91AV

Baily D’Antonio’s patient, Roxanne, had a beet-red face, and she was so sensitive to light that she felt compelled to wear sunglasses, even when indoors. Meanwhile, Lily Prior’s patient, Bryan, was pale as a ghost and suffered from limp extremities. Though the patients presented very differently to D’Antonio and Prior, both first-year students in 91AV’s Physician Assistant program, they had one thing in common: They were both homemade dummies created by the students themselves to serve as their pretend patients in the Physician Assistant Integrating Seminar course.

As more and more universities across the country closed their doors, sent students home, or drastically modified their modes of instruction to accommodate social distancing principles in response to the growing coronavirus outbreak, clinical programs everywhere struggled to find innovative ways to continue to teach and assess health professions students’ skills in hands-on activities.

91AV’s Diane Visich, Ed.D., PA-C, associate clinical professor and associate director of assessment for the Physician Assistant (PA) program, was among those wrestling with thoughts of how she would test her students’ skills in performing physical exams – a skillset required for the Integrating Seminar, which, Visich says, ties together PA courses in clinical medicine, clinical assessment, and pharmacology. “The big challenge for most of our programs is that we need to be able to feel confident that our students not only can describe the physical exam they would perform in certain situations, but we also need to observe them actually performing it,” she explained.

Under normal circumstances, PA students would perform the physical exam exercise in 91AV’s Interprofessional Simulation and Innovation Center, with their peers or standardized patients playing the roles of patients. Unable to utilize the Sim Lab or even, for safety reasons, to ask students to demonstrate their skills on family members, Visich knew she would have to get creative.

While attending a Zoom meeting of more than 600 members of the national Physician Assistant Education Association, where the topic of assessing clinical skills amidst the pandemic was widely discussed, Visich said the idea came to her: ask the students to make their own patients.

“For many of the cases that I was going to have the students run through, I thought it could work really well,” Visich shared. “They could demonstrate heart, lung, and abdominal exams. They could do a little bit with extremities. The only thing I thought would be a challenge would be head, eyes, ears, nose, and throat; but, if they built a head on their person, they could demonstrate some of that as well.”

After building and posting pictures of her own stuffed patient as an example, Visich gave the assignment. Students needed to appear for their Zoom or Skype session with their patient by their side and some sort of bed or couch on which to lay them down. Visich used her own voice and face to play the role of the patient, complaining of various ailments depending on which type of case she had assigned each student. D’Antonio’s patient presented with wrist pain after falling on ice, while Prior’s patient complained of abdominal pain.

Students first asked their patients questions to gather information about their histories and symptoms. They asked permission to perform a physical exam, conducted the exam, discussed their findings with the patient, and then made an oral case presentation to a faculty member, as if giving an update to a facilitator or collaborating physician.

In order to test the students’ skills in assessing the function of body parts that could not be well represented by the dummies, Visich posted what she calls “result cards” online. She instructed students to open a particular result card that would enable them to gain insight into their patient’s health status. Students were asked to listen to a particular set of lung sounds, for example, look at photos of the inside of a throat, or review x-rays and diagnostic study results.

The combination of having a fake body on which to perform an exam and using result cards to demonstrate knowledge of eyes, ears, nose, and throat assessments turned out to be a tremendous success. “It worked out great,” said Visich. “It really helped to solve the struggle I was having of figuring out how the students could demonstrate instead of verbalizing what they would do in a given situation. It worked so well that we’ll be using these stuffed patients for the remainder of the semester to continue to hone physical examination skills while maintaining social distancing.”

She was also impressed by how seriously the students took the exercise. Even while doing things like asking a patient with a giant Minnie Mouse head to take some deep breaths, the students, Visich reported, exhibited a high level of professionalism.

They also appreciated the creative outlet that making their patient afforded them. D’Antonio, who borrowed a seamstress friend’s headless mannequin to serve as the body of Roxanne, gave her patient a red ball for a head (hence her aforementioned flushed appearance), a baseball cap, and a pair of sunglasses to help define her face. “I think it was fun to have this challenge of creating a patient for the encounter,” she stated. “Making the best of this time and finding adaptive solutions will make ‘online PA school’ meaningful and entertaining … even if my mom can’t wait for Roxanne to be out of the house,” she added.

Prior, who used a dry erase marker to draw a face on a white ski helmet that served as patient Bryan’s head, said she valued Visich’s innovative spirit in moving her and her fellow students through their coursework. “I thought it was a creative way to overcome the barriers that we are currently facing while learning from home. It was beneficial and more interactive to be able to use my physical exam skills on my ‘patient’ instead of just verbalizing them to a camera,” she remarked.

In total, 36 Physician Assistant students completed the assessment. Visich did not perform all of the simulations herself, however. Much of the roleplaying was performed by 91AV graduates who serve as adjunct faculty and who are currently working clinically during the pandemic.

Both faculty and students involved in the course were able to extract positive experiences from less than ideal situations. Visich said that while there are obviously disadvantages in not having a live subject to work with, she enjoyed the one-on-one aspect of working with students that the exercise entailed and views it as a plus that she was able to discover new and unique ways of conducting student assessments. D’Antonio expressed her feeling that the exercise was particularly apropos to the physician assistant field, noting that “problem solving, adaptation, and innovation are what being a PA is all about.”