Paramedic adult pain assessment: pilot study

Background: An inability to assess pain may lead to poor or incorrect treatment. However, pain is often poorly assessed in the prehospital setting. Objective: This study aimed to determine the inter-rater reliability of the Wong-Baker FACES Pain Rating Scale in the prehospital setting in Qatar with five adult standardised patients. Methods: This prospective, quantitative pilot study gathered primary data using survey questionnaires. Five members of staff played the roles of standardised adult patients presenting with differing reference levels of pain. Thirty-five paramedics assessed and recorded the pain intensity score of these five patients using the Wong-Baker FACES Pain Rating Scale. Each participant was exposed to the same five patients and the same range of facial expressions in a random order. Results: The paramedics recorded the pain score of the five patients based on their observations of their facial expressions, often unexpectedly comparing these to the FACES tool. Overall, the inter-rater reliability as determined through Fleiss' kappa indicated only a poor-to-slight agreement of the allocated pain scores against the reference standards. There was a wide grouping of the pain score levels around the reference standard; most of the allocations were 1 to 2 pain score levels away from the reference standard, although not in a normal distribution, with some of the higher reference pain levels receiving lower scores and vice versa. Sensitivity was poor to very poor throughout. Conclusion: The inter-rater reliability of the participant sample when using the Wong-Baker FACES Pain Rating Scale to determine pain levels of five standardised patients was poor because the tool was surprisingly not used appropriately by most clinicians. This could be attributed to various factors including the multinational population, language barriers, a lack of familiarisation with the Wong-Baker FACES Pain Rating Scale and other environmental factors.

Assessing Clinical Reasoning Ability in Fourth-year Medical Students via an Integrative Group History-taking Workshop With an Individual Reasoning Teaching Programme

Background: The most important factor in evaluating a physician’s competence is strong clinical reasoning ability, leading to correct principal diagnoses. The process of clinical reasoning includes history taking, physical examinations, validating medical records, and determining a final diagnosis. In this study, we designed a teaching programme to evaluate the clinical reasoning competence of fourth-year medical students.Methods: We created five patient scenarios for our standardised patients, including haemoptysis, abdominal pain, fever, anaemia, and chest pain. A group history-taking workshop with individual reasoning principles was implemented to teach and evaluate students’ abilities to take histories, document key information, and arrive at the most likely diagnosis. Residents were trained to act as teachers, and a post-study questionnaire was employed to evaluate the students’ satisfaction with the training programme.Results: A total of 76 students, five teachers, and five standardised patients participated in this clinical reasoning training programme. The average history-taking score was 64%, the average key information number was 7, the average diagnosis number was 1.1, and the average correct diagnosis rate was 38%. Standardised patients presenting with abdominal pain (8.3%) and anaemia (18.2%) had the lowest diagnosis rates. The scenario of anaemia presented the most difficult challenge for students in history taking (3.5/5) and clinical reasoning (3.5/5). The abdominal pain scenario yielded even worse results (history taking: 2.9/5 and clinical reasoning 2.7/5). We found a correlation in the clinical reasoning process between the correct and incorrect most likely diagnosis groups (group history-taking score, p=0.045; key information number, p=0.009 and diagnosis number, p=0.004). The post-study questionnaire results indicated significant satisfaction with the teaching programme (4.7/5) and the quality of teacher feedback (4.9/5).Conclusions: We concluded that the clinical reasoning skills of fourth-year medical students benefited from this training programme, and the lower correction of the most likely diagnosis rate found with abdominal pain, anaemia, and fever might be due to a system-based teaching programme in fourth-year medical students; cross-system remedial reasoning training is recommended for fourth-year medical students in the future.

Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study

IntroductionThe aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia.MethodsStandardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth.ResultsAntibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations.ConclusionThis study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.

Virtual Integrated Patient: An AI supplementary tool for second-year medical students

Introduction: With the COVID-19 pandemic, Singapore underwent a national lockdown in which most organisations, including schools were closed. Halting face-to-face tutorials resulting in decreased clinical contact for medical students. Prior to the pandemic, we had developed the Virtual Integrated Patient (VIP). Equipped with conversational technology, it provides students online practice in various clinical skills such as history-taking, physical examination and investigations. The aim of this paper is to describe the supplementary use of VIP in the second-year class, in which a pilot study was conducted. Methods: The VIP platform was introduced to the cohort and used to supplement the teaching of history-taking in the “Communication with Patients” (CWP) module for second-year students. Traditionally, CWP tutorials involve face-to-face history-taking from standardised patients (SPs). Students, who consented to participating in the trial, had an additional 3 weeks’ access to VIP to practice their history-taking skills. They completed a survey on their user experience and satisfaction at the end of the 3 weeks. Results: Out of the 106 participants, 87% strongly agreed or agreed that using VIP helped in remembering the content while 69% of them felt that VIP increased their confidence and competence in history-taking. Conclusion: VIP was well-received by students and showed promise as a tool to supplement history-taking tutorials, prior to students’ encounter with SPs and real patients. Hence, this trend showed its potential as an alternative when clinical rotations were delayed or cancelled. Further research can be done to evaluate its effectiveness in this context.

Training nurses to perform water swallow test with use of standardised patients

Introduction: During the COVID-19 epidemic in Singapore, there was an urgent demand to train more nurses within a short timeframe to perform the Water Swallow Test (WST). The previous training model involved training with actual patients and was time-consuming. Hence, the model was revamped and standardised patients (SPs) were engaged for nurses’ training. This study further investigated nurses’ feedback about the new training model and compared the efficiency and learner-reported outcomes of the previous and new models. Methods: Nurses who completed WST training from January 2018 to July 2020 were enrolled. Training records were accessed to determine the number of nurses trained under the previous and new models. Nurses were invited to complete post-training evaluation forms and their responses were analysed. Descriptive statistics and the Mann-Whitney U test were used for data analysis. Results: Under the previous model, 52 nurses were trained over 2 years, whereas under the new model, 112 nurses were trained over two months. From the evaluation form responses, the majority of nurses trained under the new model agreed that they achieved the learning objectives and were confident in performing the WST. There was also no significant difference (p>0.05) found between learner-reported outcomes for both training models. Conclusion: Our findings demonstrated that the new model that engaged SPs was more efficient in training more nurses. Nurses were also satisfied with the new training model, which achieved similar learner-reported outcomes as the previous model.

Perspectives of the Asian Standardised Patient

Introduction: Standardised patients (SPs) have been involved in medical education for the past 50 years. Their role has evolved from assisting in history-taking and communication skills to portraying abnormal physical signs and hybrid simulations. This increases exposure of their physical and psychological domains to the learner. Asian SPs who come from more conservative cultures may be inhibited in some respect. This study aims to explore the attitudes and perspectives of Asian SPs with respect to their role and case portrayal. Methods: This was a cohort questionnaire study of SPs involved in a high-stakes assessment activity at a university medical school in Singapore. Results: 66 out of 71 SPs responded. Racial distribution was similar to population norms in Singapore (67% Chinese, 21% Malay, 8% Indian). SPs were very keen to provide feedback to students. A significant number were uncomfortable with portraying mental disorders (26%) or terminal illness (16%) and discussing Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS, 14%) or Sexually Transmitted Diseases (STDs, 14%). SPs were uncomfortable with intimate examinations involving the front of the chest (46%, excluding breast), and even abdominal examination (35%). SPs perceive that they improve quality of teaching and are cost effective. Conclusion: The Asian SPs in our institution see themselves as a valuable tool in medical education. Sensitivity to the cultural background of SPs in case writing and the training process is necessary to ensure that SPs are comfortable with their role. Additional training and graded exposure may be necessary for challenging scenarios and physical examination.

Exploring potential benefits of communication training with standardised patients for medical students

Background: Physicians’ communication skills (CS) are important for improving patient-centred care. The aim of this study was to evaluate simulation training in difficult consultations with actors as standardised patients (SPs) for training CS with medical students, as regards both student satisfaction and effects on CS used. Methods: In this mixed-method study, quantitative data from student evaluations (N = 93) and results from practical examinations (N = 73) were compared between medical students who practiced CS in challenging situations through simulation training with SPs with students from previous term when SPs were not used in the training. The number of CS used during each included video-taped practical examination was counted. Differences in number of CS behaviours (active listening, empathy and motivational efforts) were examined using a MANCOVA. Further, 23 students were interviewed in focus groups about their experiences of simulation training using SPs; interviews were analysed with content analysis. Results: Students who participated in simulation training with SPs were more content with the course. There was no between-group difference in the number of CS used in practical examinations. In the focus groups, students reported that actors as SPs made the simulations more realistic. Elements such as actor flexibility in changing behaviours during roleplay and being exposed to different difficult consultations and emotions were regarded as valuable. Conclusion: Implementing actors as SPs in the medicine programme was appreciated and seemed to add elements to the learning process of CS. No firm conclusions can be drawn regarding the lack of effect of SPs on CS, considering the absence of baseline levels of CS use. Future research should use a randomised control design.

Objectively Structured Clinical Teaching (OSCT) in Undergraduate Clinical Teaching: A Pilot Study

In this study, the efficacy of a clinical teaching tool, objectively structured clinical teaching (OSCT) was assessed by comparing students’ performance in assessing standardised patients (SPs) and real patients (RPs). The final-year students were randomly divided into two arms and their performance in three different disciplines such as medicine, obstetrics and gynaecology (O&G) and primary care medicine (PCM) was assessed with RPs in one arm and SPs/simulated patients in the other. The assessments were conducted in history-taking, clinical examination and management stations by the content experts under a structured rubric. Students’ scores in each arm were compared in the respective disciplines and overall. The perceptions of both students and SPs were recorded. The OSCT and rotational average scores of the participant students in SPs and RPs were compared. The students’ mean scores for their rotational exam and OSCT were 65.31 ± 5.56 and 61.14 ± 8.53, respectively. The performance at the management station in O&G was significantly higher compared with medicine and PCM. The overall performance at all other stations in the three disciplines was comparable, with no significant difference. The reliability and content validity of OSCT was established by calculating Cronbach’s alpha and testing content validity. The results indicated that OSCT is an innovative and effective teaching tool that can be used in clinical teaching in the early clinical years to lower the student load in hospitals in a cost-effective manner.