Department of Medicine, New York University School of Medicine, New York, NY.
Department of Gastroenterology, New York University School of Medicine, New York, New York.
Clin Gastroenterol Hepatol. 2017 Jul;15(7):1095-1123.e3. doi: 10.1016/j.cgh.2016.12.037. Epub 2017 Jan 20.
BACKGROUND & AIMS: Patient education is critical in ensuring patient compliance and good health outcomes. Fellows must be able to effectively communicate with their patients, delivering enough information for the patient to understand their medical problem and maximize patient compliance. We created an objective structured clinical examination (OSCE) with 4 liver disease cases to assess fellows' knowledge and ability to inform standardized patients (SPs) about their clinical condition.
We developed 4 cases highlighting different aspects of liver disease and created a 4-station OSCE: hepatitis B, acute hepatitis C, new diagnosis of cirrhosis, and an end-stage cirrhotic nontransplant candidate. The SP with hepatitis B was minimizing the fact that she could not read English. The acute hepatitis C SP was a nursing student who is afraid that having hepatitis C might jeopardize her career. The SP with the new diagnosis of alcoholic cirrhosis needed to stop drinking, and the end-stage liver disease patient had to grapple with his advanced directives. Twelve fellows from 4 GI training programs participated. Our focus was to assess the fellows' knowledge about liver diseases and the Accreditation Council for Graduate Medical Education competencies of health literacy, shared decision making, advanced directives, and goals of care. The goal for the fellows was to communicate effectively with the SPs, and acknowledge that each patient had an emotionally charged issue to overcome. The SPs used a checklist to rate fellows' performance. Faculty and the SPs observed the cases and provided feedback. The fellows were surveyed on their performance regarding the case.
The majority of fellows were able to successfully summarize findings and discuss a plan with the patient in the new diagnosis of cirrhosis (76.92%) and hepatitis C case (100%), but were less successful in the hepatitis B case (30.77%) and the end-of-life case (41.67%). Overall, a small percentage of fellows reflected that they did a good job (22%-33%), except at the end-of-life case (67%). The fellows' greatest challenge was trying to cover a lot of information in a single outpatient visit.
Caring for patients with liver diseases can be complex and time consuming. The patients and fellows' observations were discordant in several areas: for example, the fellows believed they excelled in the end-of-life case, but the SP thought only a small percentage of fellows were able to successfully summarize and discuss the plan. This discrepancy and others highlight important areas of focus in training programs. OSCEs are important to help the fellows facilitate striking the right balance of information delivery and empathy, and this will lead to better patient education, compliance, rapport, and satisfaction.
患者教育对于确保患者的依从性和良好的健康结果至关重要。住院医师必须能够与患者有效沟通，提供足够的信息以使患者了解自己的医疗问题并最大程度地提高患者的依从性。我们创建了一个包含 4 个肝病病例的客观结构化临床考试（OSCE），以评估住院医师告知标准化患者（SP）其临床状况的知识和能力。
我们开发了 4 个病例，重点介绍了肝病的不同方面，并创建了 4 个站点的 OSCE：乙型肝炎、急性丙型肝炎、新诊断的肝硬化和终末期肝硬化非移植候选者。患有乙型肝炎的 SP 尽量不提及她不会读英语的事实。急性丙型肝炎的 SP 是一名护理专业的学生，她担心患有丙型肝炎会危及她的职业生涯。新诊断的酒精性肝硬化的 SP 需要戒酒，而终末期肝病患者则必须处理他的高级指令。来自 4 个胃肠病学培训计划的 12 名住院医师参加了该考试。我们的重点是评估住院医师对肝病的了解以及住院医师对健康素养、共同决策、高级指令和治疗目标的研究生医学教育认证委员会的能力。住院医师的目标是与 SP 进行有效沟通，并认识到每个患者都有一个需要克服的情绪化问题。SP 使用检查表来评估住院医师的表现。教师和 SP 观察了病例并提供了反馈。住院医师对他们在病例中的表现进行了调查。
大多数住院医师能够成功地在新诊断的肝硬化（76.92％）和丙型肝炎病例（100％）中与 SP 一起总结发现并讨论计划，但在乙型肝炎病例（30.77％）和终末期病例（41.67％）中则不太成功。总体而言，只有一小部分住院医师（22％-33％）认为自己做得很好，而在终末期病例中（67％）则没有。住院医师最大的挑战是试图在一次门诊就诊中涵盖大量信息。
照顾患有肝病的患者可能会很复杂且费时。患者和住院医师的观察在几个方面存在差异：例如，住院医师认为自己在终末期病例中表现出色，但 SP 认为只有一小部分住院医师能够成功地总结和讨论计划。这种差异和其他差异突出了培训计划中的重要重点领域。 OSCE 对于帮助住院医师在信息传递和同理心之间取得适当的平衡至关重要，这将导致更好的患者教育，依从性，融洽关系和满意度。
