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GILBERT ET AL
ment of physician competencies. A systematic review found
that use of such evaluations by an adequate number of colleagues,
coworkers, and patients were highly reliable, valid,
and feasible. 28 Many competencies can be evaluated using
multisource evaluations. For example, trainees can be assessed
on their milestones, inpatient care, and communication
skills by a wide array of members of the health care team,
including peers, ward and clinic nurses, pharmacists, social
workers, administrative workers, and by their patients. In addition,
these evaluations may also reflect the competencies of
professionalism and systems-based practice. Program coordinators
can assess professionalism and communication
skills.
Unprofessional behavior may be identifıed by 360-degree
evaluations as trainees are unlikely to exhibit this behavior in
the presence of a supervising physician. Interestingly, in a
study of multisource evaluation of physicians’ professionalism,
ratings by peers, coworkers, and patients were highly
correlated, but did not correlate with self-evaluations. 29 One
example of a 360-degree assessment based on the ACGME
core competencies is the B-29. It is a validated instrument
for identifying unprofessional behaviors and can be used
as a feedback tool for physicians to improve behaviors. 30
Like the previously cited study, reliability of multisource
ratings depended on an adequate number and type of evaluations.
TEACHING STRATEGIES
Simulation/Standardized Patient Experience
The standardized patient (SP) or patient simulation is an individual
trained to act as a real patient in order to simulate a
set of symptoms or problems. Standardized patients present
a high-fıdelity simulation of a real clinical situation. 31 They
also provide a standardized presentation of the same patient
problem from examinee to examinee in assessment settings.
31 Prior studies of medical students have demonstrated
that although real patients are the preferred method for medical
students to learn communication skills, experiential
techniques such as simulated patients, videotaped interviews,
and instructor feedback are more effective than didactic sessions
for teaching communication skills. 32 Simulation allows
participants to experience the patient in a variety of roles and
as often as required in a nonthreatening environment. 33 Despite
prior studies indicating anxiety and skepticism associated
with performing in front of peers, the feedback on
performance skills provided by facilitators, peers, and patient
actors broadens the experience for participants and, thus,
could increase the learning experience. Back et al have shown
that using patient actors does not require that the learners are
skilled at acting, but rather enables trainees to learn in their
usual role as physicians and introduces them to the value of
simulated patients for refıning communication skills. 34
Moreover, the use of SPs compared with real patients avoids
the ethical conundrums of using real patients and ensures
each trainee has the same experience. 35
Let’s return to the milestone mentioned previously: Responds
to each patient’s unique characteristics and needs.
Although the faculty member might globally note that a
trainee is professional, has the evaluator actually witnessed
the trainee communicating with the patient in a culturally
competent manner and is the trainee able to involve the patient
in his or her own care? Although this may occur in the
course of clinic or ward duties, it is recognized that such opportunity
may not regularly occur. Educators could use simulation/standardization
training to inform this milestone in a
structured encounter where the trainee discusses end-of-life
issues with a patient from a different ethnic or socioeconomic
backgrounds. Although this may occur in the course of training,
this structured activity allows trained evaluators to observe
these behaviors, and provide direct feedback (from
both patient and evaluator) immediately at the point of interaction.
Examples of such SP/simulation examples to teach
this skill can be seen in Table 3.
Trainees would rotate through each example in a half-day
session devoted to development of these communication
skills. On a resource level, several items will be required including
space, funding, faculty who are trained and willing to
develop scripts for SP, training for the SP, faculty trained in
communication skills and observation to observe and provide
direct feedback (ideally several faculty members), and
faculty and trainee time to perform these activities. The
ACGME now mandates all programs to participate in training
using simulation. Thus, the onus remains on the medical
educator to plan and perform activities that meet the needs of
the learners at each institution.
TABLE 3. Proposed Standardized Patient Simulations
to Evaluate Cultural Competencies
Each trainee would rotate through each scenario below:
Standardized
Patient 1:
Standardized
Patient 2:
Standardized
Patient 3:
The patient is an African American woman age 85.
She is computer illiterate and very involved with
her church. She is able to read at an 8th-grade
level. She always comes to clinic with a daughter
and granddaughter. She has been unable to
tolerate previous chemotherapy for her metastatic
breast cancer and has already had three regimens
for metastatic disease. Discuss best treatment
options.
The patient is a Latino man, age 48, who is a recent
immigrant. He does not speak or read English. He
works in the construction industry. He is a smoker.
He is now diagnosed with metastatic pancreatic
cancer. He does not have family in this country. He
does not have insurance. He has lost 30 lbs in the
past 6 months and his performance status is 3.
Discuss best treatment options.
The patient is a Caucasian woman, age 32, from a
rural community that is 60 miles from your medical
center. She reads on a 4th-grade level. She can
play games on the computer. She has three small
children. She is married. She is unable to work. The
annual household income is less than $15,000. She
now has recurrent and refractory acute myeloid
leukemia, but is eligible for a clinical trial. Discuss
her options.
36 2015 ASCO EDUCATIONAL BOOK | asco.org/edbook