative to a real patient.
A limitation of the study was that the only measure of the students' understanding of the material was their self-perceived assessment. Students were not objectively evaluated on their knowledge before and after the lecture. At the time of this writing, a research study that objectively measures student knowledge of the MSE before, immediately after, and one week after the lecture has been completed, with analysis pending. The data might help to elucidate whether this type of lecture makes a difference in the integration and retention of the lecture material. In addition, a follow-up study is being developed to compare two groups of students, one receiving the lecture with the SP and one without (wait-list control group). This study should help to quantify whether there is a difference in knowledge gained between the two groups because of the added illustration.
These results support our hypothesis that using an SP to demonstrate an MSE in a large group setting is a useful teaching technique, creating a dynamic and interesting learning experience. It also helped students feel that they understood the material better. Expanding the use of an SP into a large group setting proved feasible and beneficial. The integration of an SP into other large group teaching settings has potential across many disciplines and warrants further investigation.
This work was previously presented at the American Academy on Physician and Patient Research and Teaching Forum, Linthicum, MD, March 7-9, 2002.
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Catherine A. Birndorf, M.D.
Marsha E. Kaye, R.N., M.S.N.
Dr. Birndorf is Clinical Instructor in the Department of Psychiatry and Behavioral Sciences and Ms. Kaye is Assistant Director of the Clinical Education and Evaluation Center of the Office of Medical Education and Faculty Development, Northwestern University, The Feinberg School of Medicine, Chicago, IL. Address correspondence to Marsha E. Kaye, Northwestern University, The Feinberg School of Medicine, Clinical Education and Evaluation Center of the Office of Medical Education and Faculty Development, 710 North Lake Shore Drive, Mailbox 22, Chicago, IL 60611-3078. E-mail: [email protected].
Copyright American Psychiatric Press, Inc. Fall 2002