The use of trained patient instructors for teaching and assessing rheumatologic care

Abstract

The training of professionals in rheumatologic care requires review and study. To improve teaching methods, 6 patients with stable rheumatic disease were trained to evaluate and teach medical students by using themselves as models for musculoskeletal examinations. Checklists for scoring performance and content were developed. Criteria established to give evidence of the validity of the checklists and of the reliability of the patient instructors in their scoring were met or exceeded. The patient instructors are now an integral part of the Preparation for Clinical Medicine curriculum at our institution and serve as resources for evaluation and Address reprint requests to Eric P. Gall, MD, Rheumatology, Allergy & Immunology Section, University of Arizona Health Sciences Center, Tucson, AZ 85724.Submitted for publication August 8, 1983; accepted in revised form December 12. 1983. teaching in the continuing education of practicing professionals.Two recent international workshops on rheumatology manpower and education have focused on the inadequacy of current training in rheumatic diseases (1,2). This problem is highlighted by the fact that 95% of all rheumatologic care is being provided by primary care physicians who have limited knowledge of the musculoskeletal examination (2).An informal record review of general medicine inpatients and outpatients cared for by faculty and house staff at the University of Arizona Health Sciences Center in Tucson was conducted by the authors, and it substantiated these assertions. Although Tucson is a city with a high incidence of arthritis (Warren Benson, Southern Arizona Arthritis Foundation: personal communication), we found that most of the records failed to mention rheumatic diseases in either the history or physical examination. When musculoskeletal abnormalities were noted, they were described in vague or general terms such as "arthritic deformities," rather than by a precise medical definition of the physical findings.In an effort to improve training in rheumatologic diagnosis and care, both in course work for medical students and in continuing education for practicing health professionals, we have developed a patient instructor (PI) program based on the "simulated patients" model originally developed by Barrows and Abrahamson (3). Unlike the simulated patients, who were normal individuals trained to simulate abnormalities, the PIS in our program are real patients who are trained in history-taking and the musculoskeletal examination. 558 GALL ET ALThe simulated patients appear to be adequate models for some medical problems, but not for others. In Barrow's original program, normal individuals trained to simulate abnormal neurologic signs were used to teach neurology students (4) and to test neurology board candidates (3). Nonphysicians have also been used to assess interviewing skills of pediatric students who questioned mothers of newborn infants (5). This procedure was extended by Stillman, Sabers, and Redfield at the University of Arizona. Those investigators trained non...

Positive impact of an intervention by arthritis educators on retention of information, confidence, and examination skills of medical students

“…Moreover, as previously shown (11,12) and as noted here, arthritis educators are well accepted by physicians-in-training. Finally, the results of this study provide evidence that the significant improvement noted after the arthritis educator intervention persists for at least two weeks.…”

“…Thus, face validity and sampling validity for maneuvers specified in the checklist were previously established by peer judgment, and criterion validity was established by consensus of rheumatologists (11). Similarly, reliability of the checklist as administered by the arthritis educators was previously documented (11) and reconfirmed in the current study. Thus, the evaluation of the students appears to be valid and reasonably objective.…”

“…The 85-point musculoskeletal examination checklist has previously been described and validated (11). Thus, face validity and sampling validity for maneuvers specified in the checklist were previously established by peer judgment, and criterion validity was established by consensus of rheumatologists (11).…”

“…Standardized patients have been used to determine the clinical competence of physicians-in-training to address musculoskeletal symptoms (9,lO). In addition, patients with arthritis have been trained to teach the musculoskeletal examination (11). The use of actual patients has been suggested to add the extra value of introducing students to persons with physical abnormalities as well as allowing students to experience the symptoms and impact of arthritis firsthand (11).…”

Research priorities for arthritis professional education

“…For example, the use of trained patient instructors who evaluate and teach musculoskeletai examination skills was introduced in the University of Arizona MAC. Preliminary studies of the use of this teaching method indicated that it identified correctable skill deficits in many primary care practitioners (9). Although this technique is now used in many medical schools, its full potential for inclusion in CME programs has not been realized.…”