CPX brings together standardized patients and a high-tech monitoring system to test medical students

To graduate from the UNC School of Medicine, students must pass the Clinical Performance Examination (CPX), a test that combines use of standardized patients, a feature of the UNC curriculum since the early 1980s, with a high-tech monitoring system that enhances learning and teaching.

CPX brings together standardized patients and a high-tech monitoring system to test medical students
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Medical students adding notes to the medical record after an exam.
CPX brings together standardized patients and a high-tech monitoring system to test medical students
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Medical student Jessica Zvara reviews options with a patient during a CPX exam.

by Zach Read - zread@unch.unc.edu

Every year groups of rising fourth-year medical students filter into the Clinical Skills and Patient Simulation Center at Burnett-Womack to take their required summative Clinical Performance Examination (CPX).

The exam, which lasts approximately six-and-a-half hours, presents students with a wide variety of faculty-developed medical cases acted out by standardized patients. Unlike other exams run at the Center, the cases test students’ broad knowledge across departments rather than focus tightly on a small number of areas such as OB, family medicine, or surgery. To pass, students must perform basic interviewing and physical exams on patients and provide excellent bedside manner, demonstrating that they’ve learned the clinical and professional skills required to move on in their training.

“From our perspective, CPX is an invaluable tool for students to demonstrate on a live patient what they’ve learned over the past three years,” says Benny Joyner, MD, MPH, clinical co-director of the Center. “We often talk about how to read patients in a conceptual manner, but on live patients it’s more difficult. This is an opportunity to utilize skills and gain confidence.”

During the course of the exam, students evaluate a total of 14 medical cases, of which 12 are graded. The remaining two cases are faculty-developed pilot cases that may be used as part of future exams, depending on the results the interactions produce. Students have 15 minutes with each patient and 10 minutes to draft notes in the hallway outside the exam room. Using a paging system, the CPX staff keeps the students informed of how much time they have left in each phase.

Despite the high-intensity conditions of the exam, UNC medical students pass at a 95-percent clip, which can be attributed to their broad educational training and their experiences running formative simulations early in their first two years.

“For the first two years, any simulations we run are all about formative skills,” says Brian Loveland, assistant director of clinical skills at the Center. “Are they learning how to communicate with the patient during that time? Are they learning how to perform a focused physical for shoulder pain? Are they doing the correct exams, asking the correct questions? And then in the third and fourth year, it’s more of a summative evaluation.”

But critics of the exams say that successful testing results serve simply as evidence of rote memorization rather than as the product of good training, and that standardized patients, who participate in the grading by evaluating bedside manner and interpersonal skills, aren’t equipped to judge medical students.

“This is one of the few times in which you interview patients without a supervising physician assisting in the direction of the conversation,” says Joyner. “Some wonder if it’s useful, and they think it’s just memorization. But this is an opportunity for us to drill down on techniques we may talk about but never utilize, and a great chance for patients to provide insight to students.”

Students, naturally, learn more when standardized patients are good at their portrayals. Instead of providing hints or clues to students, the patients give answers they’ve been trained at length to give for the cases they’ve been designated to portray. Some patients may simulate an emergency room setting while others simulate a clinical or in-patient setting.

“We have a broad range of people that we work with, but there’s also an exceptional core group of standardized patients that we bring in for the higher-stakes exams like CPX,” says Julie Messina, director of assessment at the Center. “Their jobs aren’t easy. They have to hit the same important marks for each of the students.”

UNC’s unique approach to comprehensive simulated testing emphasizes history taking and bedside manner, among other key areas the students are graded on. While other simulation programs run through single scenarios, they don’t focus on as many areas critical to doctor training. But that trend is starting to change, says Jackson Szeto, who manages the CPX monitoring equipment at the Center.

“At other universities, I know of only two that are this extensive,” Szeto says. “Others are starting to develop more comprehensive exams, but we’ve been doing this for six years.”

The current monitoring equipment proves especially helpful as students work to improve interpersonal skills. After they’ve finished the exam and all testing results are in, students can watch and listen to recordings of their interactions with the patients. Medical student Anna Rodenbough recently finished her CPX exam and plans to go into the monitoring room and review her interactions, which will be archived and available once all students have taken the exam. Rodenbough, who plans to go into pediatrics, believes that the exam has already impacted her awareness of bedside manner.

“Every time we have simulated exams I become hyperaware of my bedside manner and more aware of the interaction I have with the patient,” says Rodenbough. “Sometimes when you’re in a real-life clinical situation you lose sight of that a little bit. You’re trying to get things done and get the correct information. You get more feedback on your presentations and your notes than on the clinical interactions. CPX gives us a chance to hear more from the patient perspective and to get good and honest feedback.”

As the Center continues to advance its technology, more opportunities for enhancing learning and teaching will exist for students and faculty, says Brian Loveland. The Center will be moving to Berryhill next year and will implement a new system for monitoring CPX. The new system will have a live annotation process in which faculty can actually review the student-standardized patient encounter and bookmark it as they’re watching it.

“They’ll be able to say, ‘Perfect exam technique’ or ‘Perfect physical technique,’” says Loveland. “Or they’ll add, ‘This is where you should have gone further into some of the history about X.’ So right now there is a lot more responsibility on the students to go back through and learn from what they’re doing, especially for their third- and fourth-year clerkship rotations, but it will become more shared.”

The technology will make the process more interactive. Faculty members will be able to evaluate from their offices or homes or on their iPads or laptops when they’re at conferences. And thanks to these advancements, the monitoring room at the Center in Berryhill will be more nimble, requiring only three or four computers instead of bunches of stations for students to come in and review their encounters.

CPX testing has been a critical measurement of what medical students have learned through three years at UNC. Faculty, the Center staff, standardized patients, and the students themselves have embraced the tools available to them to enhance the educational experience at the School of Medicine, and as the teaching of students continues to evolve, the capabilities for greater learning will grow as well.

This is the first of a three-part series on the Clinical Skills and Patient Simulation Center. The next two stories will feature the use of standardized patients and high fidelity adult, child, and baby simulators in the training of medical students.