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In Canada, residents in psychiatry training programs sit the Royal College of Physicians and Surgeons of Canada (RCPSC) examination in their last year of training to allow them to obtain their specialist certificate and practise as independent psychiatrists. The RCPSC exam has 2 major components: the written, comprising multiple choice and short-answer questions, and the oral, comprising a long case and 4 half-hour stations. The half-hour stations are designed to examine several CanMEDS roles and competencies (for example, knowledge, the communicator role, and the manager role) in various clinical situations. The long case lasts 1 hour and 45 minutes and comprises, first, a 55-minute (maximum) interview of a psychiatric patient of whom the candidates have no prior knowledge. One examiner is present in the room, and another observes and listens through a 1-way mirror. In the second part of the long case, for which the patient is not present, the candidate presents the case and answers the examiners’ questions on it. The resident is assessed on interview skills and knowledge. Currently, the individuals used for these long case interviews are volunteer patients who have a psychiatric illness. This contrasts with the use of standardized patients (SPs) in Canadian undergraduate and postgraduate Objective Structured Clinical Exams (OSCEs). SPs are actors who are trained and paid to simulate a particular disorder or clinical situation. Recent published literature has focused on the use of SPs in psychiatric and nonpsychiatric oral exams in regard to, but not limited to, 1) psychological effects of the exam on SPs; 2) validity, reliability, and cost; and 3) potential performance differences in residents when interviewing real patients, compared with SPs (1–12). Most of the published literature refers to SPs in an OSCE format wherein they generally have to act for a maximum of 10 minutes per candidate. In contrast, the literature on using patients with psychiatric illness for oral exams is much smaller. Two published British studies discuss the views of participating volunteer patients in psychiatry final exams. One study (13) investigated patients participating in a membership examination for the Royal College of Psychiatrists. This exam is somewhat similar to the RCPSC oral exam: the patient spends approximately an hour with the candidate, and the candidate then presents the “history, diagnosis, and management.” The study reported that 71% enjoyed the exam experience, and 91% agreed that they did not feel pressured to participate. Another study focused on patients participating in medical finals for a final MB exam. Two-thirds of the patients found the exam pleasant, and fewer than 10% felt pressured to participate (14). There has not been a comparable study of psychiatric patients’ views and perspectives on their participation in the Canadian oral long case RCPSC exam. However, it is extremely important to investigate this area when considering the viability of using real patients for exam purposes. This paper discusses results of a survey completed by psychiatric patients participating in the oral long case of the RCPSC exam for psychiatry. Patients’ views from this survey are compared with previously published patient views as well as with literature on SPs who had to role-play emotionally complex patient roles. MethodVolunteer patients are recruited for the RCPSC oral exam from psychiatry inpatient wards and outpatient clinics in various hospital locations within each oral exam site (currently, there are 2 sites in Canada). They are screened to evaluate their understanding of the exam process and are required to be stable, able to tolerate the length of the exam, and able to give informed consent. The Participant Impact Questionnaire has 12 specific questions and 3 open-ended questions; it was originally developed at the Department of Psychiatry, University of Toronto, for local use. For this study, patients were given the questionnaire immediately following their participation in the exam, and questionnaires were collected before they left the exam centres. In 2002, the questionnaire was administered as a pilot project to patients at the Edmonton site (responses received, n = 23); in 2003, it was administered to all patients at both the Edmonton (responses received, n = 42) and Montreal (responses received, n = 67) exam sites. This paper combines the 2002 and 2003 results. Written comments from the open-ended questions were assessed for relatability to the 12 specific questions and included in the results section. Because this is a descriptive study, we employed only descriptive statistics. ResultsThere was a 93% response rate for the 2 sites combined (132/142 patients). Site response rates were 98% (65/66 patients) for Edmonton and 88% (67/76 patients) for Montreal. The single missed survey in Edmonton was owing to the patient’s being “too tired” to complete it. No reasons were given for missing surveys from the Montreal exam. Table 1 illustrates the questionnaire results. Of the participating patients, 94% responded that they would participate again.
When asked whether there were any specific reasons for participating, most (67%) answered “no.” Patients who answered “yes” responded with written comments such as “to help the future psychiatrists,” “to gain more confidence,” and “my small part in giving back for all the great help I have received.” Most said that they participated to help future psychiatrists and to develop more insight into their illness. The open-ended questions asking for any additional positive or negative comments were categorized into 3 themes: personal comments (Textbox 1), comments about the candidate (Textbox 2), and comments about the exam process (Textbox 3).
DiscussionThis study investigated psychiatric patients’ opinions about participating in the RCPSC oral exams. With respect to patients finding the exam stressful, 76% either disagreed or strongly disagreed. Some patients commented that they were “relaxed” throughout the exam process. Specific comments about their own stress regarding the exam process include the following: “Apart from [my] being quite nervous, the interview went well,” “examiner’s calm approach made me feel relaxed and comfortable,” and “I was comfortable with the interviewer.” Most written comments were positive with respect to the patients’ learning more about themselves and how they had progressed with their treatment. Only 1 patient responded, “It’s difficult knowing the watchers are there.” When asked, 82% strongly disagreed that they had been pressured to participate by their own psychiatrist. There were no open-ended patient comments with regard to feeling coerced into participating. Most commented that they participated to help future psychiatrists. In addition, 92% of the participating patients either agreed or strongly agreed that the exam was well organized. Written comments regarding the exam process were mostly positive: “very well presented, no pressure”; “examination environment was relaxed, unrushed, and thorough”; “well organized”; “ refreshments was a very neat idea”; “ carried out very professionally”; and “I found the staff very friendly, cheerful, and courteous.” There was one negative comment about there being “too little time.” Our results are similar to those of the 2 other existing studies. One study investigating patients’ perceptions of medical finals (14) showed that 92% of patients did not feel pressured into participating in the exams. It also found that only 29% of participating patients felt “distressed.” Of the patients, 72% said they would participate again, and 62% were pleased with the payment they received after participation. Most (90%) found the exam enjoyable, and 91% felt helpful. The other study (13) investigated 21 patients who participated in a membership examination for the Royal College of Psychiatrists at Bethlem Royal Hospital, London, UK, and concluded with similar results. Of these patients, only 29% felt some distress about the exam, because they felt it unpleasant to talk about experiences from their past. When the patients were asked whether they would participate again in such an exam, 62% agreed that they would. Most patients (91%) did not feel pressured to participate; they participated to help and repay their own doctors for the help they had been given in their own treatment. As well, 76% said that, although they did not participate for payment, they quite appreciated it. Our study found that most patients (94%) were willing to participate again and 82% felt that they were treated well throughout the exam process. In addition, 82% felt they were not pressured to participate in the exam by their own psychiatrist. Most of the written comments made by the participating patients were positive and reflected altruistic reasons for participating. Conversely, a study that investigated the effects on SPs of portraying psychiatric roles reported a negative impact on most SPs and very few positive outcomes (1). SPs discussed the portrayal of psychiatric disorders as being emotionally stressful, with physical as well as mental effects. SPs reported problems sleeping after the exam, psychological irritation, and exhaustion. Only 11% of the participating SPs found it enjoyable to portray a role as difficult as a psychiatric disorder. Despite the negative impact on SPs, this study concluded that they would be willing to continue to portray psychiatric roles. There are obviously many issues to consider when deciding to use real patients vs SPs for the long case of the RCPSC oral exam. These areas include, but are not limited to, cost, availability, validity, reliability, and whether SPs can successfully portray psychiatric disorders. Table 2 summarizes comparisons of real patients vs SPs taken from the literature. A discussion of reliability and validity is beyond the scope of this paper, because we wished to focus on the impact of the exam on the patient. However, both cost and availability do have direct impact on the patient and are discussed below. Cost The cost-effective approach would be to use patients rather than SPs. In our study, most patients (78%) did not participate to earn extra money; therefore, money is not a prime motivator. One study shows that SPs receiving $12 per hour actually felt underpaid, especially because they were portraying psychiatric roles (1). Psychiatric disorders are difficult to portray and require extensive training, which leads to higher costs (4,15). Availability
ConclusionFrom this study, it appears that volunteer psychiatric patients experience the RCSPC oral exam as positive, with minimal negative impact. This should be taken into consideration in future discussions about the use of SPs vs real patients for psychiatry oral exams in Canada. AcknowledgementsWe thank Dr Brian Hodges, Dr Mark Hanson, and Dr Susan Abbey for use of the Participant Impact Questionnaire. We also thank the local organizing committee of the 2003 Montreal RCPSC oral exam for participating in this project. References1. McNaughton N, Tiberius R, Hodges B. Effects of portraying psychologically and emotionally complex standardized patient roles. Teach Learn Med 1999;11:135–41. 2. Norman G, Tugwell P, Feightner JW. A comparison of resident performance on real and simulated patients. J Med Educ 1982;57:708–15. 3. Woodward CA, Gliva-McConvey G. The effect of simulating on standardized patients. Acad Med 1995;70:418–20. 4. Yudkowsky R. Should we use standardized patients instead of real patients for high-stakes exams in psychiatry? Acad Psychiatry 2002;26:187–92. 5. Hodges B, Hanson M, McNaughton N, Regehr G. Creating, monitoring, and improving a psychiatry OSCE. Acad Psychiatry 2002:26;134–61. 6. McLay RN, Rodenhauser P, Anderson DS, Stanton ML, Market RJ. Simulating a full-length psychiatric interview with a complex patient. Acad Psychiatry 2002;26:162–7. 7. Klamen DL, Yudkowsky R. Using standardized patients for formative feedback in an introduction to psychotherapy course. Acad Psychiatry 2002;26:168–72. 8. Lewis JM. On the use of standardized patients. Acad Psychiatry 2002;26:193–6. 9. Swartz MH, Colliver JA. Using standardized patients for assessing clinical performance. Mt Sinai J Med 1996;63: 241–9. 10. Tamblyn RM, Klass DJ, Schnald GK, Kopelow ML. Sources of unreliability and bias in standardized patient rating. Teach Learn Med 1991;3:74–85. 11. Broquet K. Using an objective structured clinical examination in a psychiatry residency. Acad Psychiatry 2002;26:197–201. 12. Norton J. The use of patient-actors on the oral psychiatric examination and in the residency training process. Acad Psychiatry 2000;24:176–7. 13. Persaud RD, Meux CJ. Clinical examinations for professional qualifications in psychiatry: the patients’ views. Psychiatr Bull 1990;14:65–71. 14. Sharma T, Katona CLE. Patients’ perceptions of medical finals. Med Teach 1994;16:61–70. 15. King A, Perkowski-Roger L, Pohl S. Planning standardized patient programs: case development, patient training and costs. Teach Learn Med 1994;6:6–14. 16. Collins JP, Harden RM. AMEE medical education guide no. 13: real patients, simulated patients and simulators in clinical examinations. Med Teach 1998;20:508–21. Author(s)Manuscript received December 2003, revised, and accepted May 2004. 1. Assistant Professor and Director, Postgraduate Training Program in Psychiatry, University of Alberta Hospital, Department of Psychiatry, Edmonton, Alberta. 2. Education Research Assistant, University of Alberta Hospital, Department of Psychiatry, Edmonton, Alberta. Address for correspondence: Dr P Tibbo, University of Alberta Hospital, Department of Psychiatry, 8440-112 Street 1E7.11 Walter Mackenzie Centre, Edmonton, AB T6G 2B7 e-mail: ptibbo@ualberta.ca
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