f [MINI/11H!!! HUI/WIll/IIIINIHIIIHIINMHHHHHH 3 1293 10401 4216 ABSTRACT AN EXPERIMENTAL STUDY INVESTIGATING THE EFFECTS OF REAL AND SIMULATED CLINICAL TRAINING ON PSYCHOMOTOR, AFFECTIVE AND COGNITIVE VARIABLES DURING REAL CLINICAL PERFORMANCE OF FIRST YEAR OSTEOPATHIC MEDICAL STUDENTS BY Fred C. Tinning The purpose of this study was to investigate the effects of simulated clinical training using simulated patients and real clinical training using real patients on psychomotor skills, affective behaviors, cognitive (medical) knowledge and on measures of total clinical competency in the performance of a complete Neurological Evaluation History and Physical Examination. The theoretical founda- tion for this investigation combines Twelker's propositions cylinstructional simulation, Barrow's propositions of gmogrammed patients in Neurological evaluation, and pm0positions of Gagne, Glaser, and others on transfer of learning from the representative world to the real world. In order to test the effects of these two methods of clinical training, treatment experiences were developed in (flinical Neurology which provided first—year Osteopathic hmdical students with necessary clinical education experi- emces during the Systems Biology II Neuromuscular Systems Unit. The clinical experiences were as identical as gmmsible, using simulated patients in a simulated clinical Fred C. Tinning setting and real patients in a real clinical setting. The neurological cases used for both real and simulated experi- ences were selected or programmed to be representative of the problems encountered in a Neurological Evaluation History and Physical Examination. During the 10 weeks of the Systems Biology II Neuromuscular Systems Unit, each student had three clinical training treatment experiences. In addition, all students completed a video-taped final practical examination on a real neurological patient. In order to eliminate the Hawthorne effect, the entire class received the clinical training experiences. All students were treated, rated, and evaluated with the same procedures. The treatment materials were prepared in advance and presented to the entire class prior to the treatment period. Each student was aware of the objectives of the entire Neuromuscular Systems Unit and, specifically, the clinical training experiences. An advance organizer on the clinical training experiences, course description handouts, schedules, and other material used as part of the training experience were presented to the students in the pre- treatment period. The subjects in the investigation were a random sample of 24 students from the first-year class of 33 OsteOpathic Medical students at the College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan. The subjects were randomly assigned to the two treatment groups. The remaining students enrolled in the Systems Biology II Fred C. Tinning Neuromuscular Systems Unit were considered an inactive control. The inactive control received identical training to the real clinical training treatment group. The treatments were administered separately in group settings. Students were aware that the clinical treatment assignments were different, but this was expected. Clinical experi- ences are generally different for each student or group of students. After the nine weeks necessary for clinical rotation in completing the three treatment training clinical experiences, each subject completed the final practical Neurological Evaluation History and Physical Examination in the tenth week with a real patient in order to test the results of the treatment. The criteria measures were of six types: 1. Cognitive Knowledge Performance 2. Psychomotor Skill Performance 3. Affective Behavior Performance 4. Total Performance in Clinical Competency 5. Patient Evaluation Rating of Student Performance 6. Student Ratings of Self-Performance Experiences and Satisfaction To measure the behaviors represented in the criteria measures, the experimenter developed or adapted evaluation and rating scales on all of the variables. This required training of raters, establishing standardization procedures, and the development of reliabilities, where possible, on the various rating scales. To measure cognitive medical knowledge, a pre- and post-objective test was developed on Fred C. Tinning neurological problems and taken by the students. To measure psychomotor technique and skill, a neurological practical examination was developed for rating performance before and after treatment. To measure affective physician behavior, a semantic differential scale on establishing a relationship and evaluating data was developed for the rating of effective affective behaviors. To measure patient satisfaction, a semantic differential scale was developed for patient rating during the clinical treatment and final evaluation experiences. To measure student behaviors, clinical experience and final examination evaluation ratings were used and rated by the students. To measure total performance in clinical competency, the clinical competency formative and summative evaluation rating scale was developed for the clinical instructors' ratings of student performance. Both multivariate and univariate analysis procedures were completed. A multivariate analysis of covariance was initially planned; however, the covariate information did not correlate with the dependent variables and added little information to the analysis of the study. Additionally, chi-square and correlational tests were used in the analysis of the data. These tests were used in analyzing the ten directional hypotheses. The results of the hypotheses testing indicate that simulated clinical training provided the first-year OsteOpathic Medical students with an opportunity to vary behavior, problem solve, and make decisions in an environment that was positive and free from Fred C. Tinning distraction. The experience provided relevant feedback on critical behaviors which were transferred to the real world in demonstrated learning outcomes. The experiment has demonstrated an alternative in medical education and has added to the body of knowledge of instructional methods in physician education as related to the training and transfer of psychomotor skills, affective behaviors, cognitive knowledge, and clinical performance abilities. The implications of this investigation indicate that real clinical training with real patients, utilizing the {upcedures developed for this study, proves to be effective msa clinical instructional technique in medical education. lkmever, the key result is that the use of simulated pajents in a simulated clinical environment provides a \mhicle for transfer of learning, and therefore can be umsidered a viable alternative for the clinical teaching ofbehaviors necessary to the medical student in his fommtive period of learning. AN EXPERIMENTAL STUDY INVESTIGATING THE EFFECTS OF REAL AND SIMULATED CLINICAL TRAINING ON PSYCHOMOTOR, AFFECTIVE AND COGNITIVE VARIABLES DURING REAL CLINICAL PERFORMANCE OF FIRST YEAR OSTEOPATHIC MEDICAL STUDENTS BY Fred C. Tinning A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Counseling, Personnel Services and Educational Psychology 1973 Q Copyright by FRED C. TINNING 1973 Dedicated to my wife, Janet, for her faith never ending, my bonnie daughters, Marie and wee Jean, to my Mother, family, and friends. They all prove that . . . Love is patient and kind; love is not boastful; it is not arrogant or rude. Love does not insist on its own way; it is not irritable or resentful; it does not rejoice at wrong, but rejoices in the right. Love bears all things, believes all things, hopes all things, endures all things. Love never ends; ........ St. Paul ii ACKNOWLEDGMENTS The writer wishes to express his appreciation to the following individuals: To Dr. James R. Engelkes, Committee Chairman and major advisor, who exhibited an active interest in my total pro- gram and provided the guidance and friendship so necessary to the completion of the entire doctoral program. To Dr. Gregory A. Miller, Committee member, who pro- vided the initial push to return to school and provided the opportunity to initiate and then the personal support to carry through the entire doctoral program. To Dr. Jack L. Maatsch, Committee member, cognate advisor, and mentor,who gave unselfishly of his talents, of his time, of his friendship, and his encouragement throughout the entire study. To Dr. Maryellen McSweeney, Committee member, who has the gift to listen and then give unselfishly of her abilities, of her time, and her encouragement throughout the entire study. To Dr. Lawrence E. Jacobson, Assistant Dean for Clinical Affairs, Professor of Osteopathic Medicine, who provided endless services, talent and time to this study. His willingness to allow behavioral research within the iii OsteOpathic Medicine curriculum, his guidance and his personal friendship made the entire study a reality. To Dr. Margaret Jones, Dr. Harry Kornhiser, Dr. Richard Calkins, and Dr. Marvin Clark, a special thanks for their professional services and guidance during the study. In a study of this magnitude there are many individuals who provided their services and support. The writer would like to express a sincere "thank you" for their individual contributions. To Dean Myron Magen and Associate Dean John Barson for the support they provided through the College cf Osteopathic Medicine. To the first-year class of Osteo— pathic Medicine students (1972). To the St. Lawrence Ikmpital and Mental Health Facility, the Detroit Osteopathic Hospital, and the Martin Place East Hospital. W\é\ “a?!" I e / to Mike Allen, Paul wand other members 0 "9e . W 5' 6 . . . f‘ . cmmera crew. To Dr. John Schneider, Dianne, Liz, and Connie 'R>the Department of Psychiatry, Michigan State University fix their time and efforts in rating students. To the shmlated patients Leta Stefflre, Jack Maatsch, Ph.D., \Y Jdu1Baumann, Ralph Oelchowski, Dick Baldwin, 0.0., \‘155 2 Julie O'Neill, R. Sitaraman, and my friend and brother, K “flint Emma Look. To the secretaries, Jo, Pam, Kris, Sherrie (Hazier, Artie Bolley, and Edna Harney, who worked (unlessly on forms and in typing the drafts of this study. Lathe real patients who were willing to serve in the training of Osteopathic Medical Students. To Dr. Howard iv Teitelbaum. Eric, Kowit, and Linda. To my dear friend, Linda Peckham. for her editorial guidance and to my many other friends. TABLE OF CONTENTS Chapter Page I INTRODUCTION TO THE EXPERIMENT................ 1 Problem....................................... Purpose............................ ...... ..... Research Hypotheses........................... Overview...................................... 1 |’-‘CJ\U'I|'--J II REVIEW OF LITEMTUREOOOOOOCOOOOOO0.00.00.00.00 12 Organization.................................. 12 Definition of Educational Simulation.......... 12 Business, Military and Educational Use...... 13 Heritage of Educational Simulation.......... 13 Simulation Design........................... 16 Educational Simulation for Training........... 23 Simulation Learning and Transfer of Training.................................... 24 Studies of Educational Simulation........... 30 Simulated Patients as a Technique for Training in Medical Education................. 36 Enacted Role-Performing Simulation.......... 36 Rationale for Simulation Training in Medical Education........................... 40 Conclusion.................................... 43 III DESIGN OF THE STUDY........................... 44 Sample........................................ 44 Sample Characteristics...................... 46 Treatments.................................... 55 Pre-treatment and Treatment Procedures and Plan.................................... 55 Treatment Materials and Administration........ 72 General Information Course Protocol (Appendix A)................................ 72 General Protocol of the Systems Biology Courses (Appendix B)........................ 73 The Advance Organizer (Course Booklet) (Appendix C)................................ 73 The Cognitive Pre-Post Test (Appendix D).... 75 vi Chapter Page Day-by-Day Class Schedule of All Lectures and Assignments (Appendix E)................ 75 Neurological Practical Examination of Psychomotor Techniques and Skills (Appendix F)................................ 76 Affective Training Aids-Video-Tape Series and Script (Appendices G and H)............. 77 Master Control Sheet (Appendix I)..... ...... 78 Simulated Cases (Appendix J)................ 79 The Clinical Rotation Schedule (Appendix K)................................ 80 Final Examination Schedule (Appendix L)..... 81 The Final Examination Packet (Appendix M)... 83 Null Hypotheses............................... 88 Measures...................................... 91 Criterion Measures............................ 92 Cognitive Knowledge Performance Criterion Measure..................................... 92 Psychomotor Skill Performance Criterion Measure..................................... 92 Affective Behavior Performance Criterion Measure..................................... 93 Total Performance in Clinical Competency Performance Criterion Measure............... 94 Patient Evaluation Rating Performance Criterion Measure........................... 98 Student Ratings of Self, the Experiences, and Satisfaction Performance Criterion Measures.................................... 99 Analysis of Data and Design................... 99 Statistical Analysis........................ 99 Level of Significance....................... 101 Design...................................... 102 Summary.................... .............. ..... 103 IV ANALYSIS OF THE RESULTS ................ ....... 105 Covariate Effects............................. 105 Results of the Tests of the Hypotheses........ 108 Total Performance in Clinical Competency, Psychomotor, Affective and Cognitive Differences Between Simulated Clinically Trained and Real Clinically Trained Groups.. 108 Differences Demonstrated in Total Perform- ance Skills in Clinical Competency on Each of the Three Treatment Training Experiences Between Simulated Clinically Trained and Real Clinically Trained Groups.............. 112 Differences in Anticipated and Demon- strated Confidence in Performance Between Real Clinically Trained and Simulated Clinically Trained Groups.............. ..... 116 vii Chapter Differences in Agreement on Student Self- Rating and Clinical Instructor's Rating on Total Performance in Clinical Competency Ratings Between the Simulated Clinically Trained and the Real Clinically Trained Groups...................................... Differences in Responses on Feelings About "Self" in the Treatment Training Clinical Experiences in Neurology Between Simulated Clinically Trained and Real Clinically Trained Groups ............. . ..... Differences in Responses About the Treat- ment Training Clinical Experience in Neurology Between Simulated Clinically Trained and Real Clinically Trained Groups...................................... Differences on Factors Contributing to Performance on the Training Experience Between the Simulated Clinically Trained and the Real Clinically Trained Groups...... Differences in Request for Simulated Instruction Experiences Between the Simulated Clinically Trained and the Real Clinically Trained Groups................... Differences in Demonstrated Improvement vs. Consistency on Patient Evaluation During the Treatment Training Between the Simulated Clinically Trained and the Real Clinically Trained.......................... Differences in Patient Satisfaction of Student Performance on the Final Patient Evaluation Between the Simulated Clinically Trained and Real Clinically Trained Groups.. Summary................ ................. ...... Status of the Research Hypotheses............. Research Hypothesis 1 ................ . ...... Research Hypothesis 2......... ..... ......... Research Hypothesis 3.... ........ ........... Research Hypothesis 4....................... Research Hypothesis 5....................... Research Hypothesis 6. ...... ................ Research Hypothesis 7....................... Research Hypothesis 8............ ....... .... Research Hypothesis 9...... ...... ........... Research Hypothesis 10...................... DISCUSSION, CONCLUSIONS, IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE, ADDITIONAL DATA I AN D S UMMARY O O O O O O O O O O OOOOOOOOOOOOOOOOOOO Discussion.......... ......................... . Conclusions.. ........ . .................. ...... viii Page 118 122 127 133 134 139 146 150 150 150 152 152 153 154 154 155 155 156 156 157 157 160 Chapter Page Implications for Future Research and PraCtice. I O O O O O O O I O O O C O O O O O O O O O O O O O O O O O O O O O 0 O O 162 Additional Data 0 O O O O O O O O O O I O O O O O O O O O O O O O O I O O O O 16 7 smarYOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOI 169 LIST OF REFERENCES 0 O O O O O O O O O O O O O O O O O O O O O O O O O O O 175 APPENDICES O O O I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 184 A. General Information Course Protocol........ 184 B. Systems Biology Courses General Protocol... 192 C. The Advance Organizer (Clinical Course BOOklet)OOOOOIOOCOOOOOOOOOO ..... OOOCOOOOOOO 197 D. Cognitive Pre-Test -- Post-Test............ 229 E. Systems Biology I & II Neuromuscular Unit Spring Summer Class Schedule Including Other Classes Scheduled.................... 233 Neurological Practical Examination of Psychomotor Techniques and Skills.......... 256 Affective Training Aids.................... 260 Video-Tape Series on Physician Behavior.... 268 Master Control Sheet....................... 272 Simulated Neurological Evaluation History and Physical Examination Forms............. 275 Clinical Rotation Schedule................. 349 Final Examination Schedule................. 361 Final Examination Packet................... 363 Zt": C4P4m¢n W ix Table 1.1 LIST OF TABLES Page Correlation Matrix for Hypothesis 1....... ..... 106 Testing Regression Coefficient for 2 Covariates of Hypothesis l..................... 107 Multivariate and Univariate Tests for HypotheSiS1..OIOOOOOCOCOOCOOOOOCCOOOOOOOOOOOOO 109 Grand Mean, Variance, S.D., and Cell Means for HypotheSiS 1....00......OOOOOOOCOOOOOOOOOOO 1'11 Multivariate and Univariate Tests for HYPOtheSj-S ZOocooooooooooooooo00.000.000.000... 113 Grand Mean, Variance, S.D., and Cell Means forHypotheSiS 2.00.00.00.000000000COOOOO‘. ..... 1'14 Correlation Matrix for Hypothesis 2............ 115 Multivariate and Univariate Tests for HypothESiS 3......OIOOOOOOOOO0.0.0.0000... ..... 117 Grand Mean, Variance, S.D., and Cell Means for HypotheSiS 3.00......OOOOOOOOOOOOOOOOOOOOOO 119 Correlation Matrix for Hypothesis 3............ 120 Testing Significance of Correlation for HypotheSj-S 4.000000...IOOOOOOOOOOOOCOOOOOOOOOO. 122 Multivariate and Univariate Tests for HypotheSis 5......0.....OOOOCOOOCOOOIOOOOOOOOOO 123 Grand Mean, Variance, S.D., and Cell Means for Hypothesis 5.............. ...... ........... 125 Correlation Matrix for Hypothesis 5 ............ 126 Multivariate and Univariate Tests for HypotheSiS 60.0.0.0...OOOOOOOOIOOOOOOI ....... O. 128 Grand Mean, Variance, S.D., and Cell Means for HypotheSiS 6.0.0.0...OOOOOOOOOOOOOOOOOOOOOO 129 X Table Page 6.3 Correlation Matrix for Hypothesis 6....... ..... 130 7.1 Multivariate and Univariate Tests for HypotheSis 70.000.000.000. 00000000000000 0...... 135 7.2 Grand Mean, Variance, S.D., and Cell Means for Hypothesis 7............. .................. 136 7.3 Correlation Matrix for Hypothesis 7 ............ 137 8.1 Chi-Square - Testing of Hypothesis 8 ......... .. 138 9.1 Multivariate and Univariate Tests for Hypothesis 9, First Experience..... ............ 141 9.2 Multivariate and Univariate Tests for Hypothesis 9, Second Experience..... ..... . ..... 142 9.3 Multivariate and Univariate Tests for Hypothesis 9, Third Experience ................ . 143 9.4 Grand Mean, Variance, S.D., and Cell Means for HYPOtheSiS 90000000000.000.00.0000000000000 144 9.5 Correlation Matrix for Hypothesis 9 ...... ...... 145 10.1 Multivariate and Univariate Tests for V HypotheSis10.000.00.0000000000000.00 00000 0000. 147 10.2 Grand Mean, Variance, S.D., and Cell Means for HypotheSis 10000000000000.00.00.00000000000 148 10.3 Correlation Matrix for Hypothesis 10........... 149 xi LIST OF FIGURES Figure Page 1 First Year Clinical Experiences............... 52 2 Basic Curricular Model........................ 53 3 Systems Biology Sequence ...................... 54 xii CHAPTER I INTRODUCTION TO THE EXPERIMENT PROBLEM Medical schools and medical educators are facing critical times in providing new approaches to the total education and training of physicians. Historically, educational programs in most of the nation's medical schools have been afforded the freedom and funds unavail- able to other educational programs (Jason, 1970). Medical education has been accountable to the practicing physician world only. As a result, the quality of medical education, the curriculum, the preparation of programs, and the process of training physicians have been developed many times without research or systematic evaluation or comparisons. Tradition has been the general rule in medical education rather than planned evaluation of pro- gram change, of the educational process, and the follow-up on the product. However, today medical education is no longer afforded the luxury of independence, but must plan on accountability to the public in the development of its programs. Medical schools and the system of medical education are being confronted by all of society. "Never perhaps has there been as much need and as much opportunity for a national examination of the total activities of medical schools"(Fein & Weber, 1971). There are increasing demands for innovation, new policies on student recruitment, pressures for expansion, requests to develop new educational programs for various health personnel, requests for new models of patient care delivery-systems, and need for community-coupled involvement. Studies in medical education are pointing out many interesting paradoxes, nearly all of which undermine the traditionally held rationale for medical education (Glazer, 1971). In fact, the evidence, though not conclusive, suggests a thorough re-examination of current programs in medical education (Wing, 1972). With the demands for re-examination of medical educa- tion has come the emphasis on curricular revision. A recent survey of medical curriculum change in Canada and the United States indicates that 88% of the medical schools are now involved in planning or actually engaged in significant curricular modifications (Hubbard, Gronvall & DeMuth, 1970). The modifications are in the content and pedagogy of traditional curricula, with the trend centering on a systems approach of coupling biomedical sciences, clinical science, and behavioral science, and in providing clinical training early in a student's medical education (Matlack, 1972; Jacobson & Kabara, 1972). Integrated medical education programs need to be coupled with early practical clinical training. This systems approach reinforced a belief developed through experience as an educator, administrator, and counselor in working with disabled, disadvantaged clients in need of rehabilitation and in providing clinical training programs for counselor education and through educational and professional involvement as a medical educator with the Office of Medical Education Research and Development and with the College of Osteopathic Medicine at Michigan State University. From this practical know- ledge, it became evident that learning centered on active involvement was, indeed, a requirement for effective training. In much of university education, real clinical experiences are difficult to program. The student in counseling or medicine, for example, may not be able to manage the complex problems of the client or patient that would be required in early clinical training exposure. The cost of transporting students to facilities that have training resources, the problems in managing acutely ill patients, and the difficulty in maintaining adequate supervision for prompt feedback are all major problems in providing quality patient-centered clinical education. Many substitute experiences have been offered as a solution for limited early active clinical education exposure. Traditional didactic instruction, programmed instruction, small group training, and modeling, using high and low fidelity experiences, have all been proposed as instructional methods to be utilized in place of "hands- on-experience" with real patients. Educational training programs requiring early and long term clinical training experiences in counseling, social work and medicine are very costly in student and faculty time and facilities. However, cost cannot be the reason for eliminating clinical experiences. A more defensible position is to maximize those clinical experiences. This can be accomplished by providing effective preparatory types of learning experiences which are realistic for the parties providing and receiving the learning experience. Instructional simulation, using simulated patients, can be logistically a less complex approach for providing effective, "hands-on," clinical experience during the formative period of learning complicated clinical skills. In the present study, the question being asked is, "Will instructional simulation using simulated patients in clinical training of first-year medical students result in learning and improved transfer of learning to the three domains (psychomotor, affective, cognitive) to real world situations?" "There is no more important topic in the whole of the psychology of learning than transfer of training," (Deese, 1958, p. 213). In the present study, transfer is considered a product of the learning process. This study is concerned with transfer as a product of the learning experience of real clinical situations versus simulated clinical situations as instructional models in performance of neurological examinations. The primary problem in the present research study is to investigate instructional simulation, utilizing simulated learning situations in the clinical education of Osteopathic Medical students as representations of the real world. PURPOSE The general purpose of this study is to ascertain the practical effectiveness of instructional simulation. This will be demonstrated by using simulated patients as a viable methodology for providing clinical training experiences in neurological examination for first-year Osteopathic Medical students. Simulation is not a substitute for real clinical experience, but rather a cost/effective method of preparing for early clinical exposure and as a supplement to active long—term training. Simulation's key attribute is that it represents reality and enhances the students' learning and transfer of skills to real patient clinical problems by practicing the necessary skills under realistic conditions. Second, simulated patients can be used early in medical education for practical clinical exposure, and they can also be available or on call at any time. Third, by using advanced medical students programmed as simulated patients, training their junior peers could result in cost/benefits, reinforcement of previous educational experiences for the advanced student, and could provide an excellent vehicle for feedback while giving first-year students immediate involvement in practical clinical experiences. Another purpose of this study is to add to the body of knowledge of instructional simulation methods as related to the training and transfer of psychomotor skills, affective behavior, and cognitive knowledge for effective clinical performance with real patients. There are six specific objectives of this comparative study: (1) the development of new instructional methodol- ogy, (2) new training techniques and educational methods in medical education, (3) development of methods of assessing student satisfaction and patient satisfaction, (4) clinical instructor ratings of clinical competency, (5) student performance success criterion measure during training, and finally. (6) more effective student behaviors, more rapid skill development, less fear of failure, and a favorable cost/benefit analysis. RESEARCH HYPOTHESES The general hypothesis of this study is that subjects exposed to instructional simulation, utilizing simulated patients, will demonstrate better performance of the psycho— motor skills, affective behaviors, and cognitive knowledge used in the total performance of a neurological examination of a real patient when compared with subjects exposed to clinical instruction using real patients. There are ten directional hypotheses investigated. The hypotheses have been stated in research form. Ha: 1 Students trained with simulated patients as models in A. simulated clinical experiences will: Demonstrate a better total performance in clinical competency during the final Neurological Evaluation History and Physical Examination, by receiving higher ratings on the criterion measure rating scale than students trained with real patients as models in real clinical experiences. Demonstrate better psychomotor skills by receiving higher ratings on the final performance criterion measure rating scale than students trained with real patients as models in real clinical experi- ences. Demonstrate more effective affective behaviors by receiving higher ratings on the final performance criterion measure rating scale than students trained with real patients as models in real clinical experiences. Demonstrate more cognitive knowledge by receiving higher scores on the final performance criterion measure than students trained with real patients as models in real clinical experiences. Ha: Ha: Students trained with simulated patients as models in a simulated clinical experience will demonstrate greater total performance skills in clinical com- petency in each of the three treatment training experiences by receiving higher ratings on the performance criterion measure rating scale than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will: A. Demonstrate a greater confidence by anticipating higher total performance in clinical competency on the final performance criterion measure self- rating than students trained with real patients as models in real clinical experiences. Demonstrate greater confidence in their own psychomotor skill technique abilities on the final performance criterion measure self-ratings than students trained with real patients as models in real clinical experiences. Demonstrate greater confidence in their own effective affective behaviors of establishing a relationship and eliciting data on the final performance criterion measure self-rating than students trained with real patients as models in real clinical experiences. Ha: Ha: Ha: I). Demonstrate greater confidence in their perform- ance of a complete Neurological Evaluation History and Physical Examination with real patients on the final performance criterion measure self- rating than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will demonstrate greater agreement between the student self-rating and the clinical instructor's rating of total perform- ance in clinical competency on the final performance criterion measure ratings than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will respond more positively about their "self" in the criterion measure of self-ratings on factors secure, successful, calm, pleasurable and competent than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will rate higher in the criterion measure of self-ratings on the factors realistic, important, useful, meaningful and ~ - v“ ol ' 4‘ a p. . s ...d 0-!) .Iv' ‘oiA a I J I‘ t 0.. A" - VIA - \l. Ha: Ha: Ha: 10 successful than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will rate the factors providing all the skills and abilities, providing psychomotor skills and techniques, pro- viding the medical knowledge necessary (cognitive), providing the development of affective behaviors, and in providing feedback, higher as vehicles in performing the complete Neurological Evaluation History and Physical Examination on the final per- formance criterion measure rating than students trained with real patients as models in real clinical experiences. Students trained with simulated patients as models in simulated clinical experiences will request additional simulated instructional experiences as evidence of preference for this method of training more than students trained with real patients as models in real clinical experiences on the final performance criterion measure rating scale. Students trained with simulated patients as models in simulated clinical experiences will demonstrate greater improvement vs. consistency in the patient evaluation performance criterion measure ratings 11 than students trained with real patients as models in real clinical experiences. Ha: 10 Students trained with simulated patients as models in simulated clinical experiences will produce greater patient satisfaction, receiving higher ratings in performance on the final patient evaluation performance criterion measure rating than students trained with real patients as models in real clinical experiences. W In Chapter II, a comprehensive review of the pertinent literature concerning educational simulation is presented. In Chapter III, methodology is discussed, including descriptions of the sample, Neuromuscular Systems Biology I and II course, clinical experience protocol, treatment materials, training of simulated patients, administrative procedure, criteria measures, Research and Null Hypotheses, design, and analysis. Chapter IV is devoted to the analysis of the results, and the report on the status of the Research Hypotheses. In Chapter V, conclusions are provided; implications of the immediate results of the study on medical education program change and future research suggested by this study will be discussed, and the study is summarized. CHAPTER II REVIEW OF LITERATURE ORGANIZATION Simulation is best described in relation to its use in a discipline. Inasmuch as this study is constructed around instructional simulation in behavioral sciences related specifically to the use of simulated patients in cflinical medical educational experiences, it seems impera— 1jve that a selective review of related literature be mmwided. This is the purpose of Chapter II. The major organizational divisions of this chapter pnxmed from general considerations of simulation to spmfific contributors utilizing instructional simulation as atechnique for training in education. DEFINITION OF EDUCATIONAL SIMULATION Summation in education has been used as a blanket tern1tx>cover a multitude of activities, all describing a complex system connoting a process or a product Crwelker,]359a; Fattu, 1965). Simulation is generally defined as obtaining or relating to the essence of some- thing'hdthout all aspects of reality (Thomas & Deemer, 1957). 12 13 Maatsch (1972, pp. 1-2) identifies educational simula- tion instruction as "Verisimilar training -- an instructional method that seeks to provide learning in a truthful or realistic representation of real-world situations in which subsequent independent performance will occur. Verisimilar training employs simulation as the primary vehicle for training.“ Business, Military and Educational Use: Twelker (1969a, 1969b) estimates that simulation used as a generic term for a variety of instructional techniques has been applied in the military in over 3,000 different ways. In business and industry there are over 250 different forms of simulation in use. Zuckerman and Horn (1970) estimate over 1200 simula— tions/games are in current use in education. In the current issue of Simulation/Gaming News (Twelker et 21., 1972), Zuckerman and Horn indicate a 50% increase has occurred in the last two years in the number of simulation/ games. Heritage of Educational Simulation: Educational simulation has ceased to be the exclusive science or art of applying processes and products in the traditional boundary of military training and has spread across all levels of education—-e1ementary, secondary, college, business, and industry. Educational simulation harmed for training hospital administrators, doctors, 14 nurses, teachers, and business executives (Bartscht, 1962; Twelker, 1969b). The multi-applications of educational simulation techniques and devices used in business, industry, the military, and more recently, in education, defy a systematic scheme of classification. However, in education, the innovation called "simulation and gaming" or instructional simulation does represent a conjunction of the techniques and devices developed from various heritages-—the simulator for training drawn from the equipment oriented military aircraft simulators, the game for entertainment expanded for use in competitive problem-solving management games of business and industry, and the role playing, or small group procedures for understanding one's self and others, as used in the social and behavioral sciences (Thomas & Deemer, 1957; VonNeumann, 1944; Grambs gt 31., 1938; Twelker, 1970). m Basically, all definitions of simulation relate to the process or technique of doing an activity and/or the product which is the device or model used in the simula- tion. Several levels can be identified within a simulation system, regarding the variety of activities in which models of real life situations are developed for educational purposes. The levels can be classified: (1) to evaluate or analyze an existing program, (2) to create and evaluate a model or plan for a new program, am3(3) to provide a learning environment that represents 15 a life situation (Beck & Monroe, 1969). These three uses of simulation can be adOpted by any discipline and represented, in general, as research, development, and training, all of which imply evaluation. The most logical and workable approach concerning methods applicable to the use of simulation in research, development, and training within educational instruction and evaluation is to develop a taxonomy that utilizes the heritage of simulation. The taxonomy tends to fall into the categories of media ascendant simulation methods emphasizing interaction with equipment, machines, film, etc.; interpersonal ascendant simulation methods charac- terized by role playing, decision making, and player interactions produced by the game characteristics of the simulations; and non-simulation games emphasizing the competitive aspects of abstract games to motivate learning of concepts and principles of a particular discipline or subject matter (Twelker, 1967; Cruickshank, Broadbent & Bubb, 1967). Through the proper use of educational simulation, a significant breakthrough for improvement of educational practices is developing. Fattu (1965) indicates that the techniques and devices used in simulation will permit educators and researchers to replace negative attitudes regarding education's inability to study "real" educational problems with attitudes favorable to such exploration. In that simulation provides realistic descriptions and 16 predictions on variables such as motivation decision- making and the educational environment, research development and training programs using simulation methods can put together a larger number of propositions needing evaluation. These propositions can be developed into a realistic predictive model that can be used in solving problems, in acquiring skill proficiency, and in reducing unforseen contingencies in the training environment. Simulation Design: Perhaps, as Cherryholmes (1966) has suggested, the problem with simulation training may center on the construction of a good simulation design. The design problem appears to be critical in building an explicit theory about a referent system. The referent system (i.e., the real world that is being simulated), must be analyzed as to subject matter tasks, facts or conditions representative of the real world with actions and conse- quences of behaviors similar to the real life situation. The individual involved in simulation training should be afforded the opportunity to evaluate the design of the simulation in that confidence in the objectivity of the simulation will support the individual's learning. If aan individual can evaluate, or have input into his training taxperiences, assistance can be given for the improved development of the experience (Herron, 1960) . Guetzkow (1963) argues that in constructing a simulation model in 17 education there is need to build into the design the "isomorphism of the environment" and the critical variables that undergird the nature of reality being simulated. Abt (1967) contends that simulation designs need to consider the problem in detailing the implementation of the model. The model should relate to the learner's interests and provide an opportunity to experiment actively with the consequences of behaviors employed. The simulation/games design recommended by Abt would have steps that include (1) an analysis of the social system to be simulated, (2) a basic game model, (3) the human player model to be simulated (roles to assume), and (4) a method of refinement to allow continued improvement and simplicity in the design. Bruner (1960) wou1d_contend that simplification of complex learning may,‘in the long run, be a desirable strategy assisting the learner by considering readiness and individual differences. Coleman (1968) would insist that the simulation should state the reality parameters in specifics and that the simulation game and real life relationship be true with clearly stated objec- tives in order to allow research into content. Gagne (1965) provides a most logical and consistent grudeline for the design of simulations. The designer of :simulations must provide specificity of purpose and fhinctions. Gagne points out that "the purpose of simula- ticnm are of the utmost importance, not only in determining tflue way in which simulators are used, but also in 18 establishing the criteria for their design." The three purposes identified for simulation design are training, assessment, and development, all or some of which may be served by one design if preferred. The designer must be explicit about his choice of purpose or purposes. After the function or purpose of the simulation has been detailed, the operational situation or referent system must be defined. This approach requires definition of the learning functions in specific operational task terms and identification of the situation stimuli that are relevant to the tasks to be included in the simulation design. The situational stimuli need not be the exact replica of real life. Equivalent stimuli are sufficient. It is generally agreed that there is no justification for loading up a design system with variables that are not originally considered as part of the learning functions to be fulfilled by the simulation. Gagne (1965) would not recommend a design based upon an exact physical duplication because there would be no guarantee of maximum positive transfer of learning. Twelker (1969a) would agree with Gagne on the need for psychological fidelity. However, a critical study of the methodology of designs show that designers of educational simulations are more apt to be concerned with physical fidelity of simulation than with concern for psychological fidelity. 19 Twelker (1969a) contends, "If there exists a 'credibility gap' between instruction and the operational world, then the learner is at a disadvantage when it comes to either performing in the real world, or understanding what the real world is like." Coleman (1968) would support the position that simulation games should offer opportunities to act out life-like, decision-making roles in realistic settings. In Coleman's situation, the instructional simulation game would be a planned strategy enabling the individual learner to model the roles of real-life situations. Coleman believes that games are important to the process by which learning takes place. The game is a way of partitioning off a portion of action from the complex stream of life activities and constructing from this referent point the role which the learner would perform in real life. This approach requires constructing a game that defines the participants, the allowable actions, the time, and the environment in which the actions will take place. Again, the basic design is the same. In this case, a life-like activity of a current social problem is processed through role-playing techniques with basic game strategies as the device or model in the simulation. The design requires descriptions of the purpose, the plays, the constraints, the process of the simulation, and the criterion for assessment. Coleman desires the high invest— ment relationship of in-school activities and out-of-school 20 activities. This will result in the reduction of the gap between real life role behavior and the behavior displayed in the instructional situation. Emphasis of the "Johns Hopkins" group is on research relative to sociological concepts. The games designed are purposeful in strategy and tactics for research and testing objectives. In design, the key issues center on what should be simulated and how the simulation should be implemented to effect change in learner behavior and transfer to real- life situations. There is concern for both primary and incidental learning, and therefore, further questions of when, who, where, and why should be considered. A workable design effective in the develOpment of instruc- tional simulation systems for training is offered by Maatsch (1972) and Chapman, Kennedy, Newell, and Biel (1959). The recommendation is to develop the simulation design based on the fundamental breakdown of: (l) the functional environment or setting, (2) the task environ— ment or problem needing simulation, and (3) the scenario or training plan which includes the evaluation performance criteria measures. Through this workable model, the simulation designer can specify the technique or processes of the training evaluation system and provide the method or product necessary for a viable simulation model. This approach is inclusive of both the primary and incidental learning, and provides a functional approach in designing simulation training systems. 21 Crawford and Twelker (1969) provide the most inclusive rationale for the design of instructional simulation systems. The emphasis is on reviewing the differences between the learner before instruction and after instruction, centering on the conditions of learning. The design needs to apply the learning paradigm to the intellectual problem-solving, decision-making, physical, emotional, and social behaviors desired to be learned. The design must bridge the gap between the "learner's initial repertoire and final criterion repertoire" in an environment that is meaningful to the learner, determined by ideas about self and the world in which the simulation is to be transferred. Three basic decisions and the thirteen specific steps in designing a simulation system are outlined from the work of Crawford and Twelker (1969) to provide collec- tive insight into what is considered a master protocol in the design of simulation systems: I. Determining what shall be taught: Step 1 -- Define instructional problem Step 2 —- Describe the operational educational system Step 3 -- Relate the operational system to the problem Step 4 -- Specify objectives in behavioral terms Step 5 -- Generate criterion measures 11. Determining how best it might be taught: Step 6 -- Determine appropriateness of simulation 22 Step 7 -- Determine type of simulation required Step 8 -- Develop specifications for simulation experiences III. Validating the system: Step 9 -- Develop simulation system prototype Step 10 - Try out simulation system prototype Step 11 - Modify the simulation system prototype Step 12 - Conduct field trial Step 13 — Make further modifications where appropriate The design used in simulation by a discipline should consider the total learning experience of the individuals participating. This cannot be accomplished without pro- viding viable parameters, or an organized approach in looking at the process of performing an activity, and at the product, which is the device or model used in the simulation. If designs can be organized around the enabling and terminal objectives of a training program, perhaps evaluation through research and development will prove the relevance of simulation to the psychology of learning. Once a discipline looks at a learning experience, objec- tives can be detailed and questions can be raised regarding the learning domains; then, the simulation designer can look at cognitive, psychomotor, and affective behaviors related to the specific problem in the simulation training being used for transfer to the real world (Mager, 1962). The experimenter in educational instruction must provide strategies that utilize workable system designs of 23 simulations in order that validation of the educational application can be established. EDUCATIONAL SIMULATION FOR TRAINING It is difficult to separate training from research and development within the context of educational simula- tion. Simulation training, to be of value, should involve continual development of new uses and methods and should be organized around a research effort established in the total evaluation of the program being simulated. There— fore, it must be assumed for training purposes, that an experimenter will follow a design which provides a vehicle for development and research. Educational researchers and practitioners have professional responsibilities to use techniques and methods that are effective in simulation training, as evidenced by behavior change for the learner. Additionally, educators should make a commitment in bridging the gap between "learning theory" and instructional practices that purport to result in learning. In many educational training simulation systems, the objectives are not clearly stated and whatever learning takes place is difficult to evaluate. Boocock (1968) feels that because there is no guiding theory, there has been very little empirical evidence supporting the effectiveness of simulation. Carter (1968) states that users of simulation need to develop reliable assessment 24 procedures for determining what has been learned and how it has been learned. Criteria must be established to assess learning in simulation by implementing basic research designs for experimentation. Simulation Learning and Transfer of Training: Many of the criticisms of simulation center on the lack of supportable evidence. Cherryholmes' (1966) review of six studies concluded: "Simulation does produce more student motivation and interest compared to other teaching techniques, but these are not consistent or significant differences in learning, retention, critical thinking or attitude change.“ However, these conclusions are features of many educational research efforts. Results, often, are not significant and even ambigious between various training strategies. While it is believed that simulation may not (at the present time) be the panacea to learning, it is believed that it has the potential of proving to be the most effective instructional or training technique of converting "knowledge" or "theory" into practical action situations which approximate real life. The methods of media ascendant simulations, inter- personal ascendant simulations or non—simulation games emphasize active responding by the learner in the environ- ment. In a response situation feedback is given as the primary condition to motivate and enable learning. In media and interpersonal simulations the fidelity or realism 25 of the learning situation is promoted to assure relevance and transfer of learning to similar real world situations (Twelker, 1969a; Gagne, 1965; Biel, 1962; Gagne, 1962). In simulation training techniques, propositions or situations can be established that provide the vehicle for individuals to learn from the consequences of their behavior (operant learning), from conditions that become associated with their behavior (respondent learning), and from the human models present in the simulated environment (model learning) (Krumboltz, 1966; McDonald, 1965). In simulation training the common characteristic is that the learning situation can provide the essence of "real life" without all of the particular reality. Either, on the basis of design or on the basis of instructional application, educational simulations utilize the principles and rationales of psychological learning theories. Perhaps the greatest contribution to the theory of the design of educational simulation is the criteria, developed by Twelker (1969a), which embrace the stimulus- response (S-R) theory of learning. Twelker considers that an instructional simulation must embody a stimulus situation presented to the learner, a response, which is an observable change in the learner's behavior, and a feedback sequence (or reinforcer) which interprets the consequence of actions taking place within the learning environment. It also serves as the basis for modifying subsequent responses to the stimulus. In the use of 26 simulation for training, Twelker (1969a) would state that simulation (1) presents or demonstrates information of the real world through a model that is difficult to distinguish from what is real, (2) provides opportunities for practice or exercise of previously learned principles or for the trialéand-error learning of principles, and (3) assesses performance as used in criterion measures. The second point is classed by Twelker as a "contextual response simulation," and is the activity or process involved in training simulation that makes simulation a viable learning system. The contextual response simulation activity looks at the learner's perceptions of the realness or non-realness of the environment. Twelker (1969a) characterizes contextual response simulations (those that provide a simulated stimulus which allows a representative response of real life) as: (l) enacted or life-like responses made to (2) simulated stimulus situations that (3) provide feedback to the learner vis-a-vis the learner's behavior in the ongoing training context, and they (4) offer control measuring for realism. In the interaction involved in an enacted or life-like response, the learner either role plays and assumes the role of someone else or the learner practices a role that may be his own future role. In the latter, the "role— performing simulation,‘ the objective is to reinforce transfer from the training experience to the real-life 27 situation. The greater the representation to the real life role for which the learner is preparing, the more the transfer (Garvey, 1967; Kersch, 1963; Twelker, 1967). Even though the distinction between the learner assuming a role and the learner performing his own expected role appears to be hair-splitting, it is, nevertheless, important. The closer the representation is to reality for the learner, the higher the psychological fidelity and perhaps the greater the transfer. Basically, Twelker is stating a learning paradigm. The "contextual response" model is simply a unique method employed in using simulation training. Twelker emphasizes the need for representative real-life responses made to simulated stimuli with feedback (reinforcement) in the learning experience. In turn, the simulated learning experience offered should provide ”control," which is only the assurance that the simulated environment allow the "stress," the "reproduction,' and the "planned variations" that occur in real-life situations. The "contextual response" simulation concept developed by Twelker (1969a) utilizes both major theories of learning. Simulation allows for both discovery learning and reception learning. The learner can practice previously learned principles and/or discover the prin— ciples to be learned. The intent of this study is not to become involved in the controversy concerning discovery versus reception learning. The proponents of both theories 28 contend that their own theory facilitates retention, transfer, and motivation for the learner (Bruner, 1960; Asubel, 1963; Gagne, 1965). What appears to be the more important purpose of simulation training is the promotion of positive transfer of learning from the simulated training experiences to the real-world situation. There- fore, in simulation experiences, efforts should be directed at the training situations to determine if the experience in the simulation task facilitates learning of the real-world task and to determine if the learning in a simulated experience will generalize to the same general class of tasks in the contexts of the real world (Gagne & Rohwer, 1969). Gagne (1965) has delineated transfer as "lateral transfer,‘ which refers to the generalizing of material learned over a broad class of situations at about the same level of complexity, and "vertical transfer," which involves the ability to apply basic principles previously learned to the learning of additional principles requiring higher levels of ability. Twelker (1969a), however, in discussing the training techniques of simulation, offers an additional term: "parallel transfer." Simply stated, "parallel transfer" involves the learner in moving from the role—performing simulation training experience to the real-world situation. In other words, all the learning represented in a simulation situation is operationally the same and the learner simply applies the learning. The 29 "parallel transfer" concept is of critical importance when the simulation used in training requires performance in the real world. Studies regarding fidelity of simulatiOn are revealing differing results (Gagne, 1962; Cox, Wood, Boren & Thorne, 1963; Gryde, 1966; Crawford, 1962; Bugelski, 1956). Some of these studies state that the simulating must have perfect fidelity or realism for maximum transfer. Others show it is the practice effect that is more important than the realism. However, Muckler et 21* (1959) points to psychological fidelity as the key to transfer. Schalock (1967) contends that in order to accurately measure performance, the fidelity of a measure requires that the simulation training experiences be isomorphic (i.e., identical or similar in form and structure). If a stimulus is a real one from the real world then the response must be a real—life response. In "contextual response" training simulations, the stimulus is simulated and as such, the response is representative of real-life stimulus. This allows the contention for transfer of what has been learned from simulated training situations to the reality situation. Gagne (1965) would argue that a simulation is not real-life; it is a repre- sentation of real life. Therefore, the degree to which a simulation represents the real-world situation can certainly be measured in a direct manner in terms of the amount of transfer; and "to the extent that the simulation 30 is 'real' the performance is 'real' and one cannot define something which is 'more real.'" Studies of Educational Simulation: A few select studies are included in this section to show the recent research on simulation training techniques. Twelker (1966a) found simulation training a powerful vehicle for teaching principles of instruction or principles of classroom management and control. Prompting as an instructional variable was introduced within the study and it was found that the use of prompts assisted learning. The purpose was to determine if prompting would increase learning efficiency without reducing transfer. The concern again was on the issue of learning by discovery. Wittrock, in Twelker (1966a) study, felt that withholding principles may reduce performance, increase the time required for learning and decrease affectivity toward the learning experience. In further study in teacher preparation, Twelker (1967) found that realism in simulation and prompting are not important variables in enhancing trans- fer, in comparison with instructor differences and, possibly, length of training. Cruickshank and Broadbent (1968) found simulation experiences to be at least as effective as an equal period of student teaching in the areas of attitude change, confidence in ability to meet classroom problems, teaching loehavior, and the amount of time needed to assume full 31 teaching responsibility as a student teacher. Kersh (1965) from his study "Classroom Simulation: Further Studies on the Dimensions of Realism," concluded that students who underwent simulation training were judged to be ready to assume full responsibility for a new class up to three weeks earlier than students who had no simulation training. However, Kersh (1962a, 1962b) found that simulation training had no measurable effect on actual student teaching one year after students underwent a series of simulation experiences, nor on the types of problems that student teachers found most difficult to overcome during their experiences in student teaching. Also, in this same study, Kersh found that students responded to filmed simulated experiences better when the projections are less realistic (small) than when the projections are life-size (realistic), but that there is no significant difference in post—test performance of students who enact responses to problems on film and those who simply describe how they respond. In a further elaboration, Kersh, in his studies on simulation in teacher education begun in 1961, suggested that high fidelity in simulation is sometimes important for motivation and that the transfer effects may be minimally affected by highly accurate laboratory simulation. Stewart, Danielian, and Foster (1969), in simulating intercultural communication through role-assuming techniques found that the exercises (role playing) are an effective 32 means of bringing about desired changes in cultural per— spective at the emotional as well as the intellectual level. In addition, the technique yielded strong trainee involvement. Grimsley (1969) examined the effects of varying fidelity of training devices on acquisition, retention, and reinstatement of ability to perform procedural tasks. There was no difference in training time to learn the procedural task, initial performance level, amount remembered or retained between individuals trained on high fidelity devices and those trained on low fidelity. Results of a survey on a study utilizing simulation as a training experience for administrators in developing decision-making skills in management found that the participants evaluated the simulation exercise as a valuable technique (Dillman & Cook, 1969). Beaird and Standish (1964) utilized a simulated counseling interview as a training experience to provide counselors with the behaviors of discriminating between cognitive and affective elements of client verbalization and in responding to verbalizations in ways that would facilitate further affective verbalization by the client. The results indicate that the subjects trained with simulation demonstrated a significant gain in their per— formance from pre-training to post-training interview assessments. 33 In another study by Twelker (1968) investigating “Successive vs. Simultaneous Attainment of Instructional Objectives in Classroom Simulation," the author concluded, after analysis, that the simultaneous method was more efficient in terms of the learning rate of pre-service teachers. Alexander 33 31. (1967) used model simulation tech- niques (in the form of exercises in decision making) with a group of prospective principals to provide practice in administrative decision making, problem solving, and to incorporate these techniques into the training program. The results suggest that in the analysis of behavior on a questionnaire, simulation exercises were effective as training tools for improving administrative decision- making and problem-solving skills. Johnson (1968) in a study with 288 high school boys used simulated vocational problems in determining the optimal difficulty level of some occupational problems. The criterion for successful performance was set at three levels of difficulty. Difficulty level was not found to produce differences in the measures of expressed interest scores on an information test and incidents of information seeking behavior. However, the simulation technique did generate interest and exploration in the specific occupation used in simulating vocational problems. 34 In a study on interaction analysis and classroom simulation as adjunct instruction in teacher education, Twelker (1968) used the two approaches as methods for involving maximum student participation in the learning experiences of student teachers. The subjects received either interaction analysis and/or simulation training or neither. Effects were measured with simulation tests, classroom performance records, course grades, Minnesota Teacher Attitude Inventory, Edward's Personal Preference Schedule, and a cognitive test. The study revealed that students receiving only simulation training spent more time than others in simulation and management behaviors. The hypothesis that students in simulation training would benefit from interaction analysis training was not supported. It appeared that concurrent training inhibited students from discriminating problematic cues and responding appropriately on simulation tests. Wayne State University (1967) in a summer industrial work experience and occupational guidance program called Project Pit, with Detroit's inner-city youth, provided occupational information and guidance to help youth see the need for a good education, provided financial means to return to school and to make useful goods for non-profit organizations. Those aims were fulfilled through a simu— lated industrial setting and an intensive guidance program. (Questionnaires and analysis of the Detroit High School population revealed that most youths either have not 35 selected an occupational goal or have selected a goal that is unrealistic for their abilities and potentials.) Project Pit's most important aim, the upgrading of the employee's goals and aSpirations and the acquisition of a sound background of the occupations available to them, is an intangible that is difficult to measure in a short- range program; however, results were obtained which indicated a significant shift in educational and occupa- tional aspirations to both a higher and more realistic level through the use of simulated training experiences. Kersh (1964a, 1962c) in a presentation to the American Educational Research Association, discussed the issue of fidelity in classroom simulation based on the experimental results obtained from his study on the effects of variations in the visual display on learning rate and laboratory performance ratings. He found in his results that there was no support for Thorndike's long-standing identical elements theory of transfer. The results were supportive of more current thinking regarding verbal mediation as a mechanism of transfer. Stone (1972) in a study on the effect of fidelity of simulation on counselor training found that counselor- tacting-response leads (CTRL's) were learned and transferred to differing conditions. Stone's question was based on Thorndike's theory of transfer of training (Thorndike & Woodworth, 1901) that "improved efficiency at one task, acquired as a result of training, would trasfer to another 36 task only insofar as the two tasks had identical elements." This is also supportive of Bandura's (1969) suggestion that exposure to a variety of stimulus components facilitates generalization (response). SIMULATED PATIENTS As A_TECHNIQUE FOR TRAINING IE MEDICAL EDUCATION Enacted Role-Performing Simulation: In 1962, Dr. Howard Barrows (1971) created the simulated patient technique in medical education training and evaluation. In working as a consultant in neurology at the Goldwater Memorial Hospital in New York during 1959 and 1960, Barrows became involved with David Seegal who was actively investigating the performance of medical students in clinical competency. Additionally, Barrows recalled a personal experience with the board examinations in neurology. The association of these two events provided the spark that gave birth to the use of "programmed patients" used as a technique for evaluation of the neurological performance of medical students in neurolog- ical service rotation. Simulated realism in an enacted role-performing situation through the use of mock—up clinical facilities and programmed or simulated patients has been used by Barrows and Abrahamson (1964) for instruction and assess- ment of skills in clinical neurology. In their study, 37 established out of the desire to provide quality measurement of student performance, to determine effectiveness of teaching methods, to establish a tool used for providing guidance, and to provide criterion measures in appraising student performance, the authors concluded: "Not only does this technique avoid the problems incurred when an observer is pre- sent, it offers the far more important advantage of guaranteeing that the patient is constant for all students being tested. Thus, faculty may far more easily determine the strengths and weaknesses of the teaching program through a careful analysis of the types of errors made by students. In addition, records of the performance by individual students may be readily analyzed for purposes of further individual instruc- tion and counseling. While it is true that other techniques of measurement of clinical performance may be used similarly, the virtual elimination of the variable of patient behavior seems to make the use of the programmed patient a most effective evaluative tool." (Barrows & Abrahamson, 1964, p. 802). What more can really be said in support of simulation training in medical education? The pioneer study has set the standard for further research, development, and use in training medical students. Further support has been provided by McGuire and Soloman (1971) who used simulation for the assessment of clinical skills in orthopedic medicine. Simulation has been used by Jason, Kagan, Werner, Elstein, and Thomas (1970) and Froelich (1969) in the undergraduate training of doctor-patient interaction skills, by Elstein, Kagan, Shulman, Jason, and Taupe (1972) for research on the process of medical inquiry, by Kagan 38 and Schauble (1969) in the assessment and modification of affective responses, and by Levine and McGuire (1968) in developing simulation examinations employing role—playing techniques (i.e., simulated patients). With increased interest in innovative instructional programs in the preparation of medical students, Morrison and Jones (1972), at the University of Dundee, developed through role-playing sessions using simulated interviews, a pilot study video-taping a 'doctor' who was an experi- enced general practitioner and a patient who was an actor or actress trained to assume the role of a patient with particular problems and/or symptoms. The entire experience was made as realistic as possible. The objective was to review the video-tapes in an effort to develop an appropriate observation schedule which would record objectively different aspects of the performance of the doctor and the patient, to develop comparative records of the various interviews, and to assist in developing a training program model for student trainees in general practice. Barrows (1971) reports that Professor Gauthier at the University of Geneva presented a simulated patient at a weekly neurological clinic as a real patient. After the complete presentation, when it was announced that the patient was simulated, all participants were shocked. In an innovative approach using simulation techniques for performance evaluation, Hubbard 33 31. (1965, 1971), after stating dissatisfaction with Part III of the National 39 Board examination, completed a critical incident study to redefine clinical competence that should be assessed in medical student performance. The FLEX test was then developed which used new testing procedures of films, slides, and photographic reproductions to measure diagnostic recognition skills and programmed examinations assessing problem-solving ability. It appears that simulation techniques in medical education of the variety involving media ascendant methods are securing more research efforts within the United States than the enacted role-performing techniques using simulated patients. McGuire and Babbott (1967) are utilizing the simulated physician patient encounters called patient- management simulation requiring students to problem-solve in reaching a decision on the patient's medical problems. In a study by deDombal, Smith, Modgill, and Leaper (1972), attempts were made to assess the value of four media ascendant simulation methods of the diagnostic pro- cess, used as an adjunct to conventional bedside teaching during a beginning course in clinical medicine. The evaluation of the results indicate that simulation was of benefit--in the group of students having simulation experiences, performance in the diagnostic process skills were higher than students who did not have simulation experiences. Jason and Tichtov (1971), in reviewing instructional technology in medical education, indicated multiple needs 40 in providing effective instructional methods for medical education. They feel these needs are so complex in character that simulation is likely to be the most important new educational approach of the decade. Rationale for Simulation Training in Medical Education: Role-performing instructional simulations share benefits of supervised clinical experience without its costs, risks, inefficiencies and inconveniences (Barrows, 1971). In further support of simulation in clinical education, Gagne (1965) applies simulation to the process of acquiring skills at a late stage of medical learning where "book knowledge" or "theory" must be put into practical action. Stated simply, instructional simulation in clinical training with an opportunity for feedback as a reinforcing stimulus will prove an effective instructional tool in representing real clinical experience and will provide transfer of learning for first-year osteopathic medical students. With feedback from fellow students, simulated patients, and clinical instructors as a primary condition to motivate and promote learning, the unwanted variables associated with real clinical experience can be avoided. Trivia (or as in Barrows' [1971] description, the "red herrings of medicine"), such as day-to-day variation in the training situations or the many accidental occurrences that detract from student learning, can be 41 controlled, planned variation of experiences can be made, and performance evaluations developed. Simulation training allows opportunity for continuous formative evaluation while the experience is at hand. The student will be involved in learning effective performance behaviors of the necessary psychomotor skills, affective behaviors, and cognitive knowledges necessary for making accurate clinical judgments in neurological examination. Barrows (1971) indicates that a closer review of the uses of simulation reveals many advantages in the learning of skills. Simulation allows controlled learning in that a complex task can be presented for instruction in less difficult segments appropriate to a student's level of learning. The tasks and functions that the subjects must learn are the same in the real or simulated instructional experience. The similarities are so close that there is little difference in the amount of learning necessary to excell in either training situation. The above review supports simulation training as a potentially powerful instructional aid but the answer to the other half of the question, namely the issue of trans- fer in training from simulated to real situations, can only be partially supported by past research in other areas of simulation training and education. A primary purpose of the present study is to integrate the cognitive, affective, and psychomotor aspects of learning in a role-performing simulation training activity 42 and to offer a partial solution to the problem of knowing whether performance in a representative environment will transfer to the real through demonstrated clinical com— petency. Wittrock (1967) states that hypothetical researchers may be disappointed in the realization that little is known about the conditions of transfer, but believes that Gagne's model in the study of transfer is perhaps the leading contender to be used in the study of instruction. In the present study, it is not intended to investi- gate the theoretical model of the conditions of transfer. An objective is to empirically determine if the conditions provided by simulated training (i.e., representative of real world tasks, practice, and feedback) result in better learning and transfer to the real environment in terms of better performance in the real—world situation. This study is primarily concerned with the use of simulated instruction using simulated patients as a viable alternative in training first~year Osteopathic Medical students. In the present study, transfer is considered a product of the learning process. It is hypothesized that lateral, vertical, and parallel transfer from the experimental simulated training experience will occur in the real clinical situation. The rationale for this contention is based on the review of simulation training presented in this chapter and the probability that simulation training using simulated patients in clinical training of first, 43 year medical students will result in the transfer of training within medical education. CONCLUSION This concludes the selective review, analysis, and discussion of the literature which relates to educational simulation theories and practice. An effort has been made to present a panoramic perspective of the topic, bringing into focus its utilization in education as a viable technique in training and its transfer of learning from the representative world to the real. With this conclusion, attention will new center on the problems of methodology and procedure in Chapter III. CHAPTER III DESIGN OF THE STUDY SAMPLE The population of subjects for this study consists of the 33 students in the first—year class of Osteopathic Medical students, College of Osteopathic Medicine at Michigan State University, East Lansing, Michigan. The sample randomly selected from the population will be care- fully described, allowing generalization of the results of the study to similar populations of medical students. A random sample of 24 subjects (S5) was obtained from the first-year class of Osteopathic Medical students in the College of Osteopathic Medicine enrolled in the Systems Biology I and II Neuromuscular Systems Unit, Spring and Summer terms, 1972. The Systems Biology I and II course is a requirement of the regular academic program (See Appendix A). The random assignment of the 24 S5 was made to the two treatment groups; T1 = simulated clinical treatment, and T2 = real clinical treatment, utilizing a table of random numbers. The remaining nine Osteopathic Medical students, plus a group of five Allopathic Medical students enrolled in the Systems Biology I and II 44 45 Neuromuscular Systems Unit, were assigned to real clinical experiences, but not as part of the treatment groups and not with the facilities and clinical instructors utilized for the experimental study. The assignment of gs in the experimental design is presented in the chart below. Cell Frequencies, by Treatment Groups. Treatments _1_ _2__ Simulated Patient Real Patient Clinical Experiences Clinical Experiences 12 12 The experiences and the data collected for the remaining nine Osteopathic Medical students and the five Allopathic Medical students are the same as in the experimental study, but the results are not part of the analysis. Therefore this group of 14 students can be considered as inactive control within the study. Treatment 1.(T1) Subjects in this group were trained in three clinical training experiences in Neurological Evaluation utilizing simulated patients. Treatment 2 (T2) Subjects in this group were trained in three clinical training experiences in Neurological Evaluation utilizing real patients. 46 Inactive Control The remaining students enrolled in the Systems Biology I and II, Neuromuscular Systems Unit, were trained in three clinical training experiences in Neurological Evaluation utilizing real patients. Following is a careful delineation of the sample in order to allow the reader to judge how the population in this experimental study compares with other populations to which they might wish to generalize (Cornfield & Tukey, 1956). Sample Characteristics: 1. 2. Sex: 22 males and 2 females Age: Range = 22-43 Mean = 25.58 Median = 24 T1 Mean = 25.58 (Simulated) T2 Mean = 26.08 (Real) Marital Status: 11 married; 13 single Class Standing at Michigan State University: Third term full-time Osteopathic Medical students. Program: All 24 §S are enrolled in the regular Osteopathic Medical Program. Residency: 17 students are from Michigan; 3 from Ohio; 2 from New York; 1 from Pennsylvania; and 1 from New Jersey. Location of Undergraduate Work: 17 received their undergraduate education in Michigan; 2 in Ohio; 3 in New York; 1 in New Jersey; and 47 1 in Pennsylvania. Schools represented are Michigan State University; University of Michigan; Ohio State University; Wayne State University; Siena Heights University; Rutgers; City College of New York; Brooklyn College; Ferris State College, Michigan; University of Detroit; Western Michigan University; State University of New York; Queens College, New York; Miami University of Ohio; and Millerville State College of Pennsylvania. 8. Educational Background: Undergraduate Majors: 9 majored in Zoology (Pre-Med); 5 in Biology; 3 in Psychology; 3 in Science Education; 1 in Chemistry; 1 in Political Science; 1 in Pharmacy; and l in General Studies. Graduate Work: 1 in Psychology; 1 in Biology; 1 in Medical Technology; and l in Podiatry. 9. Employment: Prior to entrance, the following employment histories were recorded for the 24 SS randomly selected as the sample from the first—year class of Osteopathic Medical students. Job Categories: 15 were students with part-time employment (i.e., machine design, lab assistant, research chemist, bartender, etc.); 1 was a teacher of high school science; 1 was a teacher of high 48 school chemistry; 1 was a substitute teacher; 1 was a research chemist and a student; 1 worked as a traveling field representative; 1 was a Podiatrist; l was a Pharmacist; l worked as a pharmaceutical representative; and l was a General Motors representative. Further description of the "experimentally accessible" population is presented to allow the reader generalization to "target" populations (Bracht & Glass, 1968). The researcher was restricted to one Osteopathic Medical School, but the sample having characteristics the same as the majority of the Osteopathic Medical students (and perhaps Allopathic Medical students) in the country allows appli- cation of the conclusions to be generalized to larger target populations of medical students. Cornfield and Tukey (1956) promote generalizations from samples to populations with characteristics like those in the original study. The reader may make inference to other populations based on the characteristics of the sample detailed in this study. To dissuade concern for other problems of external validity, such as the ”Hawthorne Effect," "Novelty and Dissruption Effects," and "Experimenter Effects" (Bracht & Glass, 1968), the reader will have to accept the con- trols implemented for the study. However, a brief description will be of assistance. 49 The Systems Biology I and II, Neuromuscular Unit, is the first major system in the Osteopathic Medical students' educational experience. The students (experimental and inactive control) in this study.were informed that the experimenter (E) was an administrative assistant for the Systems course, having the responsibility for the educa— tional experiences encountered in the 15 weeks of the Systems Biology I and II, Neuromuscular Unit. The students had no knowledge they were participating in an experiment. The class understanding was that they were involved in the first major systems course within the Osteopathic Medicine curriculum. One of the research hypotheses tests the concern as it relates to the specifics of realism and anxiety regarding the clinical treatment experience. All students in the course realized that they received differ- ent clinical assignments. All students in the course were aware that practical clinical experiences would be arranged at various clinics in Detroit and Lansing with real patients and that others would receive training on programmed or "simulated patients" in clinics established on campus. The entire class had other real clinical exposures varying in location and in experiences (i.e., Medicine, Pediatrics, General Office Practice, in Flint, Detroit, Grand Rapids, Lansing, etc.) during the lS-week Systems Biology I and II Unit. As a result of various clinical experiences, questions regarding the use of shnulated patients or the various clinical assignments 50 were not raised. Students were simply informed that random assignments were made to the Neurological Clinics in the same manner as other clinical experiences had been made. In order to gain perspective of the clinical exposure during the lS-week Neuromuscular Unit, Figure l is presented. During the lS-week Neuromuscular Unit, the Osteopathic Medical student received one hundred fifty (150) hours of clinical experience. His experience is divided into: 9 five-hour units in medicine rotation in the hospital with an internist; 4 five-hour units in pediatrics rotation in the hospital with a pediatrician; 3 five-hour units in neurology rotation in the Neurological Clinics as part of the Neuromuscular Systems Unit; 14 five- hour units with a preceptor, i.e., in the family physician's office; 1 final practical neurological examination evaluating total performance of clinical competency for the systems unit. Regarding novelty or disruption effects in the experiment, it must be emphasized that Osteopathic Medical students are required to follow a standard ethical decorum when functioning in clinical experiences. All students were advised before the clinical assignment of their professional responsibility to the patient, to the physician in charge, and to the hospital. Clinical experi— ences in the Osteopathic Medical curriculum are looked forward to as an important segment of the student's education. Clinical exposure as displayed in Figure l is ,u“ .5. onvu - I '— 4 ,. - “ - .. A ._ " 51 an integral part of the Osteopathic physician's education. Additionally, Figure 2 is presented as self-descriptive material to provide an overview of the basic curricular model of the College of Osteopathic Medicine. Figure 3 provides a.detailed view of Unit II, the Systems Biology Sequence, which includes the Neuromuscular Unit. Appendix B provides an excellent description of the systems courses in general. Regarding experimenter (E) effects, the E acted only as an assistant for the total course which required basic coordination of all course activities. No contact during the specific clinical experience treatments was made other than in collecting the required examination and evaluation forms as outlined and required in the advance organizer (clinical course protocol booklet - Appendix C). The duties as administrative assistant in the systems course had no effect on the behavior of the total class or, in fact, the experimental gs. The §S accepted the E's professional responsibility as that of administrative assistant, which required the coordination and contact of collecting the material required for the Systems Biology I and II course as well as for other clinical educational experiences. Other questions on external validity have no relevance for concern in this study as they have all been controlled or have no effect. first 7:35.: _ _ III: .II :1- in I O I u ("llavlfllc Ol~llul lei“ H I! N I! I! II c I: .‘V a 'II I I .| 1 ll .' 1'. I I I I I Mr ' ' | ' 1, ' h. I' I | - ‘ II ' I 52 .Eaxm 6:52 :33an Z « 53000.5 5 :n >mo_o..:cz I m notwitcm % .. 050522 E m «cot—5m .0: cm— .mi 325.0 :30... 7» VA pull- VA 7//. .- 7A : .Em £3 .33 s 2 a h. 0 .V N H. Aufimafivmonmmammxm133:0 ham? umH .F 2:9". I -[IHAVUOEIII I, UvulmWIUvm 53 n m N m _ p ¢ w . W D M _ 8328.2 m M m _ 2.258.250 bauoEocgun. W. M 9.3—om _ *ON w m E18... _ 3.23 4 .m 8230.. 30.5.0 _ .3250 0. 3.3!» 30V $qu “”1 % 9 mus-no . u m m _ m .8220 _ Sign n. _ 32.8.: m _ 3 m 322m " 8.28.... w. .03....” u...- $ON angw W. 853:8 _ F =_ :23 __ :23 _ .22: — zoo\:ms_ .mvos. 5.32.50 33m .N 6.59... 54 KK . / ,,,,,,,_ / r/. V1 {Kr/XI M/é/ fix / ,, / 4 , ,, . A ,r/ /, //, , . A 85:33 325.0 mm: cm. A“ f/A/ ”A. ifliiiiflliflflii r/ / /.. //n //,./ >mo.o.:0z 30.5.0 0.30.20 lvl 3.:0200E05 0c.u..uo$_ >u.::EEoU 05050.2 2.63 1VDIN|13 050.005. 252.0060 >mo.o.m>za. 0253.900: .m .059". 22.32:. -ozmmw .053... 390.300: .0.:omw>o.?_00 = :c: mocmswmm .nwofifi 385mm 30.00.0502 0.5.9.9050 >uo.oouE:Em DISVG >mo_o£0m >mo_o.no.o..2 mu.m>...ao.m 35.59320 EDNEIDS >Eo~0c< mimhm>m \L ~~¢ . -‘~o . x... 55 TREATMENTS Pre-treatment and Treatment Procedures and Plan: 1. In the first week of the 15-week Systems Biology I and II Neuromuscular Unit, a cognitive pre-post test was administered to the entire class (See Appendix D). The test was prepared by L. E. Jacobson, D.O., (Neurologist, Chairman of the Department of Osteopathic Medicine, Assistant Dean for Clinical Affairs and primary clinical professor in charge of the system courses) from past tests used in the evaluation of student performance in the neurological clinical science portion of the course. The internal consistency reliability (Kuder Richardson Reliability #20) is P = .83. 2. Prior to the controlled 10 weeks of the experimental study, the entire class received 5 weeks of instruction in the basic sciences of Neuroanatomy, Neurophysiology, Neuropathology, other neuroscience areas (i.e., Neuro- chemistry, Pharmacology, etc.), and in Clinical Neurology. The class lectures in the basic and clinical sciences continue for the lO-week remainder of the Systems Unit (See Appendix E). The Neurology section of the unit covers the coupling of all neuroscience information into a practical format for utilization in clinical practice. Students are instructed two times per week for a total of 6 hours in Neurology. Students have lecture seminars, video-tape instruction, and practical supervised instruction. The areas covered are motor skills, the rapport techniques p n... 56 involved in neurological examination, and the cognitive medical knowledge necessary to clinical problem solving and decision making of neurological disabilities. Each student completes a practical psychomotor pre-test on his skill in neurological physical examination. (This form is also used for the post-test of psychomotor skills-- See Appendix F). Each student has had experience in interviewing patients during his Behavioral Science Classes and in the other clinical experience during the 15-week Systems Biology I and II Neuromuscular Unit. 3. During the first 5 weeks all students received training in the affective behavior involved in physician- patient relationships and in the eliciting of information. The E prepared material on effective affective behaviors, which was distributed and discussed in detail prior to the control treatment period (See Appendix G). A video-tape on ideal physician behaviors in completing a basic physical and neurological examination was developed by the E for this study. The video-tape demonstrates critical affective behaviors in the ideal physician-patient examination inter- action. The video-tape was used as a behavioral model to assist students in the acquisition of important affective behaviors necessary in establishing a relationship and in effectively eliciting data from the patient. The litera— ture is replete with conclusive evidence that learning can occur through observation of social models (Bandura, 1969; Bourden, 1970). Additional tapes demonstrated proper S7 psychomotor skills, with the students participating in discussing and identifying the important affective behaviors that should be in operation by the physician (See Appendix H). 4. An instructional booklet was developed by the E for the lO-week clinical experience portion of the course (See Appendix C). It was used as an advance organizer in the instructional process. The students were given detailed course description, objectives, location, instruc- tors, duration, implementation, evaluation processes, and forms in the advance organizer. The students knew exactly what was expected in the clinical experience. Consequently, in this treatment period, the students did not need to discover the principles to be learned by examining discrete facts regarding the format for neurological examination or evaluation; they were subsumed in the advance organizer. Research has demonstrated the effectiveness of such an approach on several criteria of performance, particularly retention (Ausubel, 1960). David Ausubel's work in the area of meaningful verbal learning theorizes that an individual's existing cognitive structure is a major factor in the learning and retention of new material. In the discussion of cognitive structure, Ausubel (1963) describes that when an individual's knowledge is organized, clear, and stable, meaning will emerge and learning will be enhanced. The contention is that adequate cognitive structure depends upon providing the student with an advance 58 organizer, in the form, for example, of the clinical booklet (Appendix C) developed by §_for this study and for the Systems Biology I and II course. 5. Each simulated and real clinical training experience was prepared in advance by the clinical instruc- tor. The instructors attempted to provide the same types of clinical cases, (real and simulated) or as close as possible, by preparing in advance a Criterion Performance Worksheet which gives a complete and accurate description of the case to be used in the instructional experience. In addition, the Neurological Examination was prepared in advance by the clinical instructor (See Appendix C, pages ll-l4 and 15-23). The clinical instructor established in advance, the criterion on which the student was rated, based on the standard maximum of 54 points per case (See Appendix C, pages 24-28). Data was collected each week for all students in the systems unit after each training treatment experience. An office secretary under the supervision of §_was responsible for collecting and recording the required incoming evaluations after each session (See Appendix I). 6. Counterbalance of the instructors within the treatment experiences was employed in order to eliminate confounding. The clinical neurologist in Detroit instructing in the real clinical experience switched with the clinical neurologist in the simulated clinical experi- ence during the second treatment period. During the first i“. 59 clinical treatment experience the simulated and real treatment subjects were randomly assigned to one of the four clinical neurologist instructors. The objective of random assignment of instructors during the first treat- ment experience and rotation of the two primary instructors for the second and third treatment experiences was to eliminate confounding of instructors with the treatments. 7. The clinical settings for both groups were similar. Examining rooms were developed for the simulated instruc- tional experience. Examining gowns and tables were provided. Arrangements were made for the simulated clinical treatment group to have appropriate lab tests, x-rays, EEG's, etc. for discussion purposes. This material provided as close an experience as possible to that received with real patients in the real clinical treatment group. 8. Eight simulated patients were programmed. The simulated patients were from various areas of the community. In an effort to show that college trained as well as non- college trained individuals could provide effective interaction with the student physician, a variety of individuals were programmed. Eight neurological problems were identified by the neurologists. The simulated patients were instructed on how to provide feedback by viewing tapes and discussing the dynamics of physician- patient relationships. These trained simulated patients were also used to test the inactive control group in the in. .- u u - -6. .. .- —- —. .1. . n '- - u. ‘ 0‘, '- ..,,‘ “.- ~l" ‘ u u... a . 'v N 'K H. h C 60 final examination, the objective being to prove the reliability and validity of simulated patients. The simulated patient is a critical factor in this study. Dr. H. S. Barrows, in personal correspondence with the E, indicated, "I am, of course, very interested in this study. The goals, as stated are excellent, and the results should provide important answers to many of us that hold the same faith as yourself. I have concerns over quality of simulator training and how data is to be obtained to answer your questions." The communication with Dr. Barrows, one of the originators in using simulated or programmed patients, resulted from an abstract of this experimental study presented at the national meeting of the Society of Neuroscience, in Texas, October, 1972. The concern for quality control in any research project is crucial. Realizing the concern of professionals for quality control and respecting the need for accurate reporting of information, the E expended detailed efforts in training and evaluating simulated patients to develop reliability and validity. 9. Simulated Patient Characteristics: A. Sex: 2 Females, 6 Males B. Age: Range = 27-53 years, Mean 36.37 years (27, 29, 30, 32, 36, 38, 46, 53) C. Marital Status: 1 widow, 1 single female, 6 married males. 61 D. Employment Status: 1 secretary, l former nun working on Ph.D. in teacher education, 1 Ph.D. in experimental psychology working in medical education, 1 real estate salesman, l 0.0. family medicine practitioner, l foreign-born East Indian student, 2 third-year Osteopathic Medical students, (no simulated patient was known to the first—year class). E. All simulated patients are currently residing in the State of Michigan (i.e., Detroit, East Lansing, Lansing). They are, however, originally from various parts of the country and world. 10. Type of Neurological Problems Programmed: The complete Simulated Neurological Evaluation History and Physical Examination Forms are presented for the reader's review (See Appendix J). The following are provisional diagnoses for the eight simulated cases and for the eight real cases: Eight Eight Simulated Cases (TIL Real Cases (TZL a. Spinal tumor a. Spinal tumor b. Mass lesion (i.e., tumor b. Brain stem infarct or cervical spondylosis) c. Demyelinating disorder c. Cerebral neoplasm (multiple sclerosis) d. Cerebral neoplasm d. Cerebral hemorrhage e. Multiple sclerosis e. Multiple sclerosis f. Lumbar disc herniation f. Parkinson's disease g. Cervical disc g. Lumbar disc herniation (traumatic arthritis) in Sub-dural hematoma h. Sub-dural hematoma 62 The clinical cases used in both simulated patient clinical training (T1) and real patient clinical training (T2) were as close as possible in neurological provisional and differential diagnoses. A11 consideration possible was given in providing comparable experiences. The inactive control cases were also similar to the treatment groups. 11. Training Simulated Patients: First, each individual selected for simulation as a neurological patient was requested to present his past basic medical history, including any current chief complaints and onset of real medical problems. This basic core material was used for each patient in order to limit the margin of error in the details of medical history. Second, each simulated patient was given a basic neurological evaluation and general gross physical examination to determine special neurological problems if any, and to assess other medical problems. No gross neurological problems were discovered. However, one of the simulated patients had no patellar reflex on the right and was perfect in his ability to control all reflex reactions. Based on the histories and response to neuro- logical examinations, specific Neurological problems were selected to meet the needs of the Neuromuscular Systems Unit Clinical Training Experience. A total of l2 individuals were asked to participate and 8 individuals accepted. No individual was rejected once selected. Each simulated patient was presented with a Neurological Evaluation Form with his own medical history and with the complete a .u. . .- h-‘ol Dov 'albbn I o \ wt... to Wu... . u». . ~_~. ~. ‘0, y: t ’) ‘~. l.‘ ._ . z N. ‘- - . .- ., '- 0 ~‘-. ID.A‘Q .l ‘ ‘0 J. ‘ .. ‘ .‘ . 63 neurological problems presented (See Appendix J). Six of the simulated patients had an opportunity to view video- tapes of real patient pathology. Each patient was given a total of 6 hours of instruction. Additional instruction on providing feedback to the students and on the use of patient ratings was given. After each session the simulated patients were evaluated by the neurologist (Dr. L. E. Jacobson) to determine progress and needed correction. Each simulated patient was examined on three occasions, plus during the final examination. In addition to the structured training, a fifteen-minute pre-session by a neurologist before examination by the gs to determine the accuracy of response was given. This additional training period provided good control. The two best estimates of accuracy and realism of the simulated patient are discussed in the analysis section. 12. During the week prior to the 10 weeks of Systems Biology II, (the experimental treatment period) an orientation session was provided for the class. The students were instructed on the requirements of the Systems Biology II Neuromuscular Systems Unit II course. Student responsibility for attendance and completion of all requirements in the clinical experience and for completing the final neurological examination were explained in detail. The various weekly performance criterion measures and rating scales were again explained. Each student reviewed his advance organizer (Appendix C) and the "l x: 64 specific clinical assignment and dates (See Appendices K and E). The gs were instructed that their first clinical experience (of three) would be from Dr. Jones, Dr. Jacobson, Dr. Kornhiser, or from Dr. Martocci and Dr. Drapkin. (The inactive control students in Lansing with Dr. Calkins would continue with Dr. Calkins for all three experiences.) The second and third experiences were specifically arranged. The 12 §s receiving training on real patients had Dr. Jacobson for the second clinical experience, and Dr. Kornhiser for the third experience. The 12 §s trained on simulated patients received their second clinical experience from Dr. Kornhiser and the third experience from Dr. Jacobson. The original intent was to have T1 (simulated trained) work twice with Dr. Jacobson and T2 (real trained) work twice with Dr. Kornhiser. The problem, however, could have been instructor confounding. Therefore, the E decided a-priori, to utilize all clinical neurologists previously used in teaching this systems course. All of the clinical neurologists were familiar with the objectives of Systems Neurology and could provide the first clinical experience. The clinical instructors were all introduced to the advance organizer (course booklet). The instructors understood the objectives, their responsi— bility for student ratings and for providing feedback based on the various evaluation rating forms and on the type of cases required. A training session was held with all 65 instructors involved in the experiment and with the inactive control. To insure quality control, the §_observed on a random basis each instructor's clinical training session. The majority of instructors involved had been working together for two years and were quite familiar with the Systems format. However, the E checked on: (a) whether instructors followed the prescribed format for implementa- tion in the advance organizer (course booklet), (b) whether the instructors spent prescribed time in evaluating the students on the criterion measures, (c) whether they pro- vide feedback, (d) whether the material was organized, (e) whether they discussed the course objectives on each case by reviewing psychomotor, affective and cognitive skills necessary to performance of a neurological examination, and (f) whether they interacted with the students. All instructors within their own teaching styles met the requirement prescribed by the §_and most specifically the two key instructors used for the second and third clinical experience with the experimental gs. This type of control insured quality of clinical instruction for the entire class involved in the Systems Neuromuscular Unit and specifically for the gs within the experimental study. 13. Treatment Specifics: Students randomly assigned as §s for the two experimental groups, T (simulated 1 patient) and T2 (real patient) were again randomly assigned 66 in groups of 4, and remained together for the required three clinical experiences. It was necessary to rotate the gs in groups of 4, in order for each student to have three clinical experiences, plus the final practical examination, during the 10 weeks of treatment training. During the first two clinical experiences, the students in groups of 4, were again randomly assigned in pairs to work on a patient (real or simulated). This same experience held true for the entire class of students. The advance organizer (course booklet) specifies the method of clinical experience. Students work effectively in pairs, and gradually work independently as is traditional in the clinical training of Osteopathic Medical students. The third clinical experience required each student to complete a neurological examination on an individual patient. The third experience prepared all students for the final practical examination. For the first two clinical treatment experiences, each group of 2 students working together, was required to independently write up the patient's chief complaint, onset, and past history. The students were informed they could work together on the remainder of the examination, but.that they were to write up the results of their individual findings independently. After the 1 1/2 hours allowed for the complete Neurological Evaluation History and Physical Examination, all students were given 1 1/2 hours to write up the case findings. Working together v4 67 allowed all students to collectively use many sources of information. They were allowed notes and access to the library. Upon completion of this 3-hour period of time, each group of 2 students individually presented the com- plete case work-up to their clinical instructor (See Appendix C). Each student was rated according to his individual work-up. Many times partners disagreed on what they found in the neurological examination. While students were completing the physical examination of patients, the instructors made routine visits. During the third clinical treatment experience each student was assigned an individual patient. The same requirements and restrictions were maintained for each treatment experience. Each student examined his patient, completed the case work-up, and defended his total neurological evaluation based on the 10 required criterion measures used in evaluating a neurological physical and history examination (See pages 15-28 of Appendix C). Also, each student rated the clinical experience, and was himself rated by the patient on his performance (See pages 29-31 of Appendix C). 14. Final Examination as Assessment of the Comparative Study: In testing the major hypotheses of this research study, it was necessary to have a practical final exami- nation. The final practical clinical examination involved testing all thirty-eight (38) students in the Systems Biology I and II Neuromuscular Unit. The E arranged for 68 12 real patients with varying neurological disabilities, who were not used during the treatments, to be used to test both T1 gs trained with simulated patients and T2 gs trained with real patients. The 24 §5 in the study were randomly paired and assigned to patients to protect against bias of either group having the advantage of seeing the patient first on all occasions. The following 12 Neurological Disabilities were used to test the gs within the experiment: (a) 2 Parkinsonism cases, (b) 2 Multiple Sclerosis cases, (c) Optic Nerve Glioma, (d) Collagent Vascular Disease with Cranial Arthritis, (e) Charcot-Marie-Tooth, (f) Porencephalic Cyst-congenital, (g) Neuroma (Forme fruste von.Ricklinghausen'S), (h) Peripheral Vascular Insufficiency, (i) Amyotrophic Lateral Sclerosis, (j) Brain Stem Infarct. The detailed provisional and differential diagnoses of the real patients, and their complete neurological case work-ups used in the final examination, are not being included in the appendices of this study. The material is confidential, privileged, and there may be litigation pending. Each patient signed a release form allowing the student, the physician, the university, the college, and the hospital to utilize him as a patient for this study. In an agreement made with Dr. R. Calkins, the neurologist supervising the 12 real patients utilized in the final examination, the case histories were not to be printed in the study. The cases are available for review with the 69 E. Each real case was also standardized in advance of the final examination. The criterion measures and total points equaled 54, the same as in the three clinical treatment training experiences. To gain understanding of a neurological case the reader can refer to the Simulated Neurological Case Evaluations presented in Appendix J. The format and point system are identical. The remaining 14 inactive students in the Systems Biology I and II Neuromuscular Unit also had the same final examination. Eleven of the students examined the simulated patients used in the T1 simulated clinical treatment group. Three students had real patients, who requested to return to be used as real programmed patients, willing to be examined by students. The programmed patient concept was tried because the E wanted to test whether individuals with real physical disabilities would be willing, for a fee, to be used on an on-call basis to be examined by OsteOpathic Medical students. In fact, all 12 of the real patients indicated a willingness to be on-call for examination by medical students for Neurological Examination (excluding lab tests, of course). There appear to be possibilities of not only using simulated patients, but the consideration of using real patients with real disabilities (i.e., on Social Security Disability Benefits) as programmed patients on-call, willing to be examined by Osteopathic Medical students, will be discussed in the final chapter. u 70 Three weeks prior to the practical final examination, each student received a memorandum of his examination schedule (See Appendix L). (It must be noted on Page 2 of Appendix L that names have been eliminated and numbers substituted.) Prior to the practical examination, each student was given the opportunity to look at the video- taping clinical facilities. The facilities were as realistic as a doctor's examining room. In addition, each student was given refreshment and an opportunity to relax in an interviewing room off the library, which was closed for the day and used only for the students to write-up their examinations. A final examination packet (See Appendix M) was prepared in advance for each student. The students were given a blank copy of the Neurological Evaluation History and Physical Examination form. It was explained to the students that this blank examination could be used during the final as a guide and that they would be given another copy of the form to complete as their final write-up. Each student was also asked pre- and post-questions regarding the experience, similar to the rating completed after each of their treatment experiences. In addition, each student was informed that he would be rated by the patient in the same manner in which he was rated during the treatment period. Each student agreed to being video- taped and was advised that permission slips were signed by the patient for his protection. Each student was 71 advised that (a) psychomotor skills in completing the examination, (b) his affective behavior in establishing a relationship and eliciting data, and (c) the total write-up of the Neurological Examination would be reviewed and graded. Each student was also advised that the video-tape would be reviewed with him on an individual basis next quarter and he would be given the total results of the practical clinical performance final neurological examination. Each student was also advised he could review his video-tapes as often as he desired. The following forms are included in Appendix M: (l) Neurological Evaluation History and Physical Examination (2) Clinical Instructor's Formative and Summative Evaluation Rating Scale ~ (3) Pre-Test Final Assessment of Experiences in Neurology Training (4) Post-Test Final Assessment of Experiences in Neurology Training (5) Neurological History and Physical Assessment Affective Rating (6) Pre-Post Test Form for the Neurological Practical Examination (7) Patient Rating Scale (8) Medical Release Forms Upon completion of the final neurological practical examination, each student's final examination packet was held until all 38 students completed the practical examination. During the week of the final examination, the affective ratings were begun since each video-tape had 72 to be rated by one of three raters trained on the utiliza- tion of this semantic differential scale (See next section on treatment material). During the two weeks immediately following the practical examination, they were graded by Dr. L. Jacobson for the 24 gs in the experiment. The grading was accomplished on a rater-blind basis. In the next two weeks, the video-tapes were again viewed by Dr. L. Jacobson and the post-test psychomotor ratings were completed. (Dr. Jacobson also did the pre-test psycho- motor ratings.) At this point, all pertinent data were collected, rated and readied to be coded for statistical analysis. TREATMENT MATERIALS AND ADMINISTRATION The treatment materials utilized for all students enrolled in the Systems Biology I and II Neuromuscular Systems Unit were developed or adapted by the experimenter (E). All materials in Appendices A through M were used in the experimental study. General Information Course Protocol (Appendix A): The "General Information, Course Protocol" was adapted by E for the Systems Biology I and II Neuromuscular Systems Unit. The course protocol provides the students with information on (a) textbooks, (b) laboratories, (c) specialty clinics (i.e., the Neurological clinics used :hithe experimental study), (d) self-study units, 73 (e) examination, (f) grading, and (g) course organization including a description of the basic course objectives. All students received a copy of the "Course Protocol" prior to the beginning of the Neuromuscular Systems 15- week unit. The protocol was reviewed on the first day of class with students by the primary systems instructor. All students, therefore, were aware of their responsibility, authority, and accountability within the course. General Protocol of the Systems Biology Courses (Appendix 3:): This material was given to all students as a basic reminder of the breadth and depth of Systems courses. The material was developed by Dr. L. Jacobson as handout material for students to use in understanding the systems teaching model used in the Osteopathic Medical curriculum. The Advance Organizer (Course Booklet) (Appendix C): This material was developed by the E’to provide all students with a well-organized protocol to be utilized in the 10 weeks of the experimental study. All students received a copy of the advance organizer prior to the beginning of the three clinical training treatment experi- ences. The advance organizer is unique in providing the students with all of the information necessary to complete the 10 weeks of the Neuromuscular Systems II Unit. The advance organizer includes: (a) complete course descrip- tion of the clinical training experiences, pp. 1-2; 74 (b) general and specific behaviors objectives, pp. 2—3; (c) training locations, pp. 3-4; (d) clinical instructors, p. 4; (e) duration of training, p. 4: (f) implementation procedures, pp. 4-6: and (g) evaluation process and forms. The rationale of the evaluation process, forms, and techniques on pp. 6-31 include (g-l) the Physician Neurological History and Physical Criterion Performance Worksheet, pp. ll-l4; (g-2) Neurological Evaluation History and Physical Examination Form, pp. 15-23; (g-3) Instructor's Clinical Competency Formative and Summative Evaluation Rating Scale, pp. 24-28; (g-4) Student Clinical Experience Evaluation Rating Form, pp. 29-30; and (g-S) the Patient and Simulator Rating, p. 31. Prior to the beginning of the lO-week experimental study, each student, on a group basis and individually, reviewed the advance organizer with the Administrative Assistant. The advance organizer was reviewed during the 5 weeks of pre-treatment training. During this 5-week period, while students were being instructed in clinical laboratory experiences on the proper techniques of neurological examination, the advance organizer was reviewed on a group basis and individually. This allowed each student to become familiar with all forms used in the clinical training experiences. The interaction also provided the opportunity for student questions and time for the students' personal organization of the cognitive information necessary in completing a neurological evaluation. 75 The Cognitive Pre-Post Test (Appendix D): This was used to measure a student's cognitive know- ledge in Neurology. These 35 items were selected as a representative random sample of questions that would provide information on individual student's cognitive knowledge a-priori in the field of Neurology. The internal consistency reliability is F .83. The pre-test was administered during the orientation class prior to the beginning of the lS-week Systems Biology I and II Neuromuscular Systems Unit. The post-test was administered within the objective portion of the Neuromuscular Systems written final exam. It was scored as a separate sub-test. Day-by-Day Class Schedule of All Lectures and Assignments (Appendix E): This schedule was maintained for the students during the lS-week Neuromuscular Systems Unit and includes specific details of all class lectures in the Neuromuscular Systems Unit (i.e., Neuroanatomy, Physiology, Biochemistry, Neurology, Pharmacology) in addition to other classes and the clinical experiences for the first-year Osteopathic Medical student during the lS-week period. The schedule is standard operating procedure. The E assisted in scheduling in order to provide control for the experimental study. 76 Neurological Practical Examination of Psychomotor Techniques and Skills (Appendix F): This was used in the pre-post test as the criterion measure of students' psychomotor performance abilities. In the pre-treatment period during the practical laboratory session, Appendix F was used as a specific guide on psycho- motor skill and technique development in completing the neurological physical examination. Upon completing 5 weeks of the Systems, each student was given a pre-test of his basic psychomotor skills. The test is very easy to use and requires no elaborate procedures. The student either elicits the proper neurological response by (a) accuracy of instruction, (b) proper positioning of patient, and (c) proper technique, or he does not. The psychomotor test is simple and practical. If the student does excellent in any of the three areas, he receives a score of 1 point for each area; if his performance is adequate, he receives 2 points; and if he fails, he receives 3 points. The composite score obtained in completing all the various psychomotor neurological tests is the total score for each student used as the criterion measure of psychomotor performance. The lower the score the better the perform- ance. This form was used each of the 5 weeks by the students as a self-instructional tool. All students were aware of the psychomotor skills necessary in performing a neurological examination. Dr. L. Jacobson has used this practical test for three years and provided an inter-judge q~. 77 reliability of F = .94. Dr. Jacobson and another neurologist were almost in perfect agreement in comparing their rating on 10 students. With the availability of the 38 video-tapes developed in this study and the accessability to other neurologists, the E will in future research run detailed reliability studies of this rating scale. The scale is functional and either the student performs the proper test or he does not. The test certainly is consistent in measuring basic psychomotor skills and is highly recommended as an effective training aid and tool. Affective Training Aids - Video—Tape Series and Scrip; (Appendices G and H): In Appendix H, the E developed a complete training script, trained patients, and made a video-tape on affective physician behavior used in a physician-patient interaction during examination. This tape was used in the pre-treatment training period with all students in the Neuromuscular System. The basic objective was to insure that all students entered the clinical treatment experience with comparable skills in the affective domain. In working with Dr. M. Clark (the model in the video-tapes) the E attempted to reveal in the video-tape ideal physician behaviors used in establishing a relationship and in eliciting data from the patient. All students were given the training aids in Appendix G developed by the E. n - A- ..o »-. . 1. .L ._ II! . IN ... . 1 H...\ .\ u:- 78 The behaviors described in the training aids were discussed with the class prior to viewing the key training tape on May 15 and 19, 1972. The students received the memo and schedule of the review sessions, including the objectives for this short training series (Appendix H). The other scheduled tapes were not of primary concern to this study but were used as aids. The E feels that all students benefited from the video-tape made specifically for this study on ideal physician behavior, as well as from the handouts in Appendix G. The objective in identifying the (1) critical verbal and non-verbal behaviors, (2) ten important qualities inherent in a doctor-patient relationship expressed by a family physician, and (3) effective and ineffective affective behaviors in establishing a relationship and in eliciting data was to train students or assist them in becoming specific in the behaviors necessary in completing a neurological examination. Student comments were all positive about this experience and statements were made indicating that this material provided a consolidating learning experience on physician behaviors effective in a physical examination. Master Control Sheet (Appendix I): Appendix I is the master control sheet on scheduling the treatment sessions for (T1) the simulated patient clinical treatment group, for (T2) the real patient clinical ~- 79 treatment group, and for the Inactive Control group. The master control sheet was also used to record weekly data collection and for recording the practical final examination schedule. To further negate any possible Hawthorne effects, the department secretary checked in the required treatment evaluation forms; she also could advise the E of any missing data and insure immediate control. The required materials to be turned in after each treatment experience by each student are (1) Evaluation of Clinical Experience - CE; (2) Patient Evaluation - PE; (3) Neurological Examination Form - NE; and (4) The Instructor's Clinical Competency Formative and Simulative Evaluation Rating Scale - FSE. All of these forms are in Appendix C and M. If any form was not turned in, the secretary wrote a memo immediately to the student advising him of missing data. During the entire experiment, all material was turned in as scheduled. There was no missing data. In addition, it must be reported that all students met the scheduled times of the treatment. Simulated Cases (Appendix J): The eight simulated Neurological Evaluation History and Physical Examinations are presented in complete form. The (1) Chief Complaint(s), (2) Onset and Course of Chief Complaint(s), (3) Past History (family-medical and social), (4) Systems Review, (5) Physical Examination (i.e., general appearance, general findings, mental status, ' 80 reflexes, sensory, muscle function and gait, cerebellar and dorsal column functions, extrapyramidal and cranial nerves are assessed), (6) Summary (i.e., general results, assessment of area of neurological system dysfunction, and anatomical location are reported), (7) Provisional or Working Diagnoses including all systems, (8) Differential Diagnoses, (9) Tests (laboratory and other diagnostic procedures), and (10) Treatment and Therapy, are presented for each of the simulated patient cases. The cases are self-explanatory and require no interpretation for the reader. The simulated case work-ups along with the real case material (laboratory studies) were made available for student review after the completed training series. The Clinical Rotation Schedule (Appendix K): Appendix K is the Clinical Rotation Schedule for the first year class clinical experiences during the 10 weeks of the control treatment period. Student names have been eliminated from the schedule. Specific dates, physician and type of service involved in the clinical training experience are presented. From this schedule the reader can refer back to Figure l and determine the specifics of each student's clinical experiences during the treatment training period. This form of presenting student clinical schedules is very effective and easy to work with in coordinating large numbers of students and varied clinical rotations. All students received a copy of the schedule .o .0 81 prior to the ten-week control training period. All conflicts with other departments offering special training sessions and lectures were resolved before the lO-week program began. Controlled scheduling is of prime importance, not only to the experimental study, but also in the management of a medical curriculum. Final Examination Schedule (Appendix L): The Final Examination Schedule is issued to all students. The schedule gives detailed instruction on the time of the objective cognitive examinations and of the specific date and time for each student's practical neurological evaluation examination. The memo and schedule were submitted three weeks in advance in order to advise each student of his examination time. The advance scheduling and built-in controls are necessary in com- pleting 38 video-taped practical neurological examinations. The problems centered around students requesting early dates and times for practical examinations. However, only two dates were altered. The need for advance scheduling is critical in coordinating patient-student examination times. Dr. Calkins and his medical secretary scheduled all patients in advance and had back-up patients waiting. Dr. Calkins personally talked with each patient about his examination with the medical students. Patients were advised that this examination was a follow-up appointment (which it was) and that they were not to inform the student 82 of their diagnosis. Each patient was advised by Dr. Calkins and the E that he was assisting in the training of Osteopathic Medical students and would receive a $15.00 payment for each examination. Prior to the scheduled time, the E discussed the procedures and explained again to the patient (over a cup of coffee) what would happen in the examination. Also, complete details on rating the student physician (patient rating) were given to each patient. The patients were all co- operative. However, the anxiety and magnitude of completing 38 video-taped practical examinations cannot be described. Advance scheduling is essential. The camera crew included 3 individuals plus a director. A secretary from the Department of Osteopathic Medicine assisted as a nurse's aide by helping the patient dress in examining gowns and in preparing the examining room. The camera crew was assigned from the College of Osteopathic Medicine, the Department of Psychiatry at Michigan State University and from Instructional Televi- sion (ITV). The video-taping facilities were provided through the cooperation of St. Lawrence Hospital's Mental Health Center and the Department of Psychiatry. The video-tapes were provided by the College of Osteopathic Medicine. The camera crew was well trained in the procedures of video-taping physical examinations. The E acted as producer and executive director in coordinating 83 the video-taping sessions. Extra or back-up equipment and cameramen were available. The Final Examination Packet (Appendix M): This is the Final Examination Packet. In advance of the scheduled practical examination, the packet of material used in gathering the final criterion measures for each student was prepared. The material was placed in a large brown envelope, labeled with student identification number, patient identification number, and with the time and date of the final practical examination. The following forms are included in the Final Examination Packet: Form 1: Neurological Evaluation History and Physical Examination. Two copies were provided in each packet. One to be used during the examination and one to turn in as a final c0py. The examination form is self- explanatory. There are ten required factors to be completed in a neurological evaluation. Form 2: Instructor's Clinical Competency Formative and Summative Evaluation Rating Scale. This form follows specifically the 10 required criterion factors on the Neurological Examination and is used as the rating sheet for evaluating and scoring the three clinical treatment experi- ences (Formative Evaluation). It is also used Form 3: Form 4: 84 for evaluating and scoring the final performance examination (Summative Evaluation). The form has the listed key criterion to be rated and the specific questions the clinical instructor must use in scoring a student's clinical competency performance. This form provides the instructor with specific criterion required and allows objective evaluation of the data completed. Pre-Test Final Assessment of Experiences in Neurology Rating Scale. This form was used to gather evaluative data of each student's assessment of Systems Biology Neurology Systems course, of the final examination experience, of his feelings about the experience and of his self-ratings in total performance on the final neurological examination, his psycho- motor performance, and on his affective behavior in establishing a relationship and eliciting data prior to the final examination. There are six questions requiring responses. Post-Test Final Assessment of Experiences in Neurology Training Rating Scale. After the experience each student was asked to rate the final practical clinical examination experience, his feelings about "self" after taking the final practical clinical examination, his Form 5: 85 total performance in the final neurological examination, his psychomotor performance, his affective behavior and his satisfaction ratings regarding critical behaviors in the clinical training experience. In total, there are 14 questions asked on this form. The basic format for Forms 3 and 4 is the semantic differential scale. Data over and above that necessary in answering information, but wanted to insure adequate coverage for the research and for additional studies was included. Both Forms 3 and 4 were developed by the E_to answer the research hypotheses. Neurological History and Physical Assessment Affective Rating. This rating involves a semantic differential and is a modification of a scale developed in cooperation with Dr. J. Schneider, Department of Psychiatry, Michigan State University. The E wanted to assess each student's affective behavior regarding establishment of a working relationship, and in eliciting data during the examination. Interview skills are crucial to a physician's behavior. The physician must know what to observe and how to report the data gathered. Also, on this rating, the E wanted each case on the final exam assessed as to individual difficulty. In 86 working with Dr. Schneider, he provided the services of three Ph.D. counseling psychology students trained in counseling to work with the E.in obtaining reliability data on the affective rating scale. The E used the video- tape developed in training the Es on effective affective behaviors and also ten other video- tapes, of varying qualities of physicians performing neurological examinations. The model tape was used repeatedly over a 12-week period as were all training tapes. Three key tapes were identified for establishing inter-rater reliability over the 12-week training period. The three raters worked two afternoons per week for 10 weeks and one afternoon for the remaining 2 weeks of the training period. Dr. Schneider assisted in training the raters. The rating scale was reworked until all raters, Dr. Schneider and the E agreed on the evaluation factors. Each training tape was rated each time by each rater and the inter-rater reliability after 12 weeks in scoring the affective rating scale on the three key training tapes is F = .87. The affective rating scale will be used by Dr. Schneider in the Department of Psychiatry. Having inter-rater reliability of .87 with the affective rating Form 6: Form 7: 87 scale allowed each rater to rate two tapes every day in completing the affective final criterion measure ratings. In order to check the ratings, the E asked each rater during his evaluation of the student final exam video-tape to re—rate one of the other rater's tapes. The correlations between raters averaged .89. Pre-Post Test Rating Scale for the Neurological Practical Examination of Psychomotor Skills and Techniques. This form was explained in detail under Appendix F. In reviewing the form the reader will note that it is practical and self-explanatory. The form should be used as a training tool. Patient Rating Scale. This form was used during the entire experiment. After each treatment training session, the patient was asked to provide feedback to the student physician. Feedback is critical as a reinforcer in the deve10pment of physician behaviors. The E developed this form not only for the current study, but to be utilized as a tool for follow— up studies. This scale briefly evaluates a physician's behaviors in the three learning domains. There is one question on cognitive abilities, two on affective, and one on psychomotor skills. The form is simple and effective as an Form 8: 88 accurate rating device in patient assessment of physician behavior. Medical Release Forms. In order to protect all parties involved in the study, two medical release forms were developed by the E. All patients,real and simulated, signed the forms, and they were dated and wit- nessed by the E. NULL HYPOTHESES Following are the 10 null statements of hypotheses under investigation in this study: Ho: Ho: 1 There will be no significant differences in the total performance in clinical competency, psycho- motor, affective, and cognitive final performance criteria measure ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant difference on total performance in clinical competency criterion measure ratings in the three treatment training clinical experiences of students trained with simulated patients as models in simulated clinical Ho: Ho: 89 experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant difference in confi- dence demonstrated in the anticipated total performance in clinical competency, in psychomotor skill technique abilities, in affective behaviors, and in the actual total performance in clinical competency criterion measures self-ratings of students trained with simulated patients as models _in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant difference in agreement on student final performance criterion measure self-rating and the clinical instructor's rating of total performance in clinical competency on the final criterion measure ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant difference in responses about "self" in the treatment training criterion measure self-ratings on factors secure, successful, calm, pleasurable, and competent of students trained with simulated patients as models Ho: Ho: Ho: 8 90 in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant difference in responses on the treatment training criterion measure self- rating on the factors realistic, important, useful, meaningful, and successful of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant differences in the practical clinical training experience factors of providing all the skills and abilities, providing psychomotor skills and techniques, providing the medical knowledge necessary (cognitive), providing the development of affective behaviors, and in providing feedback as vehicles in performing the complete Neurological Evaluation History and Physical Examination final performance criterion measure ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. There will be no significant differences in requests for additional simulated instructional experiences 91 as evidence of preference for this method of training on the final performance criterion measure rating scale of students trained with simulated patients as models in simulated clinical experi- ences and that of students trained with real patients as models in real clinical experiences. Ho: 9 There will be no significant differences in demon- strated improvement vs. consistency in the treatment training patient evaluation performance criterion measure ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. Ho: 10 There will be no significant difference in patient' satisfaction in student performance on the final patient evaluation criterion measure rating of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. MEASURES The effects of the experimental variables of simulated clhfical training using simulated patients and real clinical trahung using real patients on the dependent variables of 92 (l) cognitive knowledge, (2) psychomotor skills, (3) affective behavior, (4) total performance, as a measure of the combined effects in a practical neurological evaluation history and physical examination experience, (5) patient ratings on student-physician behaviors, and (6) student ratings on self, the experiences, and satis- faction will be tested. CRITERION MEASURES Cognitive Knowledge Performance Criterion Measure: This pre-post test is a measure of students' medical knowledge in clinical neurology. The 35-item objective examination requires students to problem solve and arrive at the appropriate medical decision on neurological symptoms. The pre-test measure will be used as a covariate, if highly correlated with the dependent vari- ables, in the analysis (See Treatment Materials, Appendix D). Psychomotor Skill Performance Criterion Measure: This pre-post test is a measure of the students' techniques and skills in performing the physical examination tests necessary to neurological evaluation. The total score represents the student's psychomotor skill or technique in performing the mental status, reflex, sensory, muscle function, cerebellar and dorsal column hummion, extrapyramidal, and cranial nerve tests (See 93 Treatment Materials, Appendix F). The pre-test measure will be used as a covariate if highly correlated with the dependent variables in the analysis. The inter-rater reliability is P = .94. Affective Behavior Performance Criterion Measure: This semantic differential evaluative scale measures effective affective behaviors of (l) establishing an inter- personal relationship and (2) elicitation of data during the history physical examination. The scale was developed specifically for this study through cooperation with the Department of Psychiatry, Michigan State University. The E refined and reworked a scale formerly used by Dr. J. Schneider in the evaluation of student physician psychiatric interviews. The scale also had an item for the rater in evaluating patient difficulty. Trained raters (as described in detail under the section on treatment procedure) with inter-rater reliability of F = .87 rated each student's affective behavior on the practical clinical neurological performance examination. All 38 video-tapes were rated. Each rater rating independently pairs of Es'tapes (Es trained on simulated patients and Es trained on real patients) completed the 38 video-tapes in one week. In checking on reliability between the raters during the final assessment period, each rater was asked to rate one tape. For the three raters on one student tape, an inter-rater 94 reliability of F = .89 was obtained (See Appendix M, Form 5). Total Performance in Clinical Competency Performance Criterion Measure: This is a measure of the standardized Neurological Evaluation History and Physical Examination Form as rated on the Instructor's Clinical Competency Formative and Summative Evaluation Rating Scale (See Appendix C, Advance Organizer and Appendix M, Form 2). Each of the three treatment training experiences is rated using the same basic criteria. The E, in developing the 10 specific factors involved in completing a neurological evaluation, worked with Dr. L. Jacobson in assigning weights to the ten factors used as the major criteria. The rationale for weighting was based on Dr. Jacobson's professional experience as a neurologist. Dr. Kornhiser, Dr. M. Jones, and Dr. Calkins were also consulted and an agreement was reached in the assigned point system. The ten criteria included: (1) Chief Complaints - (3 points): Generally, a patient had two or three basic problems associated with a neurological difficulty, and the evalua- tion is based on the clarity, brevity, and accuracy of the student's response in reporting the chief complaints. (2) (3) (4) (5) 95 Onset and Cause of Chief Complaints - (6 points): Evaluation is based on organization and write-up as to onset, location, duration, severity, course of previous treatment, and other general symptoms or descriptive characteristics of the chief complaints. Past History (Family, Medical and Social) - (9 points): There are 9 basic questions, with l point for each correct answer on the facts regarding past history (i.e., previous hospitali- zation, allergies, surgery, diseases, habits, medications), social history (i.e., work, hobbies, recreation), family history and accidents. Systems Review - (4 points): Generally, the skilled student physician will obtain appropriate data on other medical problems (such as Obstetrical or Cardiovascular). This review will provide data for consideration in the provisional and differential diagnoses, and for the necessity of ordering various lab studies. Physical Examination - (10 points): The examina- tion is divided into 10 parts. One point was given for each part of the physical examination correctly answered. (Half points were also used for all sections of the examination.) 96 (6) Summary - (5 points): The evaluation is based on (7) (8) 1 point for general results, 2 points for assessment of the area of neurological system dysfunction, and 2 points for identifying the proper anatomical location. Provisional or Working Diagnosis - (5 points): The evaluation is based on the appropriateness of the diagnosis as related to demonstration of problem-solving, clinical judgment, and decision- making skills. The differential diagnosis is also reviewed in evaluating the provisional diagnosis. A student must be consistent in his data synthesis. Differential Diagnosis - (5 ppints): The evaluation is again based on the appropriateness of the diagnosis as related to demonstration of problem-solving, clinical judgment, and decision- making skills. The student must evaluate the entire examination. The student's observations during the History and Physical Examination are all coupled in the formulation of hypotheses about the patient's diagnosis. At this point, the student must problem solve on the synthesis of the data gathered, and make clinical judgments. 97 (9) Laboratory Test and Other Diagnostic Procedures - (5 points): The evaluation is based on the appropriateness of the tests or procedures recommended and their necessity in demonstrating the student's ability in utilizing clinical laboratory data critical to the diagnosis pre- sented. (10) Therapy and Treatment - (2 points): The evaluation is based on the supportive and specific treatment recommendations. Concern is in the clinical judgment used in planning and recommending critical (primary and supportive) forms of treat— ment necessary to patient care. Each Neurological Evaluation History and Physical Examination used in the three treatment training experi- ences has 54 points established as the maximum score. The cases were reviewed in advance and the data required for quality patient neurological work-ups by the clinical instructor were recorded. This same procedure was followed for the final performance examination--all cases were standardized in advance. The E believes that the procedures established for performance evaluation criterion measure and grading of the total performance in clinical competency is objective and well controlled. Consideration was given to case difficulty regarding type of patient neurological problems, patient's age, ability to communicate I.‘ 98 and cooperate in the examination. All cases used in the study were equitable for the students. The evaluation procedures used in standardizing the neurological cases used in the study are reliable and valid as measures of total performance. Patient Evaluation Rating Performance Criterion Measure: This semantic differential evaluative scale measures the patients' perceptions of the student-physicians' competence, secureness, interest, and gentleness. The rating scale was completed after each session and after the final examination. One of the key factors in the study is the importance of feedback used as a reinforcer in the transfer of training. The E_has hypothesized that because of the greater opportunity to provide feed- back in the simulated clinical training experience, students trained with simulated patients would perform more effectively. The patient rating scale provides necessary feedback especially in the simulated clinical experiences. During the final examination, the E had to provide a brief lS-minute training session for each patient, emphasizing the importance of and the responsi- bility for rating their physician (See Appendix C, Page 31). 99 Student Ratipgs of Self, the Experiences, and Satisfaction Performance Criterion Measures: Semantic differential evaluative scales were developed to answer questions regarding student perceptions. After each clinical treatment experience, each student rated the experience and himself in the experience. Also, after the practical final examination (post-test), self- evaluative questions were given to the students (See Appendix C, pp. 28-29 and Appendix M, Form 4 for the factors). ANALYSIS 93.: DATA AND DESIGN Statistical Analysis: The analysis to be used for Hypothesis 1 is a multi- variate analysis of covariance (MANCOVA). The effects of the experimental variables, simulated clinical training using simulated patients and real clinical training using real patients on the dependent variables of total perform- ance in clinical competency, psychomotor, affective, and cognitive performances will be tested by MANCOVA where pre-tests on psychomotor and cognitive criteria measures are used as covariates. If the pre-test measures are ppp_highly correlated with the dependent variables, 1mey will not be used as covariates in the analysis and the Evfidl then use the multivariate analysis of variance (MANOVA) . 100 The analysis to be used for Hypothesis 2 is a multi- variate analysis of variance. The effects of the experimental variables of simulated clinical training using simulated patients and real clinical training using real patients on the three treatment training clinical experiences as dependent variables will be tested by MANOVA. In Hypothesis 3, the analysis will be a multivariate analysis of variance of confidence scores obtained from the final performance criterion measure self-ratings. Hypothesis 4 will be analyzed by a test of the equality of correlations. The effects of the experimental variables of simulated clinical training using simulated patients and real clinical training using real patients on the agreement between the students' self-ratings and the clinical instructor's rating of total performance in clinical competency on the final performance criterion nmasure ratings will be tested. The analysis to be used in Hypotheses 5-7 is multi- \mriate analysis of variance. The effects of the experimental variables on the performance criteria measure rmflngs of "self" in the treatment training clinical aqmrience, the treatment training clinical experience in Nmnxdogy, and the practical clinical training experiences asaavehicle for providing all the skills and abilities lhlperforming the complete Neurological Evaluation History aindPhysical Examination will be tested. 101 In Hypothesis 8, a two-sample x2 test of homogeneity will be the analysis. The simple question of preference for and request of additional simulated instructional experiences is being tested. The analysis to be used in Hypotheses 9 and 10 is the multivariate analysis of variance. The effects of the experimental variables, simulated clinical training using Simulated patients and real clinical training using real patients on the dependent variable of improvement vs. consistency in the patient evaluation performance criterion measure ratings, and patient satisfaction in the final complete Neurological evaluation History and Physical Examination measured on the final patient evaluation rating will be tested. Level of Significance: Meaningful vs. statistical significance is an important issue in practical research studies. Caro (1971) suggests a .10 level of significance as appropriate for practical field research which attempts to measure new and innovative programs. The multivariate F ratio obtained in the analysis indicates whether there are any group differences when all dependent variables are considered simultaneously. In that the step-down F ratio is highly dependent on the order in which the dependent variables are presented to the mmmuter for analysis, the E did attempt some ordering. Ikmever, the study and the dependent variables measured are Selndque that the E could not afford to determine a 102 preference and use the step-down F ratio, because once significance is ascertained for one variable, the separate effects of all other variables following are not testable or the assumption of independence is violated. In looking at the given dependent variable, the univariate F will be used. Univariate F tests indicate vmether or not a given dependent variable is statistically significant at a given alpha level for a given hypothesis examined by the study assuming that the dependent variable is independent of every other dependent variable. Univariate F tests are not independent, and therefore, to insure that the overall alpha level of a = .10 is not exceeded in this study, each univariate F test statistic has been restricted on an a-priori basis. The MANCOVA and MANOVA programs developed by Finn on the 3600 computer were used to analyze the data (Finn, 1970). Design: (T1) (T2) Simulated Patient Clinical Real Patient Clinical Experience (N=12) Experience (N=12) .8—8100000OOOOOOOOOOOOOOOOOOESIZ §Sl3000OOOOOOOCOOIOOO§SZ4 Cognitive Cognitive Psychomotor Psychomotor Affective Affective Total Performance Total Performance Patient Ratings Patient Ratings Student Ratings Student Ratings 103 W The purpose of this study was to investigate the effects of simulated clinical training using simulated patients and real clinical training using real patients on the total performance in clinical competency, psychomotor Skill-technique abilities, affective behaviors, student ratings and patient ratings as performance criteria nmasures of a random sample of first year Osteopathic Medical students in the Systems Biology I and II Neuro- muscular Systems Unit. The specific purpose of this study is to ascertain the practical effectiveness of "instructional simulation" using simulated patients. The treatment materials were develOped by the experi— menter to transmit and to study the treatment effects. The treatment materials and procedures described in this chapter and presented in the appendices were received by efll subjects on the same days according to the master sxmedule of the 15-week Neuromuscular System Unit. After the treatment training clinical experiences, a \ddeo-taped complete practical performance Neurological Evaluation History and Physical Examination was accom- Eflished to measure the effects of transfer of training from simulated to real clinical experiences. The data were coded, key punched and verified by the E,Within one week after all required grading was Completed. 104 The data analysis was accomplished using MANCOVA, MANOVA, x2 (chi-square) and correlation tests. The 3600 computer was used to test eight different hypotheses. Hand computations were completed with a desk calculator for the remaining two hypotheses tested. The results of the study are reported in Chapter IV. "‘ «AI “'C vv. “i‘ g .. 1‘. 6..“ .‘ 'u..~ ‘- . . ’:‘ i \ “a... a y'. 1"". .‘- CHAPTER IV ANALYSIS OF THE RESULTS In this chapter, the hypotheses will be restated and discussed in terms of their statistical test on the Null and conclusions on the Research outcomes. An alpha level of .10 was chosen for all hypotheses to determine statis- tical significance for reporting this study. Both a nmltivariate and univariate analysis of variance were cmmputed comparing the groups receiving simulated clinical training and the groups receiving real clinical training. In looking at the univariate analysis of variance for the effects of the treatment training on the individual dapendent variables, an alpha level was established a-priori. COVARIATE EFFECTS Inspection of the correlation matrix between the dependent variables and the covariates yields no meaningful r81ationships (See Table 1.1). The chi—square tests for association between the dependent variables and CoVariates was not significant (See Table 1-2)- It was, therefore, decided to re-analyze the data eliminating the two Covariates in order to increase power. The multiple 105 106 oooooo.a oomoaa.o mmmmoo.o wmmamo.o1 mmmmoa.ou oohwmo.o mpmsmo.on mommwa.ou w>auflcoou numom oooooo.a mmmooo.on mwhhmo.on ~o¢~nm.ol scamma.o mmwnma.ou omahmm.o m>fiuwcoou soum oooooo.a nomnoH.on momo-.ou oovmoo.o Hmmwmo.o mnmvhm.o nuofi>mnmm m>wuommm< oooooo.a Hmovmm.o omcooa.ou mambmm.o oommaa.o ~u0w>mnom m>wuumwm< oooooo.a maomoa.ou Nmmvmm.o mmmmh~.ou zuoH>wnmm o>auomwm¢ oooooo.H ~mmvm~.o mmmmom.on nouoEosoxmm nu mom oooooo.a onqvm~.ou Houoeonoxmm noun oooooo.a mosmENOMNDm amuoa Assam u>wuwcmou m>wuwcmou nuow>mnom ~u0w>mnmm _u0a>mnmm youOEonoxmm uouoeonoamm DUGMEHOuumm numom noun m>wuowww¢ o>wuoouu< m>fiuomum< numom umum Hmuoa Assam .H mamwnu0d>m Hem xwuumz coHumamuuou .H.H manna . . _- i‘ v (1‘ .— . r.‘. d. 107 Table 1.2. Testing Regression Coefficient for 2 Covariates of Hypothesis 1. CNerall Chi-Square Test of no Association Between Dependent and Independent Variables D.F. = 12 Chi-Square = 13.2875 p < 0.3485 Adding Covariate l (PRE-COGNITIVE) to the Regression Equation D.F. = 6 Chi-Square = 8.4352 p < 0.2080 Adding Covariate 2 (PRE-PSYCHOMOTOR) to the Regression Equation D.F. = 6 Chi-Square = 4.9413 p < 0.5514 108 regression data revealed no significant effect of the co- variates upon the dependent variables with the exception of some minor potential effect on affective behaviors. Adding only the pre-cognitive covariate revealed some minor effect in total final performance. RESULTS 913; THE TESTS (_)_F_ THE HYPOTHESES Total Performance in Clinical CompetencyL Psychomotor, Affective and Cognitive Differences Between Simulated Clinically Trained and Real Clinically Trained Group§ Null hypothesis 1. There will be no significant chiferences in the total performance in clinical compe- tency, psychomotor, affective, and cognitive final performance criteria measure ratings of students trained With simulated patients as models in simulated clinical experiences and that of students trained with real Patients as models in real clinical experiences. Both multivariate and univariate analyses comparing the Simulated clinically trained and the real clinically traihedgroups were computed. A summary of the results is diflilayed in Table 1.3. The F ratio for the multivariate tESt cxf equality of mean vectors is significant at p <0.0907. Of particular interest in the test of Hypothesis 1 is the univariate analysis of the effect on the dependent variables. The results on the dependent v . . . . arléflole of Final Total Performance in Clinical Competency Table 1.3. Multivariate and Univariate Tests for 109 Hypothesis 1. Multivariate D.F. = 6 and 15 F-Ratio = 2.2281 p < 0.0907* Univariate Between P variable Alpha Mean Squares Univariate F Less Than Final Total Performance . 0 5 Psychomotor . 0 1 Affective; .01 Affectivez .01 Affectivea .01 Cognitive .01 308.1667 308.1667 0.1667 15.0417 0.0417 15.0417 D.F. for Hypothesis = *Significant 1 4.5208 14.2082 0.0040 0.5123 0.0310 1.6070 D.F. for Error 0. 0. 0. 0. 0. O. 0450* 0011* 9500 4817 8619 2182 22 110 and Psychomotor Skills Show the groups differed in the direction hypothesized to a degree that was statistically significant at p < 0.0450 and p < 0.0011, respectively. Inspection of cell means in Table 1.4 indicates the simulated clinical training treatment produced signifi- cantly higher demonstrated performance on Final Total Performance in Clinical Competency and on Psychomotor Skills. The demonstrated performance of cognitive knowledge is higher in the simulated trained group. On inspection of the cell means for the pre-cognitive and pmst-cognitive performance measures, it is important to rmme the real trained group had higher pre-cognitive scores, lnm.the simulated trained group displayed significantly higher post-cognitive scores. In the affective behavior measures, the real clinical training treatment produced ndnimal performance differences which were not apparent in the simulated training treatment group. Transfer of learning was reflected in the psycho- mOtOr, affective, and cognitive knowledge behaviors dex“Onstrated in clinical competency performance in the reil‘world on real patients by the simulated clinically trained group. Based on this analysis, the null hypothesis is twejected and the conclusion is that simulated clinical training proved more effective than real clinical training. Jfill .mocmEHOHumm umuumn momeEw some uwzoq«u .mocmfiu0wuom umuuon madame“ some nonmwma Hooflcaao « cc as 2.5 homa.om nmow.ma noow.v noaa.m~ oooo.m~ oomh.HoH mmmm.moa mmmm.on doom memo: HmuAcHHo a «a at «a a 2.: oomp.am nmav.¢a mmmm.v ooom.mm hwoa.m~ mmmm.vm hmoa.moa ooom.mm pmumHsEam moms: vamo.m momo.v wmmH.a mmav.m momv.m thm.v oamm.ma mom~.m cowuwa>mo photomum mmmm.m mmwfi.ma hvvm.a mmmm.m~ mmqn.av vmmw.a~ Hmam.mha woma.mo moccauo> mmmm.om havo.ma ommo.v mmon.c~ mmmo.m~ soma.mm oomw.noa beam.mh :00: pcmum o>duwcmou m>auflsmou mu0q>mnmm ~u0w>m£mm _H0a>mzom HOuOEocoxmm uouoeonoxmm mocmEHowumm lumom Imus m>Huommm¢ m>auowuu< O>Huowuw< numom lawn Hmuoa Assam .H mamwnuomhm HOu mans: Hamu can ..o.m .mocmflum> .cmmz pcmuu .v.a manna 112 Differences Demonstrated in Total Performance Skills in Clinical Competency on Each of the Three Treatment Training Experiences Between Simulated Clinically Trained and Real Clinically Trained Groups Null hypothesis 2. There will be no significant difference on total performance in clinical competency criterion measure ratings in each of the three treatment training experiences of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. The F ratio for the multivariate test of equality of mean vectors, as reported in Table 2.1, is significant at p < 0.0101 and the null hypothesis is rejected. Of particular interest in the test of HypothesisZ, is the univariate analysis of the effect of the Second Clinical Experience (p < 0.0007) and the Third Clinical Experience (p < 1.0000). The results indicate that the simulation training produced an effect on performance. However, several factors may be in operation. The instructors were randomly assigned for the First Experience and the two principal instructors rotated between real and simulated clinical trained groups for the second and third treatment training experience. The Second Experience is the variable providing the significance at p < 0.0007. Table 2.2 demonstrates differences in cell means of the treatment groups. There may have been, as Barrows (1971) ‘Would state, "many red herrings" in operation. The 113 Table 2.1. Multivariate and Univariate Tests for Hypothesis 2. Multivariate D.F. = 3 and 20 F Ratio = 4.9370 p < 0.0101* Univariate Between Univariate P Variable Alpha Mean Squares F Less Than First Clinical .03 2.6667 0.0587 0.8108 Experience Second Clinical .03 408.3750 15.5579 0.0007* Experience Third Clinical .04 0.0000 0.0000 1.0007 Experience D.F. for Hypothesis = 1 D.F. for Error = 22 *Significant 114 Table 2.2. Grand Mean, Variance, S.D. and Cell Means for Hypothesis 2. First Second Third Clinical Clinical Clinical Experience Experience Experience Grand Mean 80.3333 82.4583 85.3333 Variance 45.3939 26.2537 35.6969 Standard Emviation 6.7375 5.1238 5.9747 Means* Simulated 80.6666 86.5833 85.3333 (T ) Clinical Means* Real 80.0000 78.3333 85.3333 oz) Clinical *Higher mean implies better performance. Table 2.3. 115 Correlation Matrix for Hypothesis 2. First Second Third Clinical Clinical Clinical Experience Experience Experience First Clinical 1.000000 Experience Second Clinical 0.221642 1.000000 Experience Third Clinical Experience 0.264981 0.088098 1.000000 116 students may have been tired from the drive, the hospital may have been extremely busy, and the patients may have been upset. These factors contribute to problems in student performance. However, provisions were made for normal stress in the simulation training. Simulation training, because of the option for control, planned variation, and the reduction of accidental occurrences, seems to reduce the distractions from learning and allow controlled learning of the complex tasks involved in medical education. Differences in Anticipated and Demonstrated Confidence in Performance Between Real ClinicallyTraineg and Simulated Ciifiically Trained Groups Null hypothesis 3. There will be no significant difference in confidence demonstrated in the anticipated total performance in clinical competency, in psychomotor skill technique abilities, in affective behaviors, and in the actual total performance in clinical competency criterion measures self-ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. Both multivariate and univariate analyses were com- puted. The F ratio for the multivariate test of equality of mean vectors, as presented in Table 3.1 is significant 117 Table 3.1. Multivariate and Univariate Tests for Hypothesis 3. Multivariate D.F. = 4 and 19 F Ratio = 2.5163 p < 0.0757* Univariate Between Univariate P Variable Alpha Mean Squares F Less Than Confidence Anticipated .05 1.0417 4.6610 0.0421* Total Performance Confidence Demonstrated .01 1.0417 4.6610 0.0421 Psychomotor Confidence Demonstrated .01 0.0417 0.1549 0.6977 Affective Confidence Demonstrated .03 1.500 5.6571 0.0265* Total Performance D.F. for Hypothesis = l D.F. for Error = 22 *Significant 118 at p < 0.0757. The null hypothesis is rejected. The multivariate and univariate analyses support the hypothe— sized direction for the simulated clinical trained group. The p < 0.0421 for confidence in anticipated total performance and p < 0.0265 for confidence in demonstrated total performance in clinical competency are significant. Inspection of cell means in Table 3.2 indicates that the simulation training treatment produced more confidence, anticipated and demonstrated, on total performance in clinical competency, and there is also evidence to support simulation training for producing confidence demonstrated in psychomotor skills and techniques. There is a minimal difference in confidence demonstrated in affective behaviors. Simulation yields greater anticipated and demonstrated confidence in a student's ability to transfer the experiences in clinical training. Differences in Agreement on Student Self-Rating and Clinical Instructor's Rating on Totai' Performance in Clinical Competency Ratings Between the Simulated Clinically Trained and the Real Clinically Trained Groupg Null hypothesis 4. There will be no significant difference in agreement on student final performance criterion measure self-rating and the clinical instructor's rating of total performance in clinical competency on the final criterion measure ratings of students trained with Simulated patients as models in simulated clinical 119 .mocmoflwcoo umummnm mmHHoEH some “6309* Hmoflsaau Auav mmmo.m moav.a mmmm.a oooo.N Hmmm «memos Hmowcflao Anev mmmm.H ooom.H oomN.H mmmm.H pmumHSEHm «mono: mvam.o mmam.o hwbv.o hmb¢.o Gofluma>ma oumocmum Hmmm.o mmm~.o mm-.o mmmm.o mocmanm> mmmm.a mmmv.a mmmv.a mamh.a :mmz ocmuu mocmfiuomumm m>wuowmm< Houoaosowmm TOSMEHOMHTQ Hmuoa omumuumsoaoo omumuumcofiwo Hmuoa omumnuchEmo mocmoflmcou monoofimcoo topmoflowus4 mocmoamcou mocmoflmcoo .m mammnuomm m How mammz HHmU paw ..Q.m .mocmflum> .mez DGMHO .N.m QHQMB 120 mmmv.o mosmEHOMHmm oooo.H ovmm.o movm.o Hmuoa omumuumcosmo mocmowmcoo oooo.a haov.o mmmq.o m>wuommm4 pmumuumcosmo mocmoflmcoo oooo.H memq.o nouoeoEDSmm omumuumSOEmo mocmoflmcoo wocmEH0mumm oooo.a Hmuoa topmofloaus< mocoofiwsou mosmEH0mHmm m>fiuoomm< nouoaonommm masseu0mumm Hmuoe omumnumcoaoo pmumuumcoEmo Hmuoe omumuumcoEmo mocmowmoou mocmoflmcoo omumofloaucm mocmoflmcoo mocmowmcoo mammnuomhm HON XHHHMZ GOHumHTHHOU .m.m. «News 121 experiences and that of students trained with real patients as models in real clinical experiences. The results of the test for equality of correlations reported in Table 4.1 indicate that the null hypothesis is not rejected. The simulation trained and the real trained groups are equal in the agreement of students' and instructors' ratings. It was hypothesized that the simulation trained group would Show greater agreement in the performance rating they thought they would receive and what they actually received on the final criterion measure rating. The results indicate that simulation training does what the real training experience does regarding a subject's ability to predict his performance in an examination situation. There are many variables operating in a subject's ability to predict, which are really over and above the immediate experience. Perhaps it would have been more realistic to predict agreement based on the statement of Gagne (1965): "To the extent that simulation is 'real' the performance is 'real' and one cannot define something which is 'more real.'" It appears that simulation training does nothing for a subject's ability to predict his perform- ance in the real world environment over that which is provided by the real world training. 122 Table 4.1. Testing Significance of Correlation for Hypothesis 4. FISHER'S Z - TRANSFORMATION N ny ZF Significance (T1) Simulated Clinical n = 12 .36 Trained 1 -.1273 N/S (T2) Real Clinical n2 = 12 .42 Trained Do Not Reject Ho:4 The Correlations are Equal F1 = F2 Differences in Responses on Feelings About "Self"iin the Treatment Training ClinicaI'Experiences in Neurology—Eetween Simulated Clinically Trained and Real Clinicallnyrained Groups Null hypothesis 5. There will be no significant differences in responses about "self" in the treatment training criterion measure self-ratings on factors secure, successful, calm, pleasurable, and competent of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. The F ratio for the multivariate test of the equality of mean vectors, as presented in Table 5.1 is significant 123 Table 5.1. Multivariate and Univariate Tests for Hypothesis 5. Multivariate D.F. = 5 and 18 F Ratio = 2.2054 p < 0.0989* Univariate Between Univariate P Variable Alpha Mean Squares F Less Than Secure Insecure .02 1.3113 3.3149 0.0823 Calm Anxious .02 3.3078 3.5683 0.0722 Competent Incompetent .02 0.2904 0.7946 0.3824 Successful Unsuccessful .02 0.0726 0.1853 0.6711 Pleasurable Unpleasurable .02 0.2904 0.5029 0.4857 D.F. for Hypothesis = l D.F. for Error = 22 *Significant but not in direction hypothesized. 124 at p < 0.0989, but not in the direction hypothesized. The ‘univariate analysis of the effect of the factors secure- insecure, calm-anxious, competent-incompetent, successful- unsuccessful, and pleasurable-unpleasurab1e indicate no significant differences at the alpha levels established a-priori in looking at each of the responses about "self" in the treatment training. However, inspection of cell means in Table 5.2 seems to indicate that simulation training results in insecure and anxious feelings about "self." Yet the experience is rated more pleasant by the simulated trained group. The direction of the individual differences on factors relating to "self" indicate that the simulation trained group is less secure, less calm but the experience was more pleasurable and more success- ful. The real clinically trained group was more secure, more calm, and felt more competent, but the experience was less pleasurable and they felt less successful. The simulation experience was more pleasurable, which one would think would not be related to anxiety. However, it appears that the anxiety is goal directed and represents a positive investment of "self" in the learning experience. Perhaps what has been isolated within simulation is the stress of learning and the elimination of uncontrolled stimuli that operate in the real world and detract from the learning task. However, the real experience may not have been challenging the competency of the students; therefore, they felt less successful and the experience ILCI-rll\- Cunt-Sic. Ali. Iii-lion: F I.IPI Uni-Ii I ln.1.-I IlIvjuu-II‘illux) IIIINIOF‘ ~.ulIl.:.-Iv IL‘II- Dv~.~'..~. 125 .mmcoommu m>wuwmoo duos mmfiHoEH some Hmsoq« Hmoflcwao ANBV m~m~.~ omno.~ omva.m mmmm.m mnmm.a doom «moms: Hmowcwao “use mmom.m owam.a mnmm.m mmmm.~ omom.~ omumHDEwm «mono: mvoo.o mmmh.o hmmm.o ommo.o ommw.o downwa>mo photomum mmwm.o mbhm.o momm.o mamm.o mmmm.o moccaum> mmmm.m mmmm.a ~mam.m mnmm.~ mama.m and: ocmuo ucmummfioocH THQMMSmmmHQSD mSOqum asmmmmoosmco musommcH ucmuomeoo THQMHSmmwam EHMU Hammmmoosm ousomm .m mammnuoowm How moms: Hamo pom ..o.m .mosmaum> .smmz pcmuo .N.m manna 126 «mom.o Hmmm.o mmeo.o vmem.o momm.o mmcoommm II II II II II Hmuoe oooo.a mamm.o noma.o momn.o momn.o ucwumosoocH ucmuwoeou oooo.a mvmo.o nmne.o Hmov.o maomusmmmaoco manmusmmwam oooo.H Hmmm.o mmbm.o msofixcd EHmO oooo.a hoeh.o stmmmoosmco Hsmmmooosm oooo.a musommcH musomm ucmumoeoocH manmusmmmaoco msowxcm Hommmmoosmco musowmsH ucmumoeoo manmusmmmam Eamu Hsmmmmoosm mnsomw .m mammnuommm How xflnumz Gowumamhuou .m.m THEME 127 was less pleasurable. On the other hand, perhaps the real experience caused the students to assume an artificial assurance about "self" to protect against the negative anxiety associated with uncontrolled variables found in the real world. Differences in Responses About the Treatment Training Clinical Experience in Neurolo ogy Between Simulated Clinicall Trained and Real Clinically Trained Groups Null hypothesis 6. There will be no significant difference in responses on the treatment training criterion measure self-rating on the factors realistic, important, useful, meaningful, and successful of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. The F ratio for the multivariate test of the equality of mean vectors, as presented in Table 6.1 is significant at p < 0.0018 in the hypothesized direction. The univariate analyses support the factors of realism at p < 0.0024 for real trained, importance at p < 0.0363 for simulated trained, and meaningful at p < 0.0207 for simulated trained. The null hypothesis is rejected. Subjects trained in simulated clinical training rate the neurology training experiences higher. Inspection of cell means in Table 6.2 dispells the concern for the issue of realism in simulation. The 128 Table 6.1. Multivariate and Univariate Tests for Hypothesis 6. Multivariate D.F. = 5 and 18 F Ratio 6.0595 p < 0.0018* Univariate Between Univariate P Variable Alpha Mean Square F Less Than Realistic Artificial .01 2.4003 11.8513 0.0024* Important Unimportant .04 4.6464 4.9753 0.0363* Meaningful Meaningless .03 1.3113 6.2211 0.0207* Useful Useless .01 0.1633 1.2774 0.2706 Successful Unsuccessful .01 0.1633 0.3708 0.5489 D.F. for Hypothesis = l D.F. for Error 22 *Significant 129 .mmcoommu m>wuflmom THOE mmflaosfl some Hmsoqa HMDHQAHU 2.3 oomm.a mnmm.a oomm.a ommm.H mnvm.H doom «moms: HMOflcwHU 2.5 omam.a oonm.a oooa.H mbma.a mmmH.H omumasE«m «moms: nmwm.o oomw.o vmmm.o Hmmv.o mhmm.o coflumw>mo oumocmum mov¢.o mmom.o mmmm.o woam.o mhma.o mommaum> mnmw.a nmmm.a oovm.a Naom.a ommm.a cmmz comma Hommmmoosmsa HmonMAuud ucmuuomEHsD mmmamcHommz mmwamms Hommmooosm oapmfiammm ucmuuooEH asumcflcmmz asmmmo .m mammnuommm How mono: HHTO pom ..o.m .mosmaum> .cmw: psmnw .N.m OHQMB 130 omnm.o mnmm.o ochm.o mmmm.o vomm.o oncoomom |.. I II .I.. I Hmuoa Hsmmmmoosmcp oooo.H mmmH.o hmom.o omo~.o noo~.o Hommmmoosm . amnooonuua oooo.a mnma.o Hmmv.o mnav.o oaumwammm usmuuoofiaco oooo.H amme.o kmms.o ucmuuomeH mmmamswcmoz oooo.a some.o Hammcscmmz mmmaoma oooo.a Hommmo HoummTUDSmco HMHDAMfluum ucmunomfiflsa mmmamcflcmmz mmmaoms Hommmmoosm owumflamom ucmuuooEH Hommcficmmz Hommmo .m mfimwnuomhm How xflnumz soflumHmHHOU .m.o manna 131 difference is in favor of the real clinical training treatment experience which is expected. However, the difference is not that great to assume that the simulation seems artificial to the students. In fact, the cell means support simulation training in all factors except in realism. On the semantic differential evaluative scale of realism vs. artificiality on a 1-7 point scale (Real = l - Artificial - 7) the mean for the simulated clinically trained group is 1.87 and the real clinically trained group mean is 1.24. This difference is minimal and, although statistically significant, it is not meaning- fully significant for the overall objectives of this study. Simulated patients are representative stimuli of the real world patient. In further explanation, within the treatment experience, each student performed a complete neurological evaluation as a final performance criterion measure. Thirty-eight video-tapes were completed, one for each student. All Es in the experiment had to complete their neurological examination on a E231 patient. Therefore, the E pro- grammed the final examination in order for the inactive control to examine the simulated patients used in the treatment of simulated clinically-trained Es. These students did not know if the patients were real or simulated. In fact, if the E was asked by the student what type of 132 case he would have for the practical final, the student was informed by all involved in the course that: "Your patient will be real, but there may, out of necessity, have to be a few simulated cases." Note again that no simulated patients were used in the final practical examination of the treatment groups. However, of the 14 students ESE involved in the experimental study (the inactive control), 11 were evaluated using simulated patients and 3 using real patients. As part of the final examination evaluation procedures, each student was asked if he thought his patient was real or simulated. (Special emphasis was placed on the 14 inactive control students not in the study.) This question was asked after each student had completed the total case write-up. The assessment of the 14 inactive control students as to whether the case they examined was real or simulated, provided the following results: The total N = 14 (total students) 11 evaluated :figh simulated patients, 3 with real patients. 8 students having simulated patients stated their patients were real. 1 student having a real patient stated his patient was simulated. 2 students having real patients stated their patients were real. 1 student having a simulated patient stated his patient was simulated. 2 students having simulated patients indicated uncertainty whether their patient was real or simulated. 133 A basic percentage computation indicates that 84% of the inactive control students could not tell whether their patient was real or simulated. Visual inspection of this data reveals that the utilization of simulated patients works and is a viable technique that can be used in the education of medical students. Differences on Factors Contributing to Performanchon the Training Experience Between the Simulated Clinically Trained and the Real Clinically Trained Groups Null hypothesis 7. There will be no significant differences in the practical clinical training experience factors of providing all the skills and abilities, pro- viding psychomotor skills and techniques, providing the medical knowledge necessary (cognitive), providing the development of affective behaviors, and in providing feedback as vehicles in performing the complete Neurological Evaluation History and Physical Examination final performance criterion measure ratings of students trained with simulated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. Both multivariate and univariate analyses comparing the simulated clinically trained group and the real clinically trained group were computed. The F ratio for the multivariate test of equality of mean vectors, as presented in Table 7.1 is significant at p < 0.0766 in the 134 hypothesized direction supporting the simulated clinically trained group and rejecting the null hypothesis. Inspec— tion of the univariate analysis is of particular interest regarding the effect of the variable Feedback. One of the key attributes of simulation training is the opportunity it gives to provide controlled feedback within training. This is reinforcement for the learning task presented, which may not be available in the real training. The univariate analysis for Feedback is significant at p < 0.0044 in the hypothesized direction. Inspecting the cell means in Table 7.2, supports simulated clinical training on all variables except in providing for the development of affective behaviors. The reported mean differences are minimal in all areas of providing for the ability to perform in the clinical experience except in that of Feedback. Simulation training more adequately provides the vehicles necessary to perform a complete neurological examination. Differences in Request for Simulated Instruction Experiences Between the Simulated Clinically Trained and theIReaIClinically Trained Groups Null hypothesis 8. There will be no significant differences in requests for additional simulated instruc- tional experiences as evidence of preference for this Inethod of training on the final performance criterion ineasure rating scale of students trained with simulated 135 Table 7.1. Multivariate and Univariate Tests for Hypothesis 7. Multivariate D.F. = 5 and 18 ; F Ratio = 3.4146 p < 0.0766* Univariate Between Univariate P Variable Alpha Mean Square F Less Than Providing All Skills and .02 0.0417 0.0485 0.8378 Abilities Providing Feedback .02 8.1667 10.0748 0.0044* Providing Medical Knowledge .02 1.0417 0.8958 0.3543 Providing Psychomotor Skills and .02 0.1667 0.2316 0.6352 Techniques Providing Affective Behaviors .02 0.6667 0.9670 0.3362 D.F. for Hypothesis = 1 D.F. for Error = 22 *Significant 136 .nouomm onu mo mcwumn mono“: momeEA some Anson; Hmowcflau 2.3 mmmm.m oomh.H mmmm.m mmmo.~ mmmo.m Hmom «momma Hmoacaao 2.3 mmHv.H mmmo.m mmam.H mmam.a oooo.~ pmumasawm «momma moom.o momm.o emso.a mmvm.o mnmm.o sowumw>mo pumoomum ooam.o vomw.o mmma.a nman.o mmmw.o mocmflum> oooo.m mmam.a omNH.m oooo.~ mavo.~ mono: ocmuo xomnoomm muofl>m£mm mmomasocx mosowscoma mmfiuflaand mcfloa>onm m>auomooa Havana: can mflaaxm can maneo>oum maoen>oum HopoeoeoSmm msflnxm Hoe mcflofi>oum mcfl©w>onm .5 mammsuoohm How moms: HHmU pom ..o.m .mocmaum> .cuwz Dunno .N.h THQMB 137 oooo.H mmm~.o omhv.o nmmm.o m¢m~.o xomooooh mafiofl>oum mu0fl>mnmm oooo.H mwma.o mmom.o Hmoo.o m>wuowmm¢ mcflofl>onm mmomasocm oooo.a mmmm.o mhm~.o Hmowomz mcwow>oum mosoficnowa oooo.H avom.o can mHwam HouoEonDMmm mcflpfl>oum mowuaawod oooo.H pom maawxm HH< mcwow>oum xomnommm mnofl>mnmm moomasocx monowccooe mmfiuwaflod mcflpw>oum m>wuommm£ HMDHomz pom maawxm pom mcoea>oum scoeo>oum nopoeoEDSma msaflxm Ham mcfiow>oum mcflpw>oum .h mammnuommm How Manon: cowumawuuoo .m.h OHQMB 138 patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. The Chi-Square test is significant at p < 0.03 (See Table 8.1). Since the Chi—Square test is significant, the null hypothesis is rejected and it is concluded that subjects with simulated clinical training requested additional simulation experiences more than do students with real clinical training. Student support for the simulation training concept is critical to the implementa- tion of the concept within the curriculum. Without student support, administration and faculty would have difficulty in providing any alternatives to traditional instruction. Students must be given options in learning the required material. Perhaps, if various methods were employed within a teaching model, the educational process would, indeed, be supporting a key objective of education which is meeting individual differences in the ability to learn. Table 8.1. Chi-Square - Testing of Hypothesis 8. D.F. = (2-1) (2-1) = 1 df Chi-Square = 5.3 p < .03 x2 (Chi-Square) .10, 1 df = 2.71 139 Differences in Demonstrated Improvement vs. Epnsistency on Patient Evaluation During the Treanment Training Between the Simulnted Clinically Trained and the Real CIinicElly Trained Null hypothesis 9. There will be no significant differences in demonstrated improvement vs. consistency in the treatment training patient evaluation performance criterion measure ratings of students trained with simu- lated patients as models in simulated clinical experiences and that of students trained with real patients as models in real clinical experiences. The F ratio for the multivariate test of equality of mean vectors for the First, Second, and Third Clinical Training Experiences, reported in Tables 9.1, 9.2, and 9.3, are significant at p < 0.0003, p < 0.0024 and p < 0.0008, respectively, in the hypothesized direction. Inspection of the univariate analysis for the First, Second, and Third Experiences, also supports an improved demonstrated satisfaction in performance for the simulated trained group on patient evaluations (See Tables 9.1, 9.2, and 9.3. The final patient evaluation criterion measure is presented in Table 10.1). Within the First Experience, the univariate analysis on the dependent variable competent-incompetent is supportive of the simulated clinical group at p < 0.0001. All other factors also support the simulated clinical group. Secure-insecure is significant at p < 0.0001 for simulation, interested- uninterested is significant at p < 0.0062, and gentle-rough 140 is significant at p < 0.0081 (all in favor of the positive behaviors). In the Second Experience, the univariate analysis is supportive of the simulated clinical group on all variables. In the Third Experience, the factors of competent-incompetent and secure-insecure support demon- strated improvement for the simulation instructional technique. Of particular interest are the cell means of Table 9.4. Inspection of this table reveals the demon- strated improvement in performance of the simulated trained group vs. the consistency in performance of the real trained group in patient evaluations criterion measures. The evidence that is provided supports the change in demonstrated behaviors which occurs in simulation training. Subjects trained in real clinical experience receive little constructive reinforcement. Real patients are reluctant to rate physician behaviors, even though the clinical instructor advised them to do so, and as a result, student- physician behaviors continue to operate without change. Through feedback from simulated patients there is a demon- strated improvement in patient satisfaction in the First, Second, and Third Experiences. 141 Table 9.1. Multivariate and Univariate Tests for Hypothesis 9, First Experience. Multivariate D.F. = 4-and 19 F Ratio = 9.1540 p < 0.0003* Univariate Between Univariate P Variable Alpha Mean Square F Less Than Competent Incompetent .025 40.0417 22.8315 0.0001* Secure Insecure .025 32.6667 31.0216 0.0001* Interested Uninterested .025 13.5000 9.1856 0.0062* Gentle Rough .025 8.1667 8.4882 0.0081* D.F. for Hypothesis = l D.F. for Error = 22 *Significant 142 Table 9.2. Multivariate and Univariate Tests for Hypothesis 9, Second Experience. Multivariate D.F. = 4 and 19 F Ratio = 6.1576 p < 0.0024* Univariate Between Univariate P Variable Alpha Mean Square F Less Than Competent Incompetent .025 28.1667 26.7482 0.0001* Secure Insecure .025 20.1667 16.8481 0.0005* Interested Uninterested .025 13.5000 8.6505 0.0076* Gentle Rough .025 8.1667 7.7554 0.0109* D.F. for Hypothesis = l D.F. for Error = 22 *Signif icant 143 Table 9.3. Multivariate and Univariate Tests for Hypothesis 9, Third Experience. Multivariate D.F. = 4 and 19 F Ratio = 7.5810 p < 0.0008* Univariate Between Univariate P Variable Alpha Mean Square F , Less Than Competent Incompetent .025 16.6667 16.1765 0.0006* Secure Insecure .025 18.3750 24.3769 0.0001* Interested Uninterested .025 3.3750 3.6073 0.0708 Gentle Rough .025 5.0417 4.7032 0.0412 D.F. for Hypothesis = l D.F. for Error = 22 *Significant 144 .oco Avocados and o>ausuoc gods Iouu o>OI canon. nouoom .oosdlu0uuom assau on» Add: nonunion and moccauoaxu Iona 00:1Iu0uuoa cu mecca-«acoo .n> touchy-cello cu acclo>oumlq can nuzouo Iona scoot. aquacuau 1.: nmom.o nnmm.o swam.o hooa.u oomn.o nnna.o hoo~.a oomn.a noaa.o nnna.o oom~.a hooa.« aqua cacao: Hosanaau 1.9. nnnn.on nooa.ou nnnw.ou ooom.on nwav.ou nooo.ou homo.ou pwno.ou oomu.on hwoo.an nnoo.an suav.au nauaasaam Cficug vmno.n «noo.o ~¢o¢.o ooao.a ”owe.” “ova.” avoo.a nouo.~ moom.o nNH~.A «ouo.d nvun.a cauuaa>oa vM-ccaum aura.“ omno.o onmh.o ndno.a ammo.a ocom.a owaa.a onno.« anoo.o snov.a onno.a onmn.a Cossaud> om~a.o noo«.o havo.o mnnn.o hon.o nnoo.o oom~.o hooa.o nnnn.o nnmo.o nnoo.o oman.ou can: cacao unoccuucou uaouounn ousuom acouonaou unoccuunou uuououcn ousuom acouooiou unocoaucoo uuououcn ousuom uaoaomloo q .ndol undue .v.a candy 145 coco.” mnHH.o unoo.o ounn.o nmvo.o v¢-.o- kn-.ou oeso.o- ammo.o onoa.ou onon.os oako.o . coco.” Hao6.o ”van.o vav.o ammo.o askn.o a-m.o hp.~.o oaom.o ama'.o noon.o . oucosuwaxm oooo.a onkm.o moo..a onno.o -.h.o .vsn.o oa-.o uao..o .Hnn.o kok~.o . ounce coco.“ unam.o conn.o k.nn.o on~n.o kan~.o n~o..o saw~.o nvso.o . oooo.~ om~m.o Gonn.o n~nn.o onun.o -m~.o asko.o- qu~.o . oooo.s Hmoo.o n~om.o ocoo.o- noop.° moom.o A~Hv.o . oocofiuomxu coco." msmo.o nmno.on a.~m.° nosm.o mas..° ~ vacuum cooo.~ hsoo.o coo..o nnnn.o ~0am.o . coco.a om-.o noao.o oko~.o . coco A mean o avnm o . cocoauoaxu coco.” mvam.o . anus» oooa.a . o n u . IIOGOHUGOO UghOUQH .90.“ USOUOQSU DIOGOmUBOU UION”v§H ONSWOm uCOua-EO. U IIOCIMUCUU “IOMWUQH .Hflnuvflm #6000? U q4zuu oa aux£m com muoumflc ucmflumm ouswc m mumnumcoEmc Ou anommwooc muouomM unavawflcmfim >cmE 30m .c "huoumflm ammo .m m moaumflumuomnmco m>flumfluomoc Hocuo no mEouMENw Hmumcmo .w pomeummuu mDOH>mHm mo mmusoo .m mufiuo>0m .v coflumooq .m coaumuso .m ummco .H .HOCCME #GTHTSOU UCM UwNflcmmHO CM CM mmHDOU USN “wa0 map CTQHHUmTQ .4 "mucfimHmEoo unficu mo Omnsoo com uwmco .N m .mucamHmEoo mmflco no mamas loud mo HOQEDS pomnnoo wcu cmflmaucwcfi mammflnn cam MHNDOHO .m "AmeuchHEEOO «mono .H m cmumamaou cmuflsomm "mmozo mM m>HBHB<2mom wUZmBmmZOU fidoHZHQU m.mOBUDMBmZH MZHUHQHS UHmfidmOWBmO m0 mumqqoo MBHmmm>HZD deBm 24OHmUHS em mama Ap.ucooe O xapnmooa 222 H0fl>ocom cam coauoucoz . NHOmcom . Houoy coauucsmeo Eoumwm HousmoHouooz mo mond mo ucoEmmom ' U1 Hooo>fisom Hmomooaousoz HmEHocn< . . Humar-imm HMOflmoHOHDoz HoEHOZ . Axoocov “muasmom Hmuocoo .m uwmeEDm .m m momoo m.ucofluom on» «O msanOS OHumocmoHc one SH Hmufl> adoEonpxo on on noowmcoo 50% on .couflOHHo ucocsum ocu coacz .mocflccflm accommcm Hmomufluo woos 30m .m mmwflucocfi poocsum ocu can cofiumcflfioxo HhOflmwcm HoOHmOHOHsoc o ououumcoeoc ou hummmoooc .Hofiuocoo no HmEHoc Hocuflo .mocflccwm HoOHmmnm DGMOHmacmfim acme 30m .d “cowuocflaoxm encammcm .m OH momoo m.ucofiumm\ocu mo mmrxuos Oflpmosmmfic ocu ca Houfl> mHoEoHuxo on on nocfimcoo so» on .coawapcocfi unocsum on» coac3 .muouoom uGMOfimacmfim acme 30m .m mNMHucocH usocoum men can mEouwNm ocu mo 3oH>ou ouonEoo o oumnumcoaoc Op mummmoooc mu0p0hm ucmommwcmao wcoE 30m .¢ "3ofi>om mEoumMm .v v momoo m.ucoflumm ocu mo ucoEomocmE com mfimocmmfic ocu ou manusnflnucoo mucfloo Hmofl> wHoEouuxo on on nocfimcoo :0» oc .coflmwucocw Dcocsum och Evans .mnouomw ucoOflmacmHm woos 30m .m "meZD m >Hoeoupxo on on Hocfimcoo 50% 0c .coMMMucoom unocsum ocu soap: .mcowumnocflmcoo mama 30m .m mamaucocfl ucocoum on» can mcaxma coflmflooc com ucoaoosfl Hmowcflflo .mcfi>aow annouo oumuumcofioc ou mummmoooc mGOHumnochcoo Oflumocomfic HmflucoHoMMHo oummnmoumom home 30m .d umfimocmmfio Hmwmcouommwo C0 wwwflucocw pcocoum och can McH>HOm anoonm o>fluoommo oumHUm Icoeoc on >umwmoooc mcofiumnocfimcoo Hmc0mmm>oum wcme 30m .0 amuflpempa unocsum ocp cap mfimocomfic mcHxHo3 m oumuumcoEoc ou mummmoooc mcomumuocflmcoo omwmocmmfic oumflumouomm acme 30m .m mamaucocfi poocsum on» cam .mcflxma coflmflooc cam ucoEmcsfl HmOHcHHO .mcfl>HOm annouo oumuumcofioc on mummmoooc mHmocomfic opmfiumoumom mama 30m .d "mwmocmmflo HmSOAwfi>Onm no mcfixnoz mononmmfifiom Hmunonou .m Eoum cflmnm .v ppoo Hmcomw .m coauocswmma uoom Ho o>uoz HmHoENWNom .N cofiuocsmwwo oaomsz mumfifium H SCAN-«MUCH HMOflEO¥fiC< .U "MMQZD mflm BZmQDBw WEB moaoflh couoamaoo conflumom mumo mumo onmmeHmo mm ommm Ac.ucoov U xwpcommd 224 oz mow mcocwmeo ocflon ommo m.ucowumo man you comoHo>oc coanoufluo on» an cocmflanmumo on umsE Ho>oa mace .o>onm no Ho>oa mmmm EdEflcflE m mo oocmEHOMHoo coumuumcofioc .:0Humcw8mxo HmOflmmcm com muoumfic ucowvmm HmOAoOHOHDoc on“ no unocsum ocu mm: .nouosuumcw Hmoficfiau m mm o>onm mocfiumn Room cH .m "couoamaoo cofinouflno mo noofisc Hmuoe "confisoou cofinoufiuo mo Hogan: Hmuoe em "mommmuo .HH mommo m.ucoflumm ocu Op HmOfiufluo xaoEonuxo on on nocfimcoo 50% 0c .coccoEEooon pcocsum on» cOHc3 .ucoaumonu no womnocu mo menom hamE 30m .0 humongous opossum ago pop pcoammpfl Hmonepoo oumuumcoaoc ou wnmmmoooc onm onsumo mumccooom oHoE m we ucoEumonu no womnocu o>flunommom Mo mommu mama 30m «Schnapps unocsum ocu mac ucoeocsn HmOHcHHO oumnpmGOEoo ou mummmoooc ammuomu Ho ucoaumonu mo mEHOm humefluo Ho HmOfluHHO mama 30m .m “ucoEumouB com ammuoce .OH N mommo m.ucowumo ocu ca memocomflo Hmcam m mcflcomou CH Hmofiuflno mHoEoHuxo on on nocfimcoo 50% 0c .coawfipcocfi ucoosum ocu cown3 .mouscooonm huoumuooma Ho mumou oaumocmmfic xcmE 30m .m m couoamfioo oouflswom ummozo mmm Bzmooam mme mumo mumo moaueh ZOHMMBHMU hm ommm Ac.pcoov U Maccommd 225 ousumcmwm m.uouosuumcH Hmowcaao L noon Lev _ poms Ame _ eooo Ame L pcmHHmoxm Ase r—ar—ao—wr—u monsoon coflumcwmeo Hmcflw H90» ma umc3 .couoaofioo umsm mnouomm mo mcflumu o>fiuoomoo ocu co commm .m umBZMZEOU mm mama Ac.ucooe O xflccooom 226 .Bzm2m949w modm Qdmm Om .Bmem mmB m0 Emma mmB B< mmmBHm mm Z¢U mBZMEMBdBm m>HBHmOm Bdma mBOZ .EmBH mam mmmzbz MZO MHZO mqumHU DZfl ZOHBmmDO mudm mMQZD SmBH Nmm>m mBmHmZOU mmqum .modm MSWBH m>Hm mBHK wZOHBmmDO 038 mm< mmmma mwdm GZHZOHHOh mm& 20 mmoHomD h m m Hey m N H Homomb .m A.>HoanHOoom Hones: on» oHOHHO cHsonm so» .Hmnuson mH poop on» usonm unoEoumum onu Hoom so» MHV coco b Amv m w m N H cmm .N .mHoanHooom HonEsc on» oHOHHO cHsonm so» coumHon NHomOHO ouHs mH umou onu usonm ucoEoumum onu Hoom so» MHV HHmmno a m m v m Ame H HHma .H a.mHonHonooom nonfisc onu oHOHHO so» .onom on» no coo ono on» on coumHoH.NHomOHo muo> mH umou onu unonm unoEoumum no umoonoo on» umnu Hoom so» MHV «mms weoumnmonsoz cw poop one .H “mqaznxm .90» on nmoE moanu omonu umns mo mHmmn onu no munofioocsh use» ome ommon .onOm on» onwomn nH .monom o>HuoHnomoc mo moHuom m umnHmmm Eon» oocsn Eon» ocH>mn an oHoooo msoHHm> Ou mocHnu nHmpHoo mo moanmoE onu oncomoe Ou mH onHumn mHnu mo omoousm one "moneoomBmzH ZMOh UZHedm ZOHB¢D4¢>M MUZMHmmmxm H40HZHHU Bzmabem am mama Ac.ucouv O chnooon 227 unouoofioonH oHansmmoHoco EHmU Hommmoooom onsoomcH nH oocoHuooxm HmOHcHHO onp nH MHomnsoNWusonm Hommmooosmno OHumHHmom unmuHOQEHnD Hommanmoz mmoHomo b m h m m m v v mmnHHoow m m N N H50» H ucouooeou .m H oHnmqumoHa .v H msowxnn .m H Homwmooosmno .N H onsoom .H mNmOHOHsoz oanomoc 50> cHso3 30: .HH H Hommmooosm .m H HmHOHMHunc .v H ucmuuooEH .m H mmoHoanmoz .N H HomomD .H "wooHousoz cH oonoHHommm HmOHnHHU n50» onHHOmoc so» OHSOS 30m .H OHnHHU cononoe oEmz m.unocoum MUZMHmmmxm HflUHZHHU om momm Ac.unoov U chnooon 228 midz BzmQDBm nmsom oHucow nmwom Nno> oHuuHH n Homoumo >Hnmn0mmom oHunoo muo> m a m N H Azauoe "mmB Houooo onp .noHpmnHmeo HmOmenm onu ocHHso .HH AoHon ou anHHmO HoHom Op msonnn cam uoz I unoquMchH AoHom ou coHuB com o: Emma mHHoannow oz HOOO coEoomv cH coumonoucH coEoomV OB nOHunouu< chav coumonouano muo> coomouounHXanmnOmmom ooumonounH Nno> m m m N H imamnov Aucmuammm Amomeoa Appomaomoo mam cnm coHunsav mHnmnommomv comeom wuo>v ousoomcH ommuo>¢ onsoom m w m N H naoaumv HonHoo mm: on “mnHoo mm: umnz 30cm uoz cHov on umnz 3onxv AunoHum mno>o unouomEOOnH ommuo>¢ unouomeou m a m m H xaooumv "mm3 noHHmnHmeo onu mnHoc Houooo onu umnu uHom H .couoHoEOD posh noHumnHmeo HmOHmwnm cam MnoumHn onu nH .H UZHB AH .anV mnHumoa HmOHmOHOHsoz AH .anV onHumoB HmOHmoHOusoz >EOpmanHsoz HH momuonuOEonO noonmu nOHumuom UHnHHU HHH oonoHom HmoHnHHO oonoHom HmHOH>mnom amsumIaHom 0>H000Hm mEoumnmousoz H momuonuoEonO Hoonmo \.ma .ama\om0\oaa\oap AconnonoHoEOU o>Huoonnov wooHOHm mEoumwm nOHumnHmem womnonuOEonO uoonmu omm ONm 0mm omm omm omm Nmm NNm 0mm ONm Hem ONm £0 23m 20 SO 20 2mm 20 Sum 20 2mm 20m 22m an3 HH a H mEoumwm HmHsomsEoudoz nHoom HH a H w00HOHm mZmBmwm m XHozmmmd oouoH omum OHum ooum ooum omuH ONANH OHuHH omum v mo: I mmomusne omuH ovumH omuHH 0Hum ooum ooum ooum omuH omuNH oHuHH omum m mm: I wmcmoncoz oouH omuH oeuNH omuHH oHum ooum ooum omuH ONuNH omum N am: I chmosa omuH oeuNH oHum ooum H um: I wmcnoz thH mmemdDO QMHmB I xmmB meHm Mdmw EmmHm 234 HoHa .Ho monnoo .uo nmEcooo .Ho HoHa .Ho nHoumnomHm .Ho noonoomo .uo wwmum nHoumnomHm .uo noHumnHmem OHnumoooumo AUG mEoumnmousoz munmmmoHQQSmocsEEH muouooooua Ac.unouv noHuomuunoo oHOmsz .nonmHEmanB Hmusonomz .nOHuOocnOO o>uoz "mooHonmna coHuOGSHmho oHomsz mo mHmunoEmcnom “hmOHOHDoz coHumuom OHnHHO HHH oonoHom HmOHnHHU oocoHOm HmHOH>mnom ampumnanmm m>apomHm nOHuomHunoo oHomsz .nOHmmHEmnmua Hmuoonomz .cOHpOsccOU o>noz "mmOHOHmmna Hem 20m ooum I omuH omuH I oquH omm SO oNuNH I 0Hum on 2mm omum I ooum m am: I mmcnoz NamH mmemnoo omHmB I MMME mazm>mw admw 9mmHa Ham Sum ooum I omuH omuH I oquH omm no QNuNH I oNuoH omm no oo"OH I QHAm omuw I ooum m mm: I mmcHHa Nmm zo ooum I oouH NNm 20a ooum I omuH omuH I ovnNH ONHNH I omuHH omm no oHuHH I 0NuoH v mm: I chmusna N ooma Am.ucoov m mecoaom 235 Hon .HD coonoomo .no monOh .no mwmum nHoumnomHm .uo omeHHHm .ao cmEHoum .no noonoomh .uo nOmnoomb .Ho mannoo .no nmEHoum .no mmmum moncoo .no cmficooo .uo mnouooooua GOHuonsHmmo oHomsz Ho mHmonomHo HmOHnHHO “woOHOHsoz mooHonummonsoz coHumuom OHnHHU HHH oocoHom HmOHnHHU mnocHOmHo unocona amoumIaHom o>Huoon cOHmmHEmnmue OHummnwm ”hmOHOHmwnm mHmocmmHo huHmHoomm maopamuIHumm .maouama AHH .anv onHUmoB HmOHooHonooz AHH .anV onHumoB HmOHmOHOHsoz Nsoumnmonsoz mamnone unofioomHmom oceauom HO monHonHHa EOHumuom OHCHHO HHH oonoHom HmoHnHHU oOcoHOm HmHoH>mnom NcsumIHHom o>Huoon wfioumnmousoz onoHHn mono Hem 0mm 0mm Nmm NNm omm omm omm omm omm omm omm Nmm NNm omm omm zoa ooum I omuH omuH I oaumH so omumH I o~.0H so OOAOH I onua omum I ooum NH Hm: I mmmaaa so ooum I oonH zoa ooum I omuH omuH I oaumH omumH I omnHH so OHHHH I om.0H zo OOAOH I 0Hua zma omum I ooum HH mmz I wmcmusne 20 ooum omuH 20 oNuNH 20 OHuHH 2mm omum omuH oeuNH omuHH oHum ooum OH Hm: I mmcmoncoz :0 ooum I oouH 20a ooum I omuH omuH I omuNH ONuNH I omuHH 20 OHAHH I OHum Ema omum I ooum m hm: I hmcmosa m ooma Ac.ucouv m chnomm4 236 nHoumnomHm .no xomnm .po oanom .Ho nOmnOomn .uo nomnoomn .uo mannoo .no nmEHoum .no wwmum mflflxcmb .HQ CMEHOfim .HD Hmflh .HQ monnob .Ho nmEHoum .Ho modumIHHom o>Huoon moonHom HmCHmm ”mooHOHmmna EmHHouom .msnmuoe ”NooHOHnOHOHz monomn muHHHuHoHIHunn HHHH .anv mnHumoB HmOHoOHousoz muocHOmHo oHOmsz wumaHua "mmOHOHsoz Naoumnmousoz EmHHonmuoz ESHOHmO coaumuoa OHcHHo HHH ooooaom HmoHoHHo oonoHom HmuoH>mnom amoumIaHom o>aooon msoumnmousoz nHHSmnH coHomoHmem oHnumaooumo Loo wfioumnmonsoz mosuo Hmnouca mumuHsuHa omm omm ONm omm omm omm ONm Nmm NNm omm ONm Hem omm OHm 20 20 23m 20 SO 20 2mm 20 Sum 20 Sum 20 2mm omuH omuNH OHAHH OOAOH omum oquH omuHH ONuOH OHum I ooum ma Hm: I Hammaoma ONuNH OHuHH omum I omuH I ovHNH omuHH OHum I ooum 5H Nmz I mmcmoncoz ooum I oouH ooum I omuH omuH I oquH omuNH I omuHH oHuHH I OHAm omum I ooum oH Hm: I Mmcmosa ooum I omuH omuH I oauNH ONHNH I 0Hum omum I ooum mH am: I mmcnoz NamH mmemnoo omHmB I mum: memon mom» EmmHa m ooma Am.uoooe m chnomom 237 cOHumuom OHcHHo HHH oocoHom HmOHnHHO wamum oOcoHOm HmHOH>mnom amoumIaHom o>Hooon msoumnmousoz maOHOOHxOB nuocoz HO moHoHoana mGHXCQU . HQ oomoao .uo HoHa .uo nOHumnHmem OHnummooumo HOV monnoo .no Paeoumcmousoz nOmsouoa .no GOHuod uansomOOIHunn Ho mEmHnmnooz Hon .no mnoumoooua nHoumnomHm .no mEoummm coumHoommn cnm HmcHEmnwo "woOHOHmwna nomnoomo .uo mnoHuOcswmwo Hmusonomz "moOHousoz nOHumoOm OHnHHO HHH oonoHom HmOHcHHU Hmmum oonoHom HmHOH>mnom Nmm NNm 0mm ONm Hem 0mm omm Hem 0mm 0mm Nmm NNm SO SUM SO Emm 20m 20 2mm ooum ooum omuH 0NuNH OHHHH omum oouH omuH oquH omuHH oHum ooum mN mm: I mmcmosa ooum omuH ONuNH omum omuH ocuNH OHum ooum NN mm: I mmcnoz mmemflbo QMHmB I MmmB Mdmw 20m 20 20 20 20h ooum omuH oNuNH oHuHH omum meH mBZHZ BmMHh omuH oquH omuHH oHum ooum aH Hm: I amoapa ooum ooum oonH omuH mH am: I wmcmusna m ooma AU.uCOUV m xfipcomad 238 Mammm woo HnHmozmz mNINmz I mmcnoz mama amaamoo amass I some mazma mama amaaa HoHa .no mnouaooona Ham soa ooum I omnH omuH I oaumH oaoomoomam .po moHHaomo Hmmmm .aaonoamama omm so omumH I omuHH COmQOUMh. .HD memuHOwHD agopmam Hmmasmnsa .aaoHouooz omm so OHHHH I oaua omum I ooum mm was I amoaaa nOHumuom OHnHHO HHH oonoHom HmOHnHHO Nmm so ooum I oouH Hmmum oonoHom HmHOH>mnom NNm sum ooum I omuH omuH I ovumH amoomIoHom o>Huoon oauma I omuaa mHoomcomHm .po eoHHoooaoo .aaoHonsoa cam so . oHuHH I o~HOH mocoo .uo EsHHononoO "mooHonumoousoz omm no co"0H I 0Hum nOmnHo .Ho mmanOmHoa cH monommoz hocomHoEm on Ema omum I ooum mN am: I mmcmusne momoooma .uo A>H .omoe aoaomoa Hmoaaoaouooz omm so oo.m I omua omuH I oquH nHoumcomHm .uo Ac.ucouv mEoumNm coumHOommn mom HmmHemaaa "saoHonama 0mm so omumn I omnHH moncoa .ao ssoumcmonooz omm so OHuHH I OHua nOmnHo .no mHmonomonHoumu .mHmonoomusz .mHmonooOpmnoB ONm Ema omnm I ooum VN mm: I wmcmoncoz o oomm Ac.ucoov m chnooon 239 nOmnoomb .no nOmnoomo .uo monoo .Ho moncoo .Ho wmmum COmnoomb .Ho nOmnoomn .no ooncob .Ho nOmnHo .no monnoo .uo nOmnHo .Ho mEoHnOHa nOHHonmo Hmmmm mo unoEumoua ”moOHOHDoz Eoumam nOHHonmo Hmmmm onu HO mnoHuonsmeo ”wooHOHsoz nOHumuom OHnHHU HHH oomoaom HmonHHO amoumIaHom_o>Hpoon nOHHonmo Hmmmm ”hooHonumoousoz meoumcmonsoz 3oH>om nOHumnHmem HmOHuomHm mnHumoB HmOHmOHOHsoz EsHHonouoU ”moOHOHsoz maoumnmousoz HH usofiumoua HmuocHund mo mEmHnmnooz nOHumuom OHGHHU HHH wocmdom HMOHGHHU smoomIaHom o>auoon meoumcmonsoz H ucoaumoua HmpocHunn HO mEmHnmnooz omm omm Nmm omm 0mm ONm omm omm omm ONm Nmm 0mm ONm SO SO 20 SO 20 2mm 20 20 20 2mm 20 SO Ema omnH I oaHNH omumn I omuaH on": I 38 om.a I ooum a moon I Hmoapa ooum I oouH ooum I omuH omuH I oauaH omumH I omuHH OHuHH I om”OH 8.3 I 38 omum I ooum ooum oNuNH 0HuHH omum H onso I chmnsna I oquH I omuHH I OHAm I ooum Hm am: I wmcmoncoz ooum I oouH ooum I omuH omuH I oquH ONANH I omuHH OHHHH I 0Hum omum I ooum om Hm: I mmcmosa a omma Ac.unoov m chnomod 240 unoEmmommn IHHom cnm mEoHnona HmOHuomnm QOmnoomh .Ho muoumnonmn mnHumoB "moOHousoz QOmnOomh .no mannoo .uo nOmnoomo cHoumcomHm .muo ouooz .uo mmHmmnmn "amOHOHsoz NEOpmanHsoz COHummnom “mooHOHmmna .mnmnqunO ou ouunH mmmum _IloonoHom HmHOH>mnom no ooaumpoa onHHo moonoHom HmOHnHHU smoumIaHom o>aoooam Hmnmu HmnHom on» NO mEoHnoua "hooHOHsoz cOmnoomo .Ho cOmnoomh .uo mmHmmno< w mmoua .noHumHOOmm4 HOOHHHOO .nOHummcom "mooHousoz oUnoHuooxm HmOHnHHU Hmm Hmm Hmm Hmm HNm mNm mmm Hmm Hmm Hmm SO SO SO SO Mdmm 20m 20 20 SO 20 an3 HH a H mEoummm HmHoomsEOHsoz cHoom ooum omuH ONHNH 0NuNH oo”OH omum omuH oeuNH omuHH ONuOH 0Hum ooum ooum omuH ONANH OHHHH omum HN ocsn I wmcmoncoz omuH oquH omuHH 0Hum ooum oN onso IIchmooB ooum omuH ONuNH omum omuH oeuNH OHHm ooum mH moon I mmcnoz meH mmBmNDO mBmDOm I xmm3 EmmHh m¢mw 9mmHm m ooma Am.ocooe m meooaam 241 mcanoo .uo onooz .no Hon .HQ monnoh .Ho ouooz .Ho Hon .HQ Hnm3oxonoH3m HHocnmz .mno mHHTK .HQ ouooz .Ho mwmum monnoo .uo onooz .Ho weoumnmousoz Ac.unouv oomeOHm OHononoch .oa.ana\os0\oaa\oo> meoumnmousoz ocmnoon UHoHonouon mnouoooona oOHcooonuuo anumHEonOOHm Ac.unoov mmsuo OHmuonoucn noHumuom OHnHHO "moonoHom HmOHnHHU no AcoonuHscnv momHuO HmnOHumusumz sooomIaHom o>Huoon weoumnmonsoz manna OHmHonoucd Hmm HNm Nvm Hmm HNm New Hmm Hmm HNm mmm mNm Hmm Hmm HNm SO HMSQ 20m 20 Hmnm 20m so so pmma 20 20m SO 20 nmna 0HuHH I 0Hum omum I ooum 5N once I mmcmose ooum I omuH omuH I oquH ONuNH IOHum omum I ooum oN mm9m¢DO mambom onso I mouse: tha I MMHB QZOUmm Mdmw EmmHh ooum I omuH omuH I oquH ONHNH I omuHH OHuHH I ONuOH oouOH I OHum omum I ooum MN onso I chHna ooum I omuH omuH I oquH ONHNH I omuHH OHAHH I OHum omum I ooum NN once I wmcmusne a ooma Ac.ucoov m chnomon 242 cOmnnOh cHoumcomHm .muo mHHos .po nomHoz .po mumum nomnnoo CHOUmemHm . who nomHoz .no mwmnm mcchoh .uo momaoz .po mmmum H.0uo .mDEmHmnuoowm IGOHumHooom Monoan Eoumwm- mso>noz OHEOnousn ”moOHonmna muumHEonoon ocanon OHmHonHHonu moaumuoa oHoHHO II "oonoHom HmoHcHHU no oocoHom HmHOH>mnom smoum oHom o>Huoon AmCOHuonsm a nOHumanmmHov "Eoumam mso>uoz OHEonous¢ "amOHOHmwna ommmnu Hand I ommmmu mOHnHHU mooHonsoz weoumnmonsoz mosuo OHmnonHHono .II oonoHom HmHOH>mnom no noHumuOm OHnHHU "moonoHOm HmOHcHHo monumImHom o>Huoon Hmm Hmm HNm mmm MNm Hmm Hmm HNm Hmm Hmm HNm MNm mmm Hmm so so pmma 20 Sum 20 so umma 20 so umma 20m 20 SO OHAHH I ONHOH oo"0H I OHum omum I ooum om moon I smoaua ooum I omuH omuH I oquH oNuNH I omuHH OHHHH I 0Hum omum ooum mN onso I mmcmusna ooum I omuH omuH I oquH oNANH I omuHH OHAHH I 0Hum omnm I ooum mN mono I chmoncoz ooum I omuH omuH I oquH ONHNH I omuHH aN ocoh IIchmosB 0H oama Ac.unouv m chnoom¢ 243 monnoh .Ho uonnoo .uo mwmum Hnm3ononoH3m HHommms .mpo nooooo .po Hwflh . .HD mGHVHCOh . HQ xoom .po Hoaa .po afioumnmonsoz osz Ho mooHOomEHmna mOHnHHO hmOHOHsoz amoomIaHom o>Huoon mOHcooonuno ocmeon OHGOHHonmw .ma.saa\oso\oaa\oo> meoumnmousoz mocHnucmx a monHEmumHnHucn mnouoooona Eoumwm mso>noz OHeonou5< ”woOHOHsoz Hmm HNm Hmm Hmm Hmm HNm New Hmm HNm New Hmm so umma 20 20 so umoa OHHHH I oHum omum I ooum m sto I chmusne ooum I omuH omuH I oquH ONuNH I omuHH oHuHH I OHum omum I ooum NNQHHOE 20h so umma m sHoa I ammmoomoz v NHSb I mmcmose ooum I omuH omuH I oeuNH omuNH I oHum omum I ooum mINHSh I hmccoz thH mmamdDO mambom I Mmm3 DMHSB 20m 20 Mdmw BmMHm ooum omuH omuH I oquH ONHNH omuHH om moon I smmHua HH oama Hp.unoov m xHonomm4 244 mannoh .Ho Honnoo .no Hon .Ho mannoh .Ho ouooz .Ho Nunom .no mocoo .Ho pooooo .ao mwmum smoumIaHom o>Hpoon weoumnmousoz mosuo ochHmo .mem .ooumo Ame Naoumnmousoz H mem muouooooum moHnumoonsoz HmuonoHuoa "mooHousoz moHnumoonsoz HmnonoHHoa “wooHonumoOHsoz .Eumna ochHmu Ho .ana lloonoHom HmHOH>mnom no coHumpom OHnHHU “oonoHom HmOHnHHO amoomIaHom o>Hooon Hmm Hmm HNm New Hmm HNm Nvm Hmm Hmm HNm MNm mmm Hmm SO 20 Hmnm 20m so Hmna mmemébo mambom Sum 20 so amma 20m 20 20 omuH I oquH ONHNH I omuHH OHHHH I OHum omum I ooum HH mHsh I chmose oonm omuH omuH oouNH oNuNH I 0Hum omum ooum OH sHoa I ammcos thH I mmm3 mBmDOW mmmw EmmHm ooum I omuH omuH I oeuNH ONHNH I oNAOH oo"0H I OHum omum I ooum NHoa IIsmoHaa ooum I omuH omuH I oeuNH ONuNH I omuHH o MHSh I hmcmusne NH ooma Ac.unouv m chnomQ< 245 Hon .Ho meBOxocoHBm HHocnmz .mno mHHos .po aooooo .po mmmum monnoh .Ho pooooo .po mmmum monnoh .Ho pooooo .po mnouooooua mUHcooonuHo muumHEonoon mosuo HmnHmnmIHun< noHumuom OHnHHU "oonoHom HmOHnHHu mm nonHonv mooHHU HmGOHumHSHmz amoomIaHow o>Hooon NEOumanHDoz Ac.unoov manna omHoumO mOHnHHO NmOHousoz mcsumImHom o>Huoon meoumnmousoz Ac.unoov manna ochHmu II oonoHom HmHOH>mnom no nOHumuom OHnHHU "moonoHom HmOHnHHO Nvm Hmm Hmm HNm Hmm mmm Hmm Hmm HNm Hmm Hmm Hmm HNm mmm Hmm Sum ooum I omuH omuH I oeumH SO omuNH I oNHOH 20 oouOH I OHum Hmnm omum I ooum vH mHoo I wmcHHm 20 20a ooum I omuH omuH I oeuNH so ONuNH I omuHH no OHAHH I OHHm Hmna omum I ooum mH NHso I mmcmusne no ooum I omuH omuH I oquH so ONHNH I omuHH so oHuHH I 0Hum nmnm omum I ooum NHINHso I chmonooz 20m so ooum I omuH HH NHso I xmcmosa MH oama Ac.unouv m chnommm 246 mmmpm cOmnnoo cHoumcomHm .muo momHos .po mmmum moGOb .Ho nomHoS .Ho Howm .HD nomHoz .uo mOHnHHO wmoHOHsoz amoomIaHom o>apoon Eoummm HmsmH> ”mooHonmna mosuo HO II oOnoHom HmHOH>mnom no nOHumuom OHnHHO "moonoHOm HmOHnHHO smoomIaHom o>aooon mnocHOmHo OHHonmuoz OHROB mOH00p>xo .emxm .ooumo Ame weoumnmousoz AH unmav mem o>HmnonoHoEOO HH .HOHm mEoummm mcHooousn Hmm Hmm Hmm HNm MNm mmm Hmm Hmm HNm Nvm Hmm HNm zo ooum I omuH omuH I oauNH zo ONuNH I omuHH so sauna I oaua umna omum I ooum aH mHso I mmcmoncoz 20a no ooum I omuH omuH I oquH so 0NuNH I omuHH so OHAHH I OHum Hmna omum I ooum mH mHSb I mmcmosa 20a ooum I omuH omnH I oquH zo oNuNH I 0Hum Hmna omum I ooum pH Nwso I wmonoz NamH mmemdbo mBmoom I xmmz mBmHh Mdmw 9mmHh «H ooma Ho.ucouv m prnomm< 247 nomnnOh nHoumnomHm .mno Hmflh . .HD Hon .HQ mHHos .uo mooa .po mwmum nOmnoomh .Ho noonnoo cHoumnomHm .mno momnos .po Eoumhm NHOUHcs< ”hooHonwna mdeU OZ .mem .ooomo Ame AN unmav H emxm .HOHm msoumsm mdeU OZ muoumooona mnoHuonsHmmo Eoummm HmsmH> “mooHousoz huumHfionOOHm ouanseHum wzu nOHumuom HmOHnHHU II "oonoHom HmOHnHHU no oOnoHom HmHOH>mnom amoDmIaHom o>Hooon Ac.unouv Hmnmo HmnHom on» HO mEoHnOHa ”moOHonsoz HHoEm com momma uwmoHonmnm mOHuonumon4 HmOOH Hmm HNm New Hmm HNm Nam Hmm Hmm HNm mmm MNm Hmm Hmm Hmm HNm so pmma 20m so pmma oouOH omum I OHum I ooum mN mHso I chmose mmemdDO nemaom I xmmg meHm 20h so so umma SO 20% SO 20 so amma ooum I omua omua I as NH omumH I cana omum I ooum am sHoa I ammmos mama mam» amaaa ooum I omua omua I sauna omuan I omuoa oouoa I oana om.m I ooum Hm Hpr I smmaaa oo.m I omua omua I oaumn omuma I omuaa OHHHH I omuoa oo.0H I oaua omum I ooum omstoa I smompoma mH oama 1m.ucooe m meooaaa 248 Hmflh .HQ HnmsononoH3m Hammoms .mpo mHHoZ .HQ wmmum COmQOUMW .HO mmmum nOmnnoo Gflmflmcmmflm .mHO mwmum wuouooooua mOHcomonuno snumHEonOOHm mméqu oz novauom OHnHHU "oonoHom HmOHnHHO oocoHOm HmHOH>mnom sooomIaHom.o>Huoon mnOHuonSHmso ananumo> a snouHcsn "sooHonsoz mdeU OZ mOHnHHo soOHouDoz smsomIaHom o>apoon oanumoH cnm manOHUHonoo usmOHOHmsnm Eoumsm HO mdeU OZ QOCTHUW HMHOfl>MSQm noHumuom OHnHHU "moonoHom HmOHnHHU smoomIaHom o>aooon HmHanumo> ”sooHOHmsna Nvm Hmm Hmm HNm mmm MNm Hmm Hmm HNm Hmm Hmm Hmm HNm MNm mmm Hmm Hmm sea ooum I omuH omuH I oeuNH so OHANH I ONAOH so oou0H I 0Hum nmna omum I ooum mm same I ammapa so sum ooum I omuH omuH I oquH so ONANH I omuHH so OHHHH I OHHm umna omum I ooum an sHoa IIsmmmuoma so ooum I omuH omuH I oquH so ONHNH I omuHH so oHuHH I 0Hum Hmna omum I ooum oNINHSh Ilecmoccoz 20h so ooum I omuH omuH I oquH so ONHNH I omuHH so OHAHH I ONuOH mN sHso IIchmose 0H ommm Ac.unoov m chnooms 249 Hmmum somHm .Ho nOmnOomo .no noon .Ho ammum HonHonm common .muo noom .Ho HoHa .Ho cOmnoomo .no nOmcnoo nHoumnomHm .muo noom .no mOHnHHO smOHOHsoz mEoHnoua msooanHoomHs com onouonmo mmo “moOHOHnOHUHs sopmsm OHnEHH "smoHOHsoz Ac.unouv mHmonumosd Hmuonou I|.oonoHom HmuOH>mnom HO GOHumuom OHnHHU "moonoHom HmOHnHHU smoumIaHom o>aoooam sooHoHcmm Ac.ucouv mHmonumon< Hmnonoo .mem .ooumo “we mEoHnona o>uoz HmHanO Honuo “smoHOHsoz chHuonsm HmsuooHHousH Hoanm cam sHOEos usmOHonmna mHmonumocn Hmuonoo Hmm Hmm Hmm HNm MNm mmm Hmm HNm Nvm Hmm Hmm HNm 20 so so Hmma Sum 20 so umma Sum 20 so umma oonm omuH oNuNH OHuHH oouOH omum omnH ovnNH omuHH omuOH 0Hum I ooum N umsmsn I smcmoncos ooum omuH oNuNH oHuHH omum I omuH I oeuNH I OMuHH I oHum I ooum H umsms< I Nmpmose ooum omuH omuNH oouOH omum omuH oquH ONuoH oHum ooum Hm sHoa I smooos thH mmfimflbo mBmDOm I mmmz mfizm>mm mflmw BmMHm pH oomm Ac.unoov m chnooom 250 Hmflh .HQ somHm .ao monoo .Ho fiOmfiOUMhJ . HQ moms .po Howm .HQ cOmnoomo .no mHHo3 .HQ zoom .po wmmum Hmmum monOh .Ho moms .po .ms.ana\os0\oaa\oo> mHuHoanos HmHnouomm “sooHoHnOHOHs GOHumEEmHHnH "smoHonumoOHsoz smooHHom HO unoEumoHB ”mooHousoz HH .mem muouooooua smooHHmm «mooHousoz sHumHEonOOHm muoNHHHsocmue ooHumooa onHHo "oonoHom HmOHnHHU mm oOHO>HouHmuHums "nOHpooconunH momHHU HmnoHumDUHm smoomIaHom o>auooam oononomnoo mEoHnona Hmoom munmmmonooo mzu Nvm Hmm Hmm Hmm HNm New Hmm Hmm HNm mmm MNm Hmm Hmm HNm 20m so so so pmma Sum 20 so pmma 20 20m 20 so pmsa ooum omuH omumH oHuHH oouOH omum omuH oquH omuHH ONHOH OHum ooum a snooze I smcnos thH mmamdoo mamoom I Mum: mamon Mdms 9mmHa ooum I omuH omuH I oquH ONHNH I ONHoH cou0H I OHum omum I ooum e umomsm I smcHHm ooum I omuH omuH I oquH ONHNH I omuHH oHuHH I OHum omum I ooum m umsmws IIchmusnB mH oama Ac.unouv m chcomo< 251 somHm .po ouoos .uo mwmpm mmmum monon .uo onoos .uo mumum somHm .ao monoo .Ho moms .po wwmum HonHonm noomom .mno mooa .po mHuHHmnmoonm HmHH> "sooHOHQOHOHs mOHmoonn< OHuoonmz nOHumuom OHnHHU II ”oonoHom HmOHcHHU no oOnoHow HmHOH>mnom smoumIaHom o>Huoon .Hnoo HmoHnHHU mEoHnonm Hmooa mHmoonnn.cnm nHma mOHcHHo smoHousoz scsumImHom o>Huoon mzu on» no mHHHHsasm .saoHoHoouoHs mEOO cam masmua usoOHonummousoz muansEHum Houoeonosma IloocoHom HmHOH>mnom so nOHumuom OHcHHO "moonoHOm HmOHnHHO smoumIaHom o>auoon soOHoHcmm soOHoomEHmnoonosma Hmm HNm mmm mmm Hmm Hmm HNm Hmm Hmm Hmm Hmm HNm mmm mmm Hmm Hmm HNm so Hmma 20 20m 20 so Hmma SO 20 20 so amsa 20m 20 20 so pmma oouoH omum OHum ooum HH umoaom I smmaaa ooum omuH ONHNH QHuHH omum omuH oeuNH omuHH 0Hum ooum ooum omuH oNuNH oHuHH oouoH omum OH umsmwn I mmcmnsne omuH oeuNH omuHH oNuOH OHum ooum ooum omuH ONuNH OHHHH omum a umnmsn I smcmoncoz omuH oquH omuHH OHum ooum m undone I mmcmose mH oomm Ac.unoov m chcooo4 252 mmmum nonHonm common .muo onoos .Ho Hon .uo HomHnnuox .uo monoo .no somHm .no ouoos .uo HoHa .no me3ononoH3m HHocnms .muo OOGQHO w HMHOH>M£OQ no noHumuom OHnHHO "moonoHom HmOHnHHO smoomIaHmm m>HuomHm soOHOHomm mOHmomHmn¢ UHuooumnlnoz .na.sna\os0\oaa\oo> mEoo ”sooHousoz masmua a ommomHo HmHsomm>ounouou "smoHOnumoousoz Ac.unouv oHuHHmnooonm HmHH> usoOHoHnOHOHs Emnooum onocmnuos mnouooooua mOHcomonuuo MNm mmm Hmm Hmm HNm Nvm Hmm Hmm Hmm HNm Nvm Hmm 20m 20 20 so nmma 20m 20 20 so umsa ooum I omuH omuH I oeuNH ONANH I omnHH QHAHH I OHum omum I ooum mH umsmsd IIchmose ooum I omuH omuH I oquH oNuNH I omuHH OHuHH omuOH oou0H I oHum omum I ooum vH umsmsm I smcnos thH mMBmdbo mBmaom I smug mBZHZ 20m 20 Mdmw BWmHm ooum I omuH omuH I oquH ONHNH I oNnoH HH umoaoa I smmHna om mama Ac.ucoov m xflpcomm< 253 Hon .HQ nomHnnuos .Ho mon0b .Ho soos .uo mumum monon .uo onoos .uo ammum HomHnnuos .no nomHnnnos .no ouoos .Ho ansomm>Ounouoo muouooooua munocHoon ”smOHousoz mHOEsB Eoumsm mso>noz "soOHonumoousoz .Eumna Hmcom Ho .nHua .HO oonoHom HmHOH>mnom nOHumuom OHnHHU "oonoHom HmOHnHHO smoomIaHmm m>auomam .amoo HmonHHo memHoopa Hmooa HonOOHs OHnHHU soOHousoz smoDmIaHmm m>HuomHm mEsmHB HmnnoHoOOHnan usoOHOHsoz mnOHuoomnH mzo "soOHOHsoz mosno OHumEsonHIHun< New 20h ooum I omuH omuH I oenNH Hmm so ONuNH I ONHOH Hmm so oou0H I OHHm HNm Hmnm omnm I ooum mH umomsd I smcHum MNm sum mmm so ooum I omuH omuH I oquH Hmm so ONANH I omuHH Hmm so OHAHH I 0Hum HNm Hmna omum I oonm 5H umomsn I chmnsna Hmm so ooum I omuH omuH I oquH Hmm so ONuNH I omuHH Hmm so OHNHH I ONAOH Hmm so OOAOH I OHum HNm Hmna omum I ooum oH umomsm I smcmonooz HN ooma 1o.mmooe a Roommaam 254 Homannos .no HomanHos .Ho soon .Ho Hmmum HocHonm common .mno noon .no HoHa .no mocOb .no nomanuos .co soon .no mOHcHHU smoHOHcoz smoumIaHmm m>HuomHm oooocsm a omHuHo> usmOHOHcoz onomcmos "smoHoucoz Ac.ucoov mOHuoHcHo TUGTHUW HMHOHs/MSQfl no cOHumuom OHcHHU "moocoHom HmOHcHHO smoumIaHmm moauomHm smOHOHcmm Ac.ucoov moHuousHo .ne.sna\os0\oaa\oo> smoHonpmooucoz OHuuchoa «smoHonummoucoz Ac.ucouv mucocHoo< ansomm>OnnouoU "smOHonsoz mOHuoHsHo Hmm Hmm Hmm Hmm HNm mmm mmm Hmm Hmm HNm Nem Hmm Hmm HNm 20 20 20 so amma SO 20 so umma 20m 20 so pmsa ooum omuH omuNH OHuHH oo“0H omum omuH oquH omuHH ONAOH OHum ooum ooum omuH 0N"NH OHuHH omum MN pmcmcs I mmomoccoz omuH oeuNH omuHH 0Hum ooum NN umsmsm I chmose ooum omuH omuNH OHuHH I omum I omuH oquH omuHH 0Hum oonm HN umsmsa I chcos NmmH mmBmNDO EBMDOM I MMNB mBZMB mdmw BmMHm mm mama Ac.ucoov m chcooos 255 Hon CHO OHmHz .uo mocOh HooanHOM ammum .muo wwmvm wwmum mocOb soos GHQ .HQ chom mmem Hmch H nonfioumom I NooHHa I mN uommsm I chHHa muoumoooua smoHoucoz OHHuchom mommomHo o>HumHocomoconnoHoo usmOHOHcoz 3oH>om cOHumuom UHcHHU ”oocoHom HmOHcHHo mm mmocHHH HmOHmsna "HoHuo ccm numoo ”momHHo HchHumsuHm spammIaHmm m>apomHm oocouomcou HmOHcHHo mEoHnOHa Hmooa HmOHmOHOHcoz Ac.ucoov mOHuoHsHo New Hmm Hmm HNm mmm MNm Hmm Hmm HNm Sum 20 so Hmnm 20 20m 20 so amma ooum I omuH omuH I oeuNH ONHNH I omuOH oouoH I OHum omnm I ooum mN umsmss IINocHuh ooum I omnH omuH I ovan oquH I omuHH OHAHH I OHum omum I ooum mN umcms< I smcmncne mm mama HU.UCOUV m MHUGOQQ¢ APPENDIX F NEUROLOGICAL PRACTICAL EXAMINATION OF PSYCHOMOTOR TECHNIQUES AND SKILLS GRADING FORM 256 APPENDIX F NEUROLOGICAL PRACTICAL EXAMINATION OF PSYCHOMOTOR TECHNIQUES AND SKILLS GRADING FORM Each test will be evaluated in the three following areas: A. Patient rapport with emphasis on accuracy of instructions given to patient before and during each test. B. Proper positioning of patient. C. Proper technigue in performing the test. Each of the above categories will be graded as follows: 1 = Excellent 2 = Adequate 3 = Fail The three categories are combined for a total score. The total score represents the students psychomotor skill or technique in performing the various neurological tests. ab 5/5/72 257 v Aswasmuuxm nmaaoe mzoa mqomos mHmmz Hmmz HflHZflmu HPmmz AHHZNMU m>mmz HQHZNMU mHmozwommMBm mmzmm ZOHBHmOm Ammum oHaHomame soooa asoaq Hmoum OHHHoommv szm ZOHBdmmH> mBUZNmBm MHUmDS maozmmam MHUmDZ U m c H4909 occhnooa pcoHumm chHuocuumcH HO HO mchOHuHmoa somucooc mBOZHMBm MAUmDZ N ommm Ac.ucoov a chcomos 259 mmoom Haaoflumgm O>Humfih0h fl Nmm .v :oHumcHaoxm HmosmoHousmz n m2 .m unmaucm Hmwm u m :oHumsHo>m ucmwumm u mm .N ucmfiumm cwumHaaHm u m mocmHummxm HUUHcHHU mo coHumsHm>m u mu .H new cucusa on ou Hosuoumz cmufiswmm "Nouoz "Houoz J m 1% A] i s so so so «H UH ” H m so W . . so so MH UH s so M so M so NH UH s ‘4 m so w m so . so HH UH m so _ so so oH UH UHsasmOHqc uuHosBZOU m>HeUHaU 3’ 3’ 3’ Hoffman Grade 279 Appendix J (Cont'd) Grade SENSORY: (Indicate A-Abnormal:Hypoactive or 1 Hyperactive Responsive, N—Normal, E-Equivocal Dysfunction) Response Location . . toe to Vibration A, foor . . legs and Pinprick A, (TR—T91 . orso up to Light touch A. ' ' 3 Position sense Eq-Ag ltqe Stereognosis N g MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations 1 Yes No x Gait: Normal Abnormal (describe also) X Ataxic slightly wide based Muscle Tone: Spastic Flaccid Rigid Normal Muscle Strength (indicate specific muscle weakness) Leg muscle weakness (mild left! leg only) 280 Appendix J (Cont'd) Page 20, No. l CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) ___N_Finger to nose ___§_Dysdiadochokinesia JiTandem gait _A:E_Heel to knee ___fl_Romberg EXTRAPYRAMIDAL (check apprOpriate headings) Spontaneous movements (describe) I____;Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) 1. All intact 7. All intact 2 . .. 8. .. 3 . .. 9 . .. 4. " 10. u s .. 11. .. 6 . .. 12. .. 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Grade Total points= 10 281 Appendix J (Cont'd) Page 21. No. 1 Grade 2. Assessment of Area of Neurological SystenJ 2 Dysfunction (check) __§__Motor __§__Sensory Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction Peripheral Nerve or Root Dysfunctiorfi ‘__§__Spina1 Cord Brain Stem Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) Total points= (include all systems) 5 Categorical Diagnosis Specific Ineuropathy, encephal- (tumor, cerebral opathy, etc.) hemorrhage, etc.) Myelopathy Tumor Arthritis (By history) Chronic Bronchitis (By history) Appendix J (Cont'd) Page 22, No. l 282 8. DIFFERENTIAL DIAGNOSIS (identify no more General Pathology Category: Vascular Infectious Traumatic Autoimmune Metabolic Inherited Neoplastic (or mass lesion) Cardiac Dysfunction Degenerative or Demyelinating Others-Chest Path—- than three neuro- logicaI disorders) Specific Type of PathoIogy: tumor Em h sem b -Urinary Obstructive Pathology--- (Prostate) 9. TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- dia nostic Tests EEG, lumbar puncture, etc.) infiduiltuan_____ Urinar f fiction test .Lumhar_nnnctnre__ (BflN_nr1naI¥sis_SpeciaI. Mveloqram r13_points) General Lab. (CBC, urinalysis, etc.) Chest X-ray X-ray studies) Grade hotel points= 5 “1 Total points= 5 43%;? ESR (2 points) 283 Appendix J (Cont'd) Page 23: NO- 1 Grade 10. THERAPY kotal points= 2 Specific Supportive m ression Analqesics for pain COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. S IMULATED CASE 2 284 Appendix J (Cont'd) Page 15, No. 2 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE:Summer 1972 6/28-1/5— TYPE OF CASE=Ngurglggigal __ 7/12 STUDENT:SIM Treatment PATIENT'S AGE: 53 INSTRUCTOR: DES Jacgbggn § RACE: C - Epmale Jones Grade 1. CHIEF COMPLAINT(S) ”fétal points= Pain in left arm 3 Numbness in left arm Weakness in left arm 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= Weakness left arm slow and progressive ove 5 past 8 months. Some moderate pain tending to radiate down left arm noted past 5 months. Aspirin gives no notable relief. Also reports chronic superficial chest wall pain 5-6 years as well as low back pain and reported degenerative disc disease 7-8 years ago. Leg cramping 3-4 years. Also some memory loss past 2—3 years and chronic headache complaints past 10-15 years. 3. PAST HISTORY (Mother, Father, Wife, 1 Siblings, Children) Endocrine Dysfunction(nghg;:diabetes) Cancer Tuberculosis Neurosis, Psychosis (Motheg-paranoid) Cardiovascular Disease(Fa§her-high blood Other pressure & "stroke") (Mother—arthritis) 285 Appendix J (Cont'd) Page 16, No. 2 Grade MEDICAL HISTORY Previous Hospitalization: 1 Surgery noted below 0 AllergieS=(Tetracyclines) "Tetramycin"1 Medications: 1 Accidents:Car accident 1969 1 Surgery:Hysterectomy 1964 l Diseases: Usual childhood diseases 1 Pneumonia 3-4 years Habits:Alcohol socially 1 1 , SOCIAL HISTORY (Work, Hobbies, Total points= Recreation) 9 Gardening Music Bicycle Riding 4. SYSTEMS REVIEW (if appropriate) Total points= (Gynecological, Obstetrical, Gastro— 4 intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro-Muscular) Cardiovascular - Chest pain Gynecolog-OB Hysterectomy Neuromuscular-1. cramping in legs at night 3-4 years 2. headache 3. memory loss 4. chest neuritis 286 Appendix J (Cont'd) Page 17, No. 2 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, Sclera) Normal Physical Deve10pment (Asthenic, Obsese, etc.) Normal build and nutrition; asthenictype GENERAL FINDINGS: BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: State of Consciousness (check) _X_ Alert ____ Unconscious or comatose Confused or obtunded Decerebrate or decorticate Grade 287 Appendix J (Cont'd) Page 18, No. 2 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Normal, 3-Hyperactive) Left Right Patellar 3, .2 Biceps l, «2 Tricep 1 1L Brachioradial l '2 Achilles 2 2 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar A, P Babinski p (A Ankle Clonus .A __A:_ Abdaminal pp p_ Hoffman p AA Grade 288 Appendix J (Cont'd) Page 19, No. 2 SENSORY: (Indicate A-Abnormal:Hypoactive or Hyperactive Responsive, N—Normal, E-Equivocal Dysfunction) Response Location Vibration A eft foot Pinprick A Right leg Light touch A Right_leg_ Position sense N Stereognosis N MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations Yes No X Gait: Normal _J§__Abnormal (describe also) Muscle Tone: Spastic _____Flaccid ___ Rigid Normal _X_. Muscle Strength (indicate specific muscle weakness) Weakness left arm and left leg Grade 289 Appendix J (Cont'd) Page 20, No. 2 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) __N__Finger to nose __N__Dysdiadochokinesia A:E__Tandem gait __n__Heel to knee N Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) Grade 1.all within normal 7. " limits 2 o " . n 3 . " 9 . u 4. " 10. n 5. " lltmeakness in trapeziub 6. n 12. " Total pOints= 10 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal 290 Appendix J (Cont'd) Page 21, No. 2 Grade 2. Assessment of Area of Neurological SysterJ 2 Dysfunction (check) X Motor X Sensory __X__Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction __X__Peripheral Nerve or Root Dysfunctio+ __X__Spinal Cord Brain Stem Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) Total points= (include all systems) 5 Categorical Diagnosis Specific (neurOpathy, encephal- (tumor, cerebral opathy, etc.) hemorrhage, etc.) Radiculopathy &- Mass lesion Myelopathy (Tumor or cervical spondylosis) Appendix J (Cont'd) Page 22, No. 2 8. DIFFERENTIAL DIAGNOSIS (identify no more general Pathology Category: Vascular Infectious Traumatic Autoimmune Metabolic Inherited Neoplastic (or mass lesion) Cardiac Dysfunction Degenerative or Demyelinating Others TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- dia nostic Tests EEG, lumbar puncture, etc.) Spine X:rav Lumbar Puncture (EMG (Nerve ConductIon Times 1 . T' Mxelogran________ 291 Grade than three neuro- lggical disorders) Specific Type of Pathology: Granulnma Diabetes (family histor (Cervical disc (soft) Spondylitis) (Tumgr 9r cervical spondylosis) Multiple Sclerosis? (SyringomyeliaL Peripheral venous insufficiency with slig varicosities in legs General Lab. (CBC, urinalysis, etc.) B FB Curve, ESR #otal points= 5 ry) ht Total points= 5 292 A endix J (Cont'd) Page 23, No. 2 Grade 10. THERAPY Total points= Specific Supportive 2 Wion—analgesismain COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. S IMULATE D CASE 3 293 Appendix J (Cont'd) Page 15, No. 3 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE: SHEEGI 1222 142?]! 9.. TYPE OF CASE:#Neu1-Q 8/5 STUDENT: SIM 3222812102111: PATIENT'S AGE: 31) INSTRUCTOR: Dr. Kornhiser RACE: C - Male Grade 1. CHIEF COMPLAINT(S) r"i‘otai points= 3 Unsteady walking Weak hands 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= Caucasian male reports having some difficulty 6 and unsteadiness in walking for the past 6 months. This problem had a fairly rapid onse and has been becoming progressively worse wit occasional periods of remission when the pati nt has been fairly symptom free. Ambulation has become significantly difficult in the past 2- weeks. The patient also has noted some weakn ss in both hands of moderate severity in the pas 4—6 weeks. Additionally reported are some mi d visual disturbances ("spots before the eyes") during the past 3-4 months. One episode of brief visual loss about 1 year ago was also recalled. The patient has additionally noted some occasional frontal and retroorbital cephalgia during the past year becoming slightly more notable in the past few months necessitating use of routine analgesics (i.e., aspirin, excedrin) when provide little relief. 3. PAST HISTORY (Mother, Father, Wife, 1 Siblings, Children) Endocrine Dysfunction Cancer Tuberculosis Neurosis, Psychosis Cardiovascular Disease (Father) Died of Other heart attack 294 Appendix J (Cont'd) Page 16, No. 3 MEDICAL HISTORY Previous Hospitalization: As below AllergieS=Seasona1 allergies Medications: Aspirin Accidentsz Slipped in bathtub Car accident Surgery: Appendix - 1967 Left Knee - 1959 DiseaseS:Mumps, measles (childhood) Habits: No smoke, no drink SOCIAL HISTORY (Work, Hobbies, Recreation) Real estate salesman Baseball 4. SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro-Muscular) Respiratory - sinus Skeletal - Knee operation Elbow pain steroid injection Injured back Grade 1 Total points= 9 Total points= 4 295 Appendix J (Cont'd) Page 17, No. 3 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, Sclera) Normal coloration Physical Development (Asthenic, Obsese, etc.) Mesomorphic musgular GENERAL FINDINGS: BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: State of Consciousness (check) _§__.Alert ____ Unconscious or comatose Confused or obtunded Decerebrate or decorticate Grade 296 Appendix J (Cont'd) Page 18, No. 3 Grade Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l l-Hypoactive, 2-Norma1, 3-Hyperactive) Left Right Patellar 3 3 Biceps 3 3 Tricep 3 U 3 Brachioradial 3 F ‘3 Achilles 2-3 2—3 Pathological or Superficial (Indicate 1 A-Absent, P-Present, E-Equivocal) Left Right Plantar A A Babinski P P Ankle Clonus A P Abdominal A A Hoffman P P 297 Appendix J (Cont'd) Page 19, No. 3 SENSORY: (Indicate A-Abnormalzfiypoactive or Hyperactive Responsive, N-Normal, E-Equivocal Dysfunction) Response Location . . le 5 feet Vibration A g 5(L Pinprick N Light touch N legs (Larg Position sense A toes) RaL Stereognosis N MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations Yes No x Gait: Normal Abnormal (describe also) Ataxic and wide based Muscle Tone: Spastic Flaccid Rigid Normal X Muscle Strength (indicate specific muscle weakness) No notable ugakngss except bands Grade ID 298 Appendix J (Cont'd) Page 20, No. 3 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) __A_gFinger to nose __£L_Dysdiadochokinesia __A_;Tandem gait __A__Heel to knee __A__Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) ‘_____Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) 1. 5]] intact fiKQEEt 7. CII R L 2. E. J: i E. .I 8. 3. 9. 4. 10. 5. 11. 6. 12. 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Grade Total points= 10 299 Appendix J (Cont'd) Page 21, No. 3 Grade 2. Assessment of Area of Neurological System 2 Dysfunction (check) __§__Motor __X__Sensory Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction __X__Peripheral Nerve or Root Dysfunctio (optic nerve involvement) X Spinal Cord X Brain Stem Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) hotel points= (include all systems) 5 Categorical Diagnosis S ecific (fieuropathy, encephalé (tumor, cerebral opathy, etc.) hemorrhage, etc.) .MYfilgpfiLhYL_92Lig_ggpritis Demyelinating disorder (Multiple Sclerosis) Arthritis (by histgry) Elbow g Knee 300 Appendix J (Cont'd) Page 22, No. 3 8. Grade DIFFERENTIAL DIAGNOSIS (identify no more than three neuro- logicaldisorders) General Pathology Spgcific Type of Categogy: Pathology: Vascular Infectious Traumatic Autoimmune Metabolic Inherited Spino cerebellar disease Tumor (Spinal canal, Neoplastic (or mass cerebellum, cervical dis lesion) Cardiac Dysfunction Degenerative or Demyelinating Others Systems Arthritis (elpow) TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- dia nostic Tests General Lab. EEG, lumbar (CBC, urinalysis, etc.) puncture, etc.) EEG CBC, Urinalysis Brain Scan ESR, RA Test Lumba Puncture 5 Chest X-raY o ‘I electrophoresis) Visual Fields g Acuity (4 points) (1 point) Total points= 5 C) Total points= 5 301 Appendix J (Cont'd) Page 23, No. 3 Grade 10. THERAPY Total points= Specific Supportive 2 ACTH or Steroids Diet Avoi 11 hot bath q \Ii taming COMMENTS Note: All Practical Exams have maximum score of 54 points. A11 Exams are standardized on a 54 point basis. SIMULATED CASE 4 302 Appendix J (Cont'd) Page 15, No. 4 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE:Summer 1972 7122—7[29—TTPE OF CASEzNeurological 8/5 STUDENT:§}M Treatment PATIENT'S AGE: 32 INSTRUCTOR:Dr. Kornhiser RACE: C - Male Grade 1. CHIEF COMPLAINT(S) - r"'Ilotai points= 3 Weakness right arm Weakness right leg Memory loss 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= 6 Five months ago the patient noted development of weakness of right arm and leg over period of 24 hours. This problem has become pro- gressively worse since that time producing notable difficulty in walking and marked ‘ restriction of use of right upper extremity. Patient also reports that some numbness and tingling on the right side were noted about 2 months prior to the onset of weakness. During the past 2 months patient has been aware of some significant problems with memory. Patie reports having consulted two physicians and being told he had suffered a "small stroke." No additional complaints are elicited, other than awareness of increasing depression over present problem. 3. PAST HISTORY (Mether, Father, Wife, 1 Siblings, Children) Endocrine Dysfunction (MgtthrDiabetes) Cancer Tuberculosis Wife Neurosis, Psychosis Cardiovascular Disease Other (Rather-Asthma) 303 Appendix J (Cont'd) Page 16, No. 4 MEDICAL HISTORY Previous Hospitalization: Pneumonia (1969) Allergies: Penicillin Medications: Isoniazid (no vitamin supplement) Accidents: Fall on back (1968) Surgery: None reported Diseases: Small pox (childhood) Pneumonia Habits: Cigarettes (1 pack per day); Alcohol (socially) SOCIAL HISTORY (Work, Hobbies, Recreation) Graduate student MSU in research Enjoys shuttle badminton 4. SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro-Muscular) Castro-intestinal - "upset stomach" Neuro-muscular - No headaches; see chief complaints Respiratory - Contact with TB Grade 1 Total points= 9 Total points= 4 304 Appendix J (Cont'd) Page 17: NO- 4 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, Sclera) , Dark coloration, _SClsrleeaL— Physical Development (Asthenic, Obsese, etc.) W0 GENERAL FINDINGS: BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: State of Consciousness (check) __x__Alert Unconscious or comatose Confused or obtunded Decerebrate or decorticate Grade ped 305 Appendix J (Cont'd) Page 18, No. 4 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Norma1, Grade 3-Hyperactive) Left Right 7 Patellar 2_ 1 Biceps 2 3 ) Tricep 2 3 Brachioradial 2 1 Achilles 22 2-3 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar P 43 Babinski A_ p Ankle Clonus 2Ap P Abdominal p (R Hoffman JL_ p_ 306 Appendix J (Cont'd) Page 19, No. 4 SENSORY: (Indicate A-Abnorma1:Hypoactive or Hyperactive Responsive, N-Normal, E-Equivocal Dysfunction) Response Location Vibration N Pinprick N Light touch N Position sense N Stereognosis A-E Rt. hand MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations Yes No x Gait: Normal Abnormal (describe also) x Hemiparetic gait with reduced right arm ___—£1.th sw1ng and fleXion arm leg slightly externally rotated. Muscle Tone: Spastic Flaccid X Rigid Normal Muscle Strength (indicate specific muscle weakness) Weakness right arm and hand_(Markefi) Some weakness right leg and thiqhi Grade 307 Appendix J (Cont'd) Page 20, No. 4 Grade CEREBELLAR AND DORSAL COLUMN FUNCTIONS 1 (indicate N-Normal, A-Abnormal, E-Equivocal) A-E Finger to nose A Dysdiadochokinesia Probably due to A-E Tandem gait pyramidal weakness and to cerebellar A-E Heel to knee dysfunction N Romberg EXTRAPYRAMIDAL (check appropriate headings) l Spontaneous movements (describe) Cog Wheel Rigidity Mask like facies Decreased eyeblinks x Loss of arm swing CRANIAL NERVES: (indicate nerves checked 1 and if pathology present.) 1.51] within Danna] 7. " 2. " limits 8. u 3. n 9, u 4. " 10. n 5. " 11. u 6. " 12. " 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Total points= 10 308 Appendix J (Cont'd) Page 21, No. 4 2. Assessment of Area of Neurological System Dysfunction (check) X Motor X Sensory x Mentation and Behavior 3. Anatomical Location (check) Primary Muscle Dysfunction Peripheral Nerve or Root Dysfunction Spinal Cord Brain Stem X Cerebral Hemispheres 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) (include all systems) Categorical Diagnosis Specific (neurOpathy, encephal- (tumor, cerebral opathy, etc.) hemorrhage, etc.) Encephalopathy Cerebral Neoplasm Grade Total points= 5 Total points= 5 309 Appendix J (Cont'd) Page 22, No. 4 8. DIFFERENTIAL DIAGNOSIS (identify no more than three neuro- logical disorders) General Pathology_ Specific Type of Category: PatholOgy: Cerebral Thrombosis (Middle Vascular cerebral artery or secondary to internal carotid obstruction) Infectious TB Granuloma Traumatic Autoimmune Diabetes Mellitus (pref Metabolic disposing to earlypcerebral vascular disease) Inherited Neoplastic (or mass lesion) Cardiac Dysfunction Degenerative or Demyelinating Others Systems Pulmonar Tube Chronic Gastritis, '5 Grade Total points= 5 Gastric or Duodenal U1¢er 9. TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- diagnostic Tests General Lab. (EEG, lumbar (CBC, urinalysis, etc. puncture, etc.) Skull X-rays ) Lumbar Puncture CBC ESR EEG: Brain Scan FBSJ 2 Hr. PPNS, GTC Echoencephalogram Chest ngay Ophthalmodynamometry Cerebral Angiogram and/or Pneumoencephalogram (4 points) (1 point) Total points= 5 310 Appendix J (Cont'd) Page 23: NO- 4 10. THERAPY Specific Supportive Craniotomy Physical Therapy Chemotherapy (?) Note: COMMENTS All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. Grade Total points= 2 S IMULATED CASE 5 311 Appendix J (Cont'd) Page 15, NO. 5 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE:Summer 1972 8/9-8/16— TYPE OF CASE:Neurological 8/23 STUDENT: SIM Treatment _ PATIENT'S AGE: 36 INSTRUCTOR: Dr. Jacobson RACE: C - Female Grade 1. CHIEF COMPLAINT(S) Total points= 3 Visual Disturbances Headaches (9 months) 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= Patient was seen because of major complaints 6 of visual disturbances during the past five months with some headaches of 9 months dura- tion. Patient reported that this difficulty began by appearing as double vision with intermittent occurrences of spots before the eyes. The patient did consult an optometrist for corrective lenses which did not appear to produce any significant improvement. The patient's problem has been intermittent but has gotten somewhat progressively worse over the five-month period. Associated with this difficulty has been headaches which appear to be somewhat throbbing in character and occur intermittently. For the latter difficulty the patient has taken aspirin and other routine analgesics, which have produced little relief. The patient also reports in retrospect some weakness in both hands-associated numbness that has been present during the past two months. (Continued on attached sheet) 3. PAST HISTORY (Mother, Father, Wife, 1 Siblings, Children) Endocrine Dysfunction Thxxgig (Mother) Cancer Tuberculosis Neurosis, Psychosis Cardiovascular Disease HBP (Father) Other Gallbladder (Mother) 312 Appendix J (Cont'd) Page 15, No. 5 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) (Cont'd) The latter problem does not appear to be particularly notable but the patient has been aware that she has occasionally been dropping objects which is not a usual occurrence. Additional questioning reveals that the patient has also noted some dizziness occurring intermittently during the past four months; as well as some distinct urinary frequency also present during the same period of time. History of accident 9 months ago with head trauma. 313 Appendix J (Cont'd) Page 16, No. 5 MEDICAL HISTORY Previous Hospitalization: Breast Biopsy (1970) Allergies: "Hay Fever" Medications:Aspirin Antihist Accidents: Car accident (1971) Surgery: Breast Biopsy Suture Forehead Diseases:Chicken Pox Measles Habits: Smokes (1 1/2 pkg) Drinks socially SOCIAL HISTORY (Work, Hobbies, Recreation) Graduate student Teaching Travel SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro—Muscular) OM Gyn - Breast Biopsy GV - Urinary GI - Epigastric distress, anorexia, Neuro-Muscular - C.C. nausea Grade 1 Total points= 9 Total points= 4 314 Appendix J (Cont'd) Page 17, No. 5 Grade 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, 1 Sclera) Normal Pallor Physical Development (Asthenic, Obsese, etc.) Ngrmgl build General Asthenictype GENERAL FINDINGS: 1 BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: 1 State of Consciousness (check) __X__Alert Unconscious or comatose Confused or obtunded Decerebrate or decorticate 315 Appendix J (Cont'd) Page 18, No. 5 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Normal, 3-Hyperactive) Left Right 1 Grade Patellar 3 3 Biceps 3 3 Tricep 3 3 Brachioradial 3 3 Achilles 2-3 2-3 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar A A Babinski P P Ankle Clonus A A Abdominal A A Hoffman P i P 316 Appendix J (Cont'd) Page 19, No. 5 , Grade SENSORY: (Indicate A—Abnormaleypoactive or 1 Hyperactive Responsive, N-Normal, E-Equivocal Dysfunction) Response Location Rt & Lt feet Vibration out elow_knee . . Rt & Lt arms, Rt. Pinprick out to e1bow;Lt. to shoulder . Rt & Lt arns, Rt. Light touch out to elbou;Lt. to shoulder Position sense N N Stereognosis N N MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations Yes No X Gait: Normal )( Abnormal (describe also) Muscle Tone: Spastic Flaccid Rigid Normal X Muscle Strength (indicate specific muscle weakness) Very slight hand weakness 317 Appendix J (Cont'd) Page 20, No. 5 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) _§:§_Finger to nose __§__Dysdiadochokinesia __E__Tandem gait __N__Heel to knee __u__Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) l-AlLiLithiILermal 7- " 2. " limits 8. u 3 n 9. " 4 u 10. " S n 11. " 6 n 12. " 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Grade Total points= 10 318 Appendix J (Cont'd) Page 21, No. 5 Grade 2. Assessment of Area of Neurological System 2 Dysfunction (check) X Motor X Sensory Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction __g__Peripheral Nerve or Root Dysfunction __L__Spinal Cord 1 Brain Stem 2 Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) Total points= (include all systems) 5 Categorical Diagnosis Specific (BeurOpathy, encephal- (tumor, cerebral Opathy, etc.) hemorrhage, etc.) Myelopathy_1Demyelination) Multiple Sclerosis Encephalopathy Periph. Neuropathv (C-Il) 319 Appendix J (Cont'd) Page 22, No. 5 8. DIFFERENTIAL DIAGNOSIS (identify no more than three neuro- logical disorders) General Pathology» Specific Type of Category: PathOlogy: Vascular Brain Stem Infarction Infectious Traumatic Cervical Disc; Post- Traumatic Syndrome Autoimmune Metabolic Diabetes Inherited Neoplastic (or mass Intracranial Tumor lesion) Cardiac Dysfunction Degenerative or Posterolateral Sclerosi Demyelinating (PA or gastric absorpti deficit) Others Chronic Gastritis, ulcs TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- diagnostic Tests General Lab. (EEG, lumbar (CBC, urinalysis, etc.) puncture, etc.) Cervical Spine X-ray GTC Lumbar Puncture with ESRL Schillings B,“ Globulin ‘1 Brain Scan GI Studies Chest X-rafi Visual Fields and Acuity (3 points) (1 point) Grade #otal points= 5 r Total points= S 320 Appendix J (Cont'd) Page 23, No. 5 Grade 10. THERAPY Total points= Specific Supportive 2 ACTH Q; Steroids Vitamins _NQ_hQI_hathS______ COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. SIMULATED CASE 6 321 Appendix J (Cont'd) Page 15 No. 6 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE:Summer 1212 869—8115‘ TYPE OF CASE: NQHIQJQQIQBJ STUDENT:SIM Treatment PATIENT'S AGE: 21 INSTRUCTOR: DI Iacohson RACE: C _ Male Grade 1. CHIEF COMPLAINT(S) r"Total points= Back pain (six weeks duration) with 3 Right Thigh Radiation 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= The patient was seen because of severe back 5 pain for the past six weeks. Pain evidently was initiated while the patient was performing some stretching and lifting maneuvers at home at which time he feels he greatly "strained" his back. The patient also has noted some numbness and tingling on the right anterior thigh with some occasional pain radiation that tends to be noted in the same area. The patient has found that rest seems to help his discomfort and is greatly aggravated by exercise. Heat, hot baths and Ben-Gay have all afforded negligible relief. The patient has also utilized aspirin and other common analgesics without success. He reports, in addition, having seen a chiropractor several days following the onset of discomfort but noted no distinct relief following manipula- tive procedures. 3. PAST HISTORY (Mother, Father, Wife, 1 Siblings, Children) Endocrine Dysfunction Cancer Tuberculosis Neurosis, Psychosis Cardiovascular Disease HBE (grandmother) Other Rheumatoid Arthritis ||| 322 Appendix J (Cont'd) Page 16, NO. 6 MEDICAL HISTORY Previous Hospitalization: Tonsils (1955) Bronchial cyst (1958-60) AllergieS=Seasonal Hay Fever plus several food allergies Medications:Antihistamine Aspirin - Excedrin- Ben-Gay Accidents:Fractures (l964-63-62-59-61)l Surgery:See Previous Hospitalization Diseases:Measles Mumps Chicken Pox Habits: Drinks socially SOCIAL HISTORY (Work, Hobbies, Recreation) Fork-lift Driver Guns Hunting Fishing 4. SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro-Muscular) Neuromuscular - (see fractures) Respiratory - Foods GI - Stomach discomfort ("queasy") Grade 1 Total points= 9 Total points= 4 323 Appendix J (Cont'd) Page 17 I No. 6 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, Sclera) No Pallor Physical Development (Asthenic, Obsese, etc.) Medium build - good muscular bulld and development GENERAL FINDINGS: BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: State of Consciousness (check) __§_.Alert Unconscious or comatose Confused or obtunded Decerebrate or decorticate Grade 324 Appendix J (Cont'd) Page 18, No. 6 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Normal, 3-Hyperactive) M Patellar _121 Q_ Biceps 0-l 10:1 Tricep 011, i_0-l Brachioradial 0-1 * 0-1 Achilles 2 2 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar AeE AeE Babinski A 4A Ankle Clonus A AL Abdominal p p_ Hoffman AL r AL Grade 325 Appendix J (Cont'd) Page 19: N0. 6 Grade SENSORY: (Indicate A-Abnormal:Hypoactive or 1 Hyperactive Responsive, N-Normal, E-Equivocal Dysfunction) Response Location Vibration N _ . Anterior dhigh to Pinprick A. below—knee on Rt. Light touch A " Position sense N Stereognosis N MUSCLE FUNCTION AND GAIT: (check appropriate headings) Fasiculations 1 Yes No X Gait: Normal X Abnormal (describe also) Muscle Tone: Spastic Flaccid Rigid Normal y Muscle Strength (indicate specific muscle weakness) Femoral Nerve Stretch iEliah's) Laseques (back pain no radiation on right) Weakness Rt. quadrups 326 Appendix J (Cont'd) Page 20, No. 6 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) N Finger to nose N Dysdiadochokinesia E Tandem gait __fl__Heel to knee __fl__Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) _____Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) 1.51] mjthjn normal 7. " limits 2. " 8. n 3 . " 9 . n 4 " 10 . u 5 H 11. u 6 " 12 . n 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Grade Total points= 10 327 Appendix J (Cont'd) Page 21, No. 6 Grade 2. Assessment of Area of Neurological System 2 Dysfunction (check) X Motor X Sensory Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction _3:__Peripheral Nerve or Root Dysfunctiom _____Spinal Cord Brain Stem Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) Total points= (include all systems) 5 Categorical Diagnosis Specific (neurOpathy, encephal- (tumor, cerebral Opathy, etc.) hemorrhage, etc.) Radiculgpathy Lumbar Disc Herniation 328 Appendix J (Cont'd) Page 22, No. 6 8. DIFFERENTIAL DIAGNOSIS (identify no more than three neuro- logical disorders) General Pathology» Specific Type of Category: PathOlbgy: Vascular Infectious Traumatic Autoimmune Metabolic Diabetes Inherited Neoplastic (or mass Tumor of Lumbar Spine lesion) Cardiac Dysfunction Degenerative or Demyelinating Others Nerve Entrapment 9. TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- diagnostic Tests General Lab. (EEG, lumbar (CBC, urinalysis, etc.) puncture, etc.) Lumbar Spine X—rays EMG and nerve con- CBC/FBS/Z Hr. PPBS/ESR duction studIES Lumbar Puncture and Myelogram Grade Lotal points= 5 Total points= 5 329 Appendix J (Cont'd) Page 23, No. 6 Grade 10. THERAPY Total points= Specific Supportive 2 Pelvic Traction Analgesics Bed Rest Muscle relaxant Supgery if necessary COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. SIMULATED CASE 7 330 Appendix J (Cont'd) Page 15, No. 7 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE: Summer 1972 8Q-8/l6- TYPE OF CASE: Neurological 8/23 STUDENT:SIM Treatment PATIENT'S AGE: 38 INSTRUCTOR: Dr. Jacobson RACE: C — Male Grade 1. CHIEF COMPLAINT(S) ”Total points= Neck pain with some radiation down right 3 arm and associated numbness and weakness - approximately three months duration 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= The patient was seen in the office noting neck 5 pain with some distinct radiation down the right arm as well as some associated numbness most evidenced in the thumb and index finger of the right hand and some minimal weakness in right-hand function. This discomfort apparenfily began with an automobile accident three months ago at which time the patient's car was struck in the rear, and the patient apparently suffered a "whiplash" injury. In addition, the patient's head struck the front windshield and he suffered some severe contusions of the forehead. The patient also reports some dizziness and cephalgia which were present at the onset of this discomfort, but appear to be resolving during the last three months, but still cause periodic discomfort. The patient also notes a good deal of associated anxiety and tension since his accident. Analgesic medication has given little relief from his discomfort, and the patient apparently is alsc* 3. PAST HISTORY (Mother, Father, Wife, Siblings, Children) 1 Endocrine Dysfunction 'nghgtes Cancer Tuberculosis Neurosis, Psychosis Epilepsy Cardiovascular Disease HBP Other *being treated with tranquilizers prescribed by a physician who has been examining him since the accident. 331 Appendix J (Cont'd) Page 16, No. 7 Grade MEDICAL HISTORY Previous Hospitalization: l Fractured skull (1952) 1 Open reduction elbow (1955) Allergies: None 1 Medications: Valium 1 Darvon compound Accidents: Car accident (6 months agJDl Kicked in the head (1952) Motorcycle accident (1956) Trampoline - elbow dislo- Surgery: cation & fracture 1 (1955) Appendectomy (1968) Open reduction left elbow Diseases: 1 Measles — Chicken Pox Habits: Smokes (1 pkg per day) l l s SOCIAL HISTORY (Work, Hobbies, Total pOints= Recreation) 9 Accountant Water ski Tennis 4. SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic, Neuro-Muscular) Neuromuscular - Fractured skull Right shoulder Left elbow Left knee Total points= 4 332 Appendix J (Cont'd) Page 17, No. 7 Grade 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, 1 Sclera) . No abnormal pigmenta- Physical Development (Asthenic, Obsese, etc.) Normal Mnssls_dsielssment_. GENERAL FINDINGS: 1 BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits Ophthalmoscopic (GRI-IV) Vessels Disc Retina MENTAL STATUS: 1 State of Consciousness (check) __y__Alert Unconscious or comatose Confused or obtunded Decerebrate or decorticate 333 Page 18 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Normal, 3-Hyperactive) Left Right Grade Patellar __22 2_ Biceps 2 0 Tricep 2 l Brachioradial 0-1 0—1 Achilles 2 2 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar P P Babinski A A Ankle Clonus A A Abdominal P P Hoffman A A 334 Appendix J (Cont'd) Page 19, No. 7 SENSORY: (Indicate A-Abnormal:Hypoactive or Hyperactive Responsive, N—Normal, E-Equivocal Dysfunction) Response 2 Location Vibration N ( Rt. thumb& Pinprick A index ' g Light touch A " Position sense N Stereognosis N MUSCLE FUNCTION AND GAIT: (Check appropriate headings) Fasiculations Yes X RT. No Gait: Normal )( Abnormal (describe also) Muscle Tone: Spastic Flaccid Rigid Normal X Muscle Strength (indicate specific muscle weakness) Left - slight limitation of elbow flexion Right - Biceps and triceps weakness Grade Br 335 Appendix J (Cont'd) Page 20, NO. 7 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) N Finger to nose N Dysdiadochokinesia N Tandem gait N Heel to knee N Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) 1-All within normal 7. limits 2. " 8. 3. " 9. 4. " 10. 5. " 11. 6. " 12. 6. SUMMARY 1. General Results: (check) Normal Neurological X Abnormal Neurological Equivocal Grade Total points= 10 336 Appendix J (Cont'd) Page 21, No. 7 7. 2. Assessment of Area of Neurological System Dysfunction (check) __X__Motor __X__Sensory Mentation and Behavior 3. Anatomical Location (check) Primary Muscle Dysfunction _LPeripheral Nerve or Root Dysfunctionfl _____Spinal Cord Brain Stem Cerebral Hemispheres PROVISIONAL OR WORKING DIAGNOSIS(ES) (include all systems) Categorical Diagnosis S ecific (neurOpathy, encephal- (tumor, cerebral Opathy, etc.) hemorrhage, etc.) Radiculopathy Cervical Disc Arthropathy, Traumatic Arthritis Grade Total points= 5 . Total points= 5 337 Appendix J (Cont'd) Page 22, NO. 7 Grade 8. DIFFERENTIAL DIAGNOSIS (identify no more #otal points= than three neuro- 5 logicaldisorders) General Pathology» Specific Type of Category: Patholbgy: Vascular Thoracic Outlet Syndrome Infectious Traumatic Ruptured Disc Autoimmune Metabolic Diabetes Inherited Neoplastic (or mass Tumor lesion) Cardiac Dysfunction Degenerative or Demyelinating Cervical Spondylosis Others Carpal Tunnel 9. TESTS (laboratory tests and other Total points= diagnostic procedures) 5 Specific Neuro- diagnostic Tests General Lab. (EEG, lumbar (CBC, urinalysis, etc.) puncture, etc.) Chest X-ray Cervical Spine X-ray CBCL_ESRLAFBS, 2 Hr. PEBS, EMG GTCL_VA Nerve Conduction Lumbar puncture and myelogram 338 Appendix J (Cont'd) Page 23, No. 7 Grade 10. THERAPY Total points= Specific Supportive 2 : . J I . J . Surgery for cervical ”Muscle_relaxant___ decompression ilaminestom¥_mith_fusion) COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. SIMULATED CASE 8 339 Appendix J (Cont'd) Page 15, No. 8 MICHIGAN STATE UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE NEUROLOGICAL EVALUATION HISTORY AND PHYSICAL EXAM DATE: Summer 1972 8/9—8/16- TYPE OF CASENeurological 8/23 STUDENTW SIM Treatment PATIENT'S AGE: 29 Ag INSTRUCTOR: Dr. Jacobson RACE: C - Male Grade 1. CHIEF COMPLAINT(S) *‘T'otal points= Headaches (three (3) months duration) 3 Dizziness 2. ONSET AND COURSE OF CHIEF COMPLAINT(S) Total points= This patient was seen because of a primary 6 complaint of severe generalized cephalgia for the past three months. The pain appears to be constant and throbbing and appears to be becoming progressively worse over this period of time. The onset is associated with a motorcycle accident three months ago when the patient suffered head trauma. Skull X-rays a that time were negative but the patient did suffer a "rib separation". No additional abnormal diagnostic findings were reported. The patient has also noted a good deal of dizziness during this period of time but this appears to be improving in recent weeks. The patient has also been aware, in the last thre to four weeks, of tingling and numbness of th right side of the body. Additionally reporte , in the past two weeks are some visual diffi- culties that are described as blurring or double vision. The patient also notes that h has a good deal of trouble concentrating on* 3. PAST HISTORY (Mother, Father, Wife, 1 Siblings, Children) + —rr Endocrine Dysfunction Diabetes (grandfath r) Cancer Tuberculosis Neurosis, Psychosis Cardiovascular Disease MI (Father) Other *things recently and appears to be occasionally forgetful. Increased irritability has also been noted within the past few months which the patient attributes to the constant head- aches and discomfort he has had. _ ".“1 E Ix- .1 __. .._ r..- 4 340 Appendix J (Cont'd) Page 16, No. 8 MEDICAL HISTORY Previous Hospitalization:None Allergies: None Medications: Aspirin and Darvon ACCidentS=Present accident (1972) Three months ago Surgery: None Diseases:Chicken Pox - Measles Habits: Coffee (20 cups per day) SOCIAL HISTORY (Work, Hobbies, Recreation) Construction work - Engineering Survey - Motorcycle Hunt - Fish 4. SYSTEMS REVIEW (if appropriate) (Gynecological, Obstetrical, Gastro- intestinal, Genito-urinary, Cardio- vascular, Respiratory, Metabolic: Neuro-Muscular) GI - Epigast pain, occasional nausea Neuromuscular - (Rib separation) Grade A“ -o-: .- C« it; 1 . Total points= 9 Total points= 4 341 Appendix J (Cont'd) Page 17, No. 8 Grade 5. PHYSICAL EXAMINATION GENERAL APPEARANCE: Coloration (Skin, 1 Sclera) No pallor or Icterus Physical Development (Asthenic, Obsese, etc.) Medium built - Muscular - well developed GENERAL FINDINGS: 1 BP Cardiac Auscultation Rate Rhythm Murmurs Neck Auscultation Bruits OphthalmOSCOpic (GRI-IV) Vessels Disc Retina MENTAL STATUS: 1 State of Consciousness (check) 3 .Alert Unconscious or comatose Confused or obtunded Decerebrate or decorticate 342 Appendix J (Cont'd) Page 18, No. 8 Speech and Language Function Aphasic or dysphasic Dysarthric or anarthric REFLEXES: Deep Tendon (Designate O-Absent, l-Hypoactive, 2-Normal, 3-Hyperactive) Left Right Patellar 1—2 3 Biceps 1172 1:2 Tricep _gtj; i _1~2 Brachioradial __1:2: 1-2 Achilles 1—2 1:2 Pathological or Superficial (Indicate A-Absent, P-Present, E-Equivocal) Left Right Plantar P 1A1 Babinski A P Ankle Clonus A 4A Abdominal P P Hoffman A i AL Grade 343 Appendix J (Cont'd) Page 19, No. 8 SENSORY: (Indicate A-Abnormal:Hypoactive or Hyperactive Responsive, N-Normal, E-Equivocal Dysfunction) Response Location Vibration N in Pinprick N .N Light touch 11 LL Position sense A Stereognosis A MUSCLE FUNCTION AND GAIT: (Check appropriate headings) Fasiculations Yes No x Gait: Normal 2; Abnormal (describe also) Muscle Tone: Spastic Flaccid Rigid Normal x Muscle Strength (indicate specific muscle weakness) ,None Grade 344 Appendix J (Cont'd) Page 20, No. 8 CEREBELLAR AND DORSAL COLUMN FUNCTIONS (indicate N-Normal, A-Abnormal, E-Equivocal) N Finger to nose N Dysdiadochokinesia N Tandem gait N Heel to knee N Romberg EXTRAPYRAMIDAL (check appropriate headings) Spontaneous movements (describe) Cog Wheel Rigidity Mask like facies Decreased eyeblinks Loss of arm swing CRANIAL NERVES: (indicate nerves checked and if pathology present.) 1.51] within norma] 7. limits 2. n 8. 3. u 9. 4. u 10. 5. u 11. 6. u 12. 6. SUMMARY 1. General Results: (check) Normal Neurological x Abnormal Neurological Equivocal Grade Total points= 10 345 Appendix J (cont'd) Page 21: N00 8 Grade 2. Assessment of Area of Neurological System 2 Dysfunction (check) __§__Motor __§__Sensory Mentation and Behavior 3. Anatomical Location (check) 2 Primary Muscle Dysfunction ___Peripheral Nerve or Root Dysfunctiori _____Spinal Cord Brain Stem X l Cerebral Hemispheres Total points= 5 7. PROVISIONAL OR WORKING DIAGNOSIS(ES) Fetal points= (include all systems) 5 Categorical Diagnosis S ecific (heurOpathy, encephal- (tumor, cerebral Opathy, etc.) hemorrhage, etc.) Encephalopathy Sub-dural 346 Appendix J (Cont'd) Page 22, No. 8 8. DIFFERENTIAL DIAGNOSIS (identify no more than three neuro- logicalfidisotders) General Pathology_ Specific Type of Category: Pathology: Vascular Aneurysm Infectious Skull and/or cervical Traumatic spins fracture Autoimmune Metabolic Inherited Neoplastic (or mass Tumor lesion) Cardiac Dysfunction Degenerative or Demyelinating Others Chronig gagtritig — ulcer TESTS (laboratory tests and other diagnostic procedures) Specific Neuro- diagnostic Tests General Lab. (EEG, lumbar (CBC, urinalysis, etc.) puncture, etc.) .EEGI_Skn11_X:raY_ .CBCI_ESBI_EBSI_GTT_____ Brain_Ssani_Cerica1 Chest,X:rayp UA Spins_X:raYsl_anbar puncture .Echoencsnhalogram .Ansiosram________ Grade #otal points= 5 Total points= 5 347 Appendix J (Cont'd) Page 23 , No. 8 Grade 10. THERAPY Total points= Specific Supportive 2 Craniotomy, Physical Therapy COMMENTS Note: All Practical Exams have maximum score of 54 points. All Exams are standardized on a 54 point basis. APPENDIX K CLINIC ROTATION SCHEDULE APPENDIX K (REVISED) CLINIC ROTATION SCHEDULE FIRST YEAR CLASS SUMMER QUARTER 1972 PROGRAM COORDINATORS: LAWRENCE E. JACOBSON, D.O. ACTING CHAIRMAN FRED C. TINNING ADMINISTRATIVE ASSISTANT DEPARTMENT OF OSTEOPATHIC MEDICINE 349 Appendix K (Cont'd) Page 2 GENERAL INSTRUCTIONS 1. Students will wear clinic uniforms at all clinic meetings. Uniform requirements will be white lab type jacket, white pants, white shoes, shirt (any color) with collar and tie, and identification plate. 2. All clinic services will meet at 1:30 p.m., unless otherwise indicated. -1- we 3. 100% attendance is mandatory at all clinics. If any student cannot attend any clinic, the following must be notified: 1::‘“-“‘"'-1 J l a. Office of the Department of Osteopathic Medicine b. Individual in charge of the clinic. 4. All students are required to turn in the evaluation material of their clinical experience no later than one day after the clinical experience. This is required for Medicine, Pediatrics, and Neurology Clinics. The preceptor experiences are to be cleared with Family Medicine. 350 Appendix K (Cont'd) Page 3 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER June 20 June 21 Ju 1 Dr. Kutinsky(MPE)Med. z m \DQQGW-hWN HHHHHHHHH mummawNI-ao 19 wwwwwuwmwwwwmwww mauNHowmemm-thr-Io L.) 0‘ 351 Appendix K (Cont'd) Page 4 STUDENT TUESDAY WEDNESDAY NUMBER June 27 June 28 Kutinsk MPE Med. Kutinsk MPE Med. Kutinsk MPE Med \OGQGM‘NNH H klrd H vs H rd H ~J o tn b L» N ti o 18 NNNNNNNNH \JO‘U‘I-waO-JCW Kutinsk MPE)Med. Dr. Calkins (Neur. THURSDAY June 29 352 Appendix K (Cont’d) Page 5 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER u Jul 5 Jul 6 HOLIDAY Det. Clinic A (Neur) \DQQC\U!.UNH (s w to u L» u no N A; N no N no N no N hi H r4 H hi H he H rd H (n a to N r4 O’ND m ~J 0 Ln a UIru H c>\o m ~4 a tn 5 to N F‘ o U 0‘ 353 Appendix K (Cont'd) Page 6 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER Jul 11 Jul 12 Jul 13 1 Dr. Kutins MPE Med. Dr Kutins MPE Med. Dr Kutins Med OGQU‘mbWN N «are M an N r4 H r4 H r» H +4 H pa p «n A u:ru H c>~o m ~J m en a Lo N ha 0 354 Appendix K (Cont'd) Page 7 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER Jul 18 Jul 19 l 2 1 t \DQQO‘U’I‘DWN H +4 H ya >4 H rd F4 H m ~J m L” A L» N ha 0 l9 wwwwaWNNNNNNNNNN O‘mwaHowmflmmwaD-‘O 355 Appendix K (Cont'd) Page 8 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER Ju l 25 26 7 \OQQO‘U‘IBUNH HHHHHHHHH mummauNHo l9 WWUUUWWNNNNNNNNNN O‘U'IBUNHOQm‘) U‘uwaD-‘O 356 Appendix K (Cont'd) Page 9 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER Au ust l u u t WOQO‘kflthO-H HHHHHHHHH mQO‘UI-bWND-‘O l9 UUUMHUUNNNNNNNNNN O‘U‘bhflND—‘O ONIO‘U‘DUNHO 357 Appendix K (Cont'd) Page 10 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER \Dm‘la‘lflfiwNH H H »a H rd H rd H m ~J m Ln a in N rd 0 1 000)wa UNNNNNNNNNN OU‘DWNHOW \JO‘UléwNI-‘O 358 Appendix K (Cont'd) Page 11 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER us 5 1 359 Appendix K (Cont'd) Page 12 STUDENT TUESDAY WEDNESDAY THURSDAY NUMBER A ust 2 mfla‘mbUND-i 360 Appendix K (Cont‘d) Page 13 DR. CALKINS' HUMAN MEDICINE - NEUROLOGY CLINIC STUDENT NUMBER l-A June 28 Jul 19 A ust 9 Dr. a ins 2-A Jul 12 t 2 t 23 Dr. Calkins Dr. Calkins Calkins HUMAN MEDICINE STUDENTS ONLY APPENDIX L FINAL EXAMINATION SCHEDULE F _W.‘mif_"A1 ‘ _ . 361 MICHIGAN STATE UNIVERSITY EAST LANSING . MICHIGAN mm COLLEGE OF OSTEOPATHIC HEDICINB - EAST PEI! HALL DEPARTMENT OP OSTEOPATHIC MEDICINE August 8, 1972 MEMORANDUM TO: All First Year Students FROM: Dr. Jacobson and Fred Tinning FRI SUBJECT: Final Examination Schedule { l . . . . 1- Attached is the finalized schedule for your Ba51c and m Clinical examination, the Pharmacology exam and most im- portant, the individual Practical Neurological Exam Schedule. You are aware of the times scheduled for your Basic and Clinical and for Pharmacology as this was cleared with your Class President, Mr. Bedecs. The practical examination in Neurology will run approximately 1 1/2 hours for each student. The examination will be held at St. Lawrence Mental Health Clinic at Oakland and Logan Streets in Lansing. The Mental Health facility building is behind the hospital. You are to report to the reception desk and they will tell you how to proceed. Upon completing your practical examination, which is to be video-taped, you will be given approximately 1 1/2 hours to complete the write-up according to your own assess- ment of the case. You will be allowed resource material in the preparation of your case write-up. However, it is suggested that you hold this material to a minimum. There will be no changes in individual times assigned for the practical exam. You will not be aware of the video— taping as the camera is hidden. The main objective in video-taping is to provide each of you an opportunity next quarter, to review in detail your own individual tape and how you performed a neurological examination. This will be one of the most beneficial learning experiences of your new career. If you have any questions, please see one of us. Remember the schedule is fixed and you are only allowed a minimum of material in writing up your case. Thank you. erh encl 362 .GOHHMGHmem Hmsflm may Hem condom MHEoucmn muoonQSm HmusmENmexm on» on mummmu NHIH mm m can NHIH mm m .ucmEHummxm on» ca no: new uHcD mamumwm HmoamoHondoz on» cw musmcsum Houucoo m>wuomcH on» on mummmu «HIH UH "wuoz NH mm m NH mm m HH mm m HH mm m OH mm m OH mm m H .ummm .hmcwum m mm m N mm m N mm m N mm m N mm m N mm m Hm .msm .wmcmusne m mm m m mm m m mm m m mm m H mm m H mm m on .msm m . aampmmcmumz H «H oH NH 0H NH UH zmcuoumm I I w. I m 0H s 0H m 0H N oH H mm m H mm m M H oH . mN .msm , u _ .NmoHum r . omumanum ooumumvum omumanuN .oouNumwuNH .omuNHumHuHH .oouHHuomum HmHnmuooum _ HamowmoHousmz Havauomum HMSQH>HUGH II mmoHoomEHmsm II HMUHGHHU cam OHmmmv MQDQmmUm ZHoumfln ucmfiumm ousmc m wumuumcoewc ou hummmmomc muouomm unmoflmwcmfim acme 30m .< "muoumfim ummm .m m moflumfinmuowumno m>Humwuommv Hmnuo Ho mEoumme Honocmo .w ucwfigmmuu msoH>mHm mo mmnsoo . Muflnm>mm . COH¥MUOH . \‘\1Vu1 comeuoo . ummco .H .HTGGNE #GQHQSOU USN UTNMQMOHO CM CM QmHDOO USN “QmCO MS“ UOQMHOWQO Q "mucfimHmEoo mmflao MO me500 cam uwmco .m m .mucwmamaoo wmfino no mEmHQ Ioum mo MODES: pomuuoo any pmfiwflucopm hawmfinn com haumwao .< "AmcuchHmsou Nano .H m UmumeEou woufldwwm "MMQZD wM m>HBHB<2mOh HUZHBMHEOU AdUHZHAU w.mOBUDMBmZH mzHUHQME UHmadmomBmO mo mumqqoo wBHmmm>HZD mBm£om can somwmucoz . anowcmm I JAI— u—u“II Houoz cowuoc9mmmo Emumhm HMOHwOHonsoz mo moufl mo ucmammwmmd .m Hwoo>mswm .m HMOflmoHousmz Hmfiuocn¢ .N HmummoHonsmz HmEHoz .H memnov "muasmmm Hmuosoo .4 umHmEESm .m m mommo m.ucmfiunm on» mo mdlxuo3 oapmoqmmfic man GA Hmufi> meEmHuxm on on HmUHmcoo so» 06 .cmufiowaw pawnsum can nuan3 .mmcficcflw Hmowmwnm Hmoflufiuo acme 30m .m NHNHucmuH ucmwsum may cHn :oHumanmxo Hmoflmwsm HMUHmoHOHsoc m mumuumsoeww ou hummmwom: .Hmfiuocnm Ho HMEHOQ nonufim .mmqflvsflm Hmowmznm unmoHMHcmHm Home 30m .d ”cofiumcmmmxm HMUHmmam .m 0H mommo m.u:wflumm‘wnu mo mmuxnoz owumocmmflp wnu CH HmuH> waEouuxw on o» Hocflmcoo so» on .cmMmmucmpfi ucmwsum map nbmnz .muouomm psmumwficmflm hams 30m .m mmwflucwcfl unopoum may pap mEoumNm 0:» mo 3mfl>mu muwamfioo m wumuumcoamp on anamwwomc muouomm ucmommwcmflm Hams 30m .¢ "3w«>0m mEmummm .v v mommo m.ucmfiumm map mo ucwfimmmcme 0cm mamocmmflc may 0» mcflusnwuucou mucfiom Hmufi> HHmEmHuxm on on Hmvwmcou 50> ow .pmfimmucwpa ucmcsuw mnu gown? .muouomm usaoaMficmmm mama 3cm .m "meZD mflm BZMQDBm mmB moavflm cwumamfiou nmufldwom mumo mama ZOHMWBHMU N comm .N Ehom A©.Dcoov z xflpommm< 374 mhwflusmmfi ucmcsum msu mam 0mmo was» mo mamocmmwc mgu on HmOHuwuo mumc anoumuonma Hmowcflao mszHHHus cw Hafiafinm on» wumupm:0Ew© ou hummmmum: mouzwoooum Ho mums» wumfinmoummm >cme 30m .d "mogsmooonm caumocmmao uwsuo mam mumoa anoumnonmq 0‘ momma m.ucmflumm‘ on» CH mflmosmmflm HmfiucwHwMMHc oaumaamou Ho mumflumonmmm Gm ou mcwusaflnusoo cw HmUH> hawawuuxm on on Homfimcoo no» om .mmHMHusowH quwoum on» Abmmz .mcoHumHomHmcoo hams 30m .m mamwucmofl ucmpsum way can mcfixme conwowm mam ucofimpsn HmoacHHo .mcw>H0m Emanoum mumuumGOEmc ou Hummmmomc mcowumuowwmcou oaumocmmam Hmwucmuouwflw muwwumonmmm acme 30m .< "mflmosmmfla HmwmcmHOMMHQ .m wwwflucocfl usocuum map ch mmH>H0m EmHnonm 0>Huommwm mumuum IcOEwo ou Hummmoom: mcofiumnmmflwcoo HmCOHmmboum wsme 30m .0 NmNHucme ucmvsum msu can mHmocmmNU mcfixuoz m mumuumGOEwc on mummmmooc mcoflpmumvmmcoo Uflwmocmmflo wumflumoummm mama 30: .m NNNHucwcH ucwvsum mgu an .mcflxmfi :onHumU 0cm usofimwsfl Hmoflcfiao .mcfi>H0m Emanoum wumHumGOEmo ou Hummmoumc mmmocmmfip mumflumoummm hcme 30m .d ”mmmoqmmwo Hmsowmfl>oum Ho mcfixuoz [\ meQSAmmeETS HMHQQHQU .m Ewuw camum puoo Hmcmmw . comuocswmho poem Ho m>nmz Hmuwnmwumm . cofluoosmnwo mHomsz NHmEHHm v m N H < :oflumooq Hmofieoum: .U "MHQZD md: BZMQDBm HEB moaodh Umuwamfioo bonanmwm mumo mumo ZOHmmBHMU m comm .N Snow A©.ucoov z xflucmmm< 375 oz mow «moqwfimxm mcamn ommo m.ucmwumm can you pomoHo>mm cownmuwuo on» an dogmHHnmumw on page Ho>oH mane .m>onm no Hm>oH ummm ESEHGHE m «0 mocmEHOMHom moumnumsosmc .coHuqumem Hmowmmam mam huoumws ucmaumm Hmowmoaonsmc on» so ucomsum on» mm: .Houosuumsw HmoHQHHu m mm m>onm mmcwumu use» cH .¢ "UmfimHmEOU COHFHTUHHO MO Rwanda HMUOB “conflswwu coaumuflno mo Hogans Hmuoa vm "mafipmuw HA mommo m.u:oflumm map on Hmofluflno mHmEmuuxw on on uwmfimcoo :0» oc .moccmfifioowu unmosum ozu nommk .ucmfiumwnu no ammumgu mo meuow acme 30m U NHNHucmuH ucomsum may an quamcafl HmoHcHHo wumuumcoEmp ou Hummmmomc mum musums humccoomm mHoE m mo unweummuu Ho mamumnu m>fiuuommsm mo momwu home 30m .m quHucme unocsum on» map unmewmsn HmOHcHHo mumnuchEom ou hummmmomc Hmmuoau Ho unmEumeu mo mEHOm xumEmum Ho HmUHHHHo Home 30m .< ”ucoeumoua cam Nmmuwne .OH mommo m.ucmflumm mnu CH mHmocmmH© Hmcflm m mcficommu CH Hmoflufiuo HHmeprm on on HmpHmcoo 50% cc icofiwflucwnfl unmosum mnu sown? .mwuswmooum HuoumuomWH Ho mummy ofiumocmmM© Home 30m .m "mmOZD mflm BzmQDEm HEB mOBUHuooflno on» so Ummmm .m umfizmzzou m comm .m Enom Ap.ucoov z xflocommd 377 quuHmmEHCD H m m S m m H HCmuHomEH mocoHHomxm HmoHCHHU ucmuuomeHco N m m N N N H ucmuuomsH an\muauomH I wuoumHC HmOHooHousoC m oCHuonEoo CH mummmmooC mHHme HmuCHmHmEoo mmHCo .HmmCo .muoumHC uCMHumm oCHuHOHHm UCm mHCmCoHumHmH m oCHCmHHnmumo .m.HV oCH3wH>HmuCH UCmHumm .m quuHomEHCD h m m v m N H quuHomEH mOCmHHomwm HmoHCHHU quuHomEHCD H m m w m N H pcmuuomEH nmq\musuooq I COHumCHmem HmoHoOHousoC HammmmOOSm m Hospcoo ou mummmoooC moomHzoCx HmOHcmz .< "mmmum oCHsoHH0m on» CH mHHHmm H50» mo uCoEmon>m© mg» 0» mumomu CHH3 mCommmmm mooCmHHmmxm HmoHCHHU on» no ooCmuHomEHCs Ho moCmuHomEH on» oCm mCOHmmom nmq\musuooa on» Ho moCmuuomfiHCC no mOCmuuomEH onp mummEou .H Emmelmmm uoCHsoHHom may mumHmEoo mmmon H BmCm .HooHousoz CH onusoo on» oCH>oumEH CH umHmmm HHH3 .Hm>m3on .omCommmH Moo» .momuo Moo» Hommmm mm3 0C CH HHH3 CoHHmCHmem HmoHCHHO HmoHuomHm HmCHm map Houmm mCm oHOHon poxmm mCOHumoso oCu on momCommmH “sow .COHumCHmem HmOHCHHU HmoHuomHm HmCHm mnu CH pCm omnsoo mHHucm oCu oCHHsU ooCmEHom Iumm Hoow Co mmOCmHHmmxo oCHCHmHu mDoHHm> Ho muoommo on» unonm moCHHmom H50» oCHEHmuoU ou HHOHHw Cm CH pmxmm oCHmQ mum mCoHumoso oCHonHom one "onBODoomBzH OZHZHde MUOHOMDMZ ZH mMUZmHmmmxm ho Bzmzmmmmmd HfiZHH H momm .m Euom HU.UCOUV z xHUCmmm< 378 HommmooosmCD N m m e m N H Hsmmmmoosm _ HmHOHmHuud N m m H m N H OHDmHHmom _ quuuomEHCD N m m v m N H quuuomEH mmoHoCHCmmz N m m e m N H HsmdeCmmz mmmHmmm N m m H N N H Hmmmmm memu on unonm mum so» CoHumCHmem HmoHCHHU HmoHuomHm HmCHm on» mnHHomoo so» mHso3 sow .4 .m moamcHNcoo oz N m m e m N H unmoHNcoo Num> mCOHumCHmeo HmoHCHHo HmoHuomum HmCHm mHCu CH CoHumsHm>o HmoHooHouooC oumHmEoo m EHOHHmm on muHHHQm H90» CH Hoom 50> ow quchCoo 3oz .N quuHomEHCD N o m v m N H quuuomEH oOCmHHomxm HmoHCHHO quuHomEHCD N m m w m N H quuHomEH an\oHsuooH I mHmOComHU HmHacoHomch ccm HmCOHmH>oum mumusoom cm um oCH>HHHN .m quuHomEHCD N m m e m N H quuHomEH moCoHHmmwm HmoHCHHu HcmuuomEHCD N m m v m N H HCmuHomEH an\oHsuomH I COHumCHmem HmoHooHousoC ouonEoo m oCHuosoCoo CH moCmonCOOIMHmm oCHmoHo>oo .o quuHomEHCD N o m w m N H quHHomEH mocoHHomxm HmoHCHHo ucmuuomEHCD N m m w m N H quHHomEH nmq\musuooa I moCHoCHm HmOHooHousmC HmEHOCnm oCm HmEHOC uHoHHm on mummmoooC Anouoeonohmmv mosoHCCoou oCm mHHme COHumCHmem HmonNCm .U N momm .m Euom HU.uCOUV z xHoCmmm< 379 quummEOOCH qummmHmCD mCOHxC< HDHMWGUUSmGD mnsommCH mumavaMCH Hoom Hflmh 0000 UCmHHmuxm ow 30Hmm HumHHsvmu mumo .MM mumHmEoo mummy CHmuno 0H Hommxm H .CoHumCHmem HMOHmoHOHCmC HMCHH mCu Co mCHumu moCmEHOHHmm he Co .v H N m m m m m v ¢ m N m N m N m N m N H H H H H omlmm OHImH omlmm OOHIom Amy ADV ADV Amy Adv "whoom mCH3OHHom may quumeOU uCMmmmHm Emu stmmmoosm wusowm mCOHHMCHmem HCUHCHHU HmoHuomnm HMCHm me mCmeu mnemmn 30C HHmmHCQNIuConm mmCHHmmm H50» mnHHome so» UHCos 30m .m m 00mm .m Ehom an.ucoov 2 anchCC 380 mamz erCmmCum u0H>mnmn CMHonHCm m>HuowHHMCH ADV H0H>mnmn CwHonwnm mmmnm>¢ Amy H0H>mnmn CCHOHmmnm m>Huowmmm NHCmHm Adv ”mm omumu ma HHH3 HOH>mnmn CMHonmnm >5 .quHumm map Scum mumw mCHuHoHHm CH UCm mmHCmCoHumHmu HMCOmHmmHmuCH mCHCmHHnmumm Co .m HHmm Auv mumsvmc¢ Amy ucmHHmoxm AC“ "mmCHCCHH HCOHmOHOHCmC HmEHOCQm Ho HmEHOC mCHUHoHHm on mummmmomC Anouoeonowmmv mevHCComu UCm mHHme CHHz CoHumsHm>m HMCHH map Ho CoHuomm COHumCHmem HmUHmHCm may Co muoom GUCMEHOHHmm mCHBOHHoH wCu CHmuno ou uommxm H .m u mmmm .m Euom AU.uCOUv z chCmmmd 381 quummEOOCH H o m v m N H quummEOU pammmmHmna N o m H m N H mmmmmmmm msonCC H o m e m N H EHmu HammmmOOCmCD N w m v m N H Hammmmoosm mmmmmmmm N m m e m N H mmmmmm ImComumCHmem HMOHCHHU HMUHHOMHm HMCHH 0C9 memu m>mn :0» Han» 30C HHmmHCO» usonm mmCHHmmm H50» mnHHomwn Co» 0H503 30: .m HammmwoosmCD N m m v m N H HCHmmmooam HmHoHHHHum N m m H m N H oHumHHmmm pamuuomcho N m m H N N H ucmuuomeH mmmHmchmmz N m m H m N H HummzHcmmz mmmmmmm N m m H m N H Hmmmmm Nmemu Hmsw m>mC so» CoHumCHmem HMUHCHHU HmoHHUMHm HMCHm map mnHHomwc so» 0H503 30m .¢ HmCHmeE mHOHmQ COHuomm Comm @me mmmmHmv ”mCH30HH0H 0C» mHmHmEOU mmmmHm .COHHMCHmem HmonoHOHCmC HmoHuomHm HMCHH may cmumHmfioo m>mn Co» umnu 302 .H BmMBIBmOm HH BMdm m 00mm .v EHom HU.HCOUV 2 xHUCmeC 382 H0H>mnmn CMHon»Cm m>HuommmeH HUV H0H>MC0Q CMHon»Cm 0>Huommmw mmMH0>4 Hmv H0H>mnmn CMHon»Cm m>HuooHHm »HCmHm HCV “mmz CMHon»Cm m mm H0H>mnmn »E .HCmHumm mCu EOHH mumc mCHuHoHHw CH ©Cm mmHCmCoHHMHmH HMComHmmHmHCH mCHCmHHnmumm CO .H Amy HHmm Hov HNV mumswmnC Hmv AHV HCmHHmoxm Aflv “mm? mmCHnCHH HmonoHOHCmC HmEHOCnm H0 HmEHOC uHoHHm 0H »HMmmmomC HHouoeono»mmv mmCUHCCUmu GCM mHHme 0C9 CHHS mCHHmmc COHHmsHm>m HMCHH 03H H0 CoHpomm COHHMCHmem Hmon»Cm 0:» C0 mHoom mUCMEHOHHmm »E Hmmm H .m mumsvmcmCH om 30Hmm Amy Hoom omImm Hay HHmm OHImH ADV woow omIam Hmv quHHmoxm OOHIom HCV "m03 COHHMCHmem HmonoHOHCwC HMCHH mnu C0 mCHHMH moCmEHOHHmm HMHOH »E Hmmm H .N m mmmm .q EHom H©.uCouv z xHoCmmmC 383 cmHHmHummmHo N m m H m N H anHmHumm HHanm NCOHHMCHmem HMCHH HmowmoH0H5mC HMOHHUMHQ 0C» mCHumHmeoo CH »HMmmmomC HHOHOE Ioao»mmv mm5wHCComH ow mHHme C0ImmCmC mCu CHHS 50» vmcH>0Hm mmH500 0:» H0 uHmm mOCmHmewm mCHCHMHH HCOHCHHU HMUHuommm H50» Han» omHmmHHMm 50» mHm .»HHm0HHHommm .m omHHmHummmHo N m m H m N H meHmHumm HHgmHm WCOHHMCHmem HMCHH Hm0H00H0H50C HMUHHUMHm 0C» mCHHmHmaoo Hom »HMmmmomC mmHuHHHmu va mHHme map HHm CHHS 50» cw©H>0Hm mmH500 0:» H0 HHmm moCmHHmmqumCHCHmHu HMOHCHHU HMUHHOMMN H50» was» cmHmmHumm 50» mHm .HmHmCmm CH .N moummmHa N m m H m N H «muma .CoHumCHmem HMCHH on» HOH C0>Hm mm3 H HCmHumm 0C» CuH3 Hmmo 0H 08 mHmmmHm u0C ch mquHumm CHHz quHmexm m50H>mHm »z .0 mmummmHo N m m H m N H mmum4 .mE @mHmCHOQ CoHum5Hm>m HMCHH map How HmuHmmom mocmszH .um 0H mmCHuumm HMCoHu05HumCH mCHCUHHsm .m mmHmmmHo H w m v m N H mema .COHHMCHmem map How we mHmmmHm HOC 0H0 mOCmHHmmxm HMUHCHHU »2 .C umCHonHOH 0C» stmCm mmmmHm .vmuommxm Cmcu mmH03 0H0 50» HH .o wmuommwm Cmnu mmH03 3052 H m m w m N H wmuowQXm CMCH Hmuumn £052 "mm3 EMXQ HMUflGHHU HMUMfiUMHQ HMGflM 05H GO mUCMEHOMHmnm WE ”HMS“ “Hm“ H .m N mmmm .v EHom AU.HCOUV S xHUCmmm< 384 mama m.quw5MM 02 mm» IIIIIII HmHCmHumm nmumHCEHm mCHm5 HmCHCHMHH HMCOHuncm HOV mCHCHmHH 0>HmomH on mxHH 50» vH503 .C0Humo5co HmoHCHHo HMOHuomHm H50» m0 HHmm mC .mH HmmmHquo: on N o m H m N H Hmmmum .Hmm» HmHHH »E CH Um: w>mn H mmoCmHHmmxm HMUHCHHU Hmnuo Hm>0 »moH0H5wC CH mmH500 mHCH CH 0H @mCmHmmm mm3 H mOCmHHmmxm mCHCHMHH HMOHCHHO HMUHHOMHQ map HmmmHm 0H503 H .NH omHHmHummmHa N m m H m N H omHHmHumm HHHmHm NmOCmHHmmxm mCHCHmHH HMUHCHHU H50» EOHH ©m>HmuwH 50» xomnommm ma» CHH3 UmHHmHumm 50» mHm .»HHm0HHHummm .HH omHHmHummmHo N o m H m N H cmHHmHumm NHmmHm H»H0>Huommmm mHMHmH 0H »HHHHQm 029v NH0H>mnmn CMHonNCmIm>HHUmHHm mHMHHQOHmmm H0 HCmEm0H0>ow map How »HHC5uHommo map CuHs 50» ©0UH>0HQ woCmHHmmxm mCHCHMHu HMOHCHHU H50» HMCH UmHHmHumm 50» mHm .»HHm0HHHommm .OH cmHHmHummmHa N m m H m N H meHmHumm HHgmHm NCOHHMCHmem HMCHH HmonoHOHCmC HMUHHUMHQ mCH mCHumHmEOU CH wammmowC mmwwHaoCx Hmomwme 0C» CuH3 50» U®©H>0Hm mmH500 mnu H0 HHMQ mOCmHHmmxm mCHCHMHH HMUHCHHU HmUHHUMHm H50» HMCH cmHHmHumm 50» mHm .»HHmoHHHommm .m m mmmm .H EHom A©.HCOUV 2 waCmmmd 385 NHmH mCHumm m>HHHCm00Im>HuomHH4 mchcHa .u cmum Bszmmmmm¢ Adonwmm QZd meBmHm HfiUHwoqomsz "mHmCHmem "CoHumooq «mumo "0802 m EHom HU.HCOUV 2 vaCmmmC 386 .mCHonHHmmxo was quHumm may H853 H0 mCOH mCHHmmH »HHmCmHCH 0:» Cqu mCHHmmo ©00H0>w .mmmCommmH mCHHOCmH »HC0 cmmC .quHumm Gnu mCHmHMC CH umm IHmuCH UHHmHHmmHC5 Cm 60mmmmem H0 quHqu 0:» wCHmen CH ummHouCH Cm mmmmem u0C 0H0 H»HHmnHm>C0C H0 »HHmnHw> GCOQmmH HOC GHU .Homucoo m»m mCHwH0>m ..m.0v EmHQOHm m.HCmHumm may CH UmummHmuCHCC omemm .oum .HHmno :H mcHuHHnm .uomuCoo m»m wCHuH0>m..mConoHn .mCHummzm .wHOEmHH mm mCOHHommH £05m »n C30Cm mm .HCmHumm 0C» CHH3 0mmm um HHH omHmmmmm w m w m N H .»HmHMH500m UCm »HCmm0 MCOH mCHHmmm m.quHumm 05H 0» omOCommmH .HquHumm msu cooumHmcC5 mmC 0C umCu mmumonCH H.0.Hv mmmCommmH mCHCmHmHH ©0HMHHmCOEw© .30H>HmuCH mHCu m0 meuCoo mCu CH mHmC 0H mmmCmCHHHH3 va ummHmuCH OHHmHHmmH m ©0mmmmem o A0090 .gaanssg .mchwoa cams .HomuCoo 0»m cmCHmuCHmE ..m.mv EmHn0Hm m.quHumm 0C» CH vmummeuCH omEmmm .30H>HmuCH 0:» H0 mmu5CHE 30H HmHHH 02H Hmumm HamHumm mgu nuHs mHnmuuoH I800 0C0 ommemH UmHmmmmm "HCmc5um may .30H>HmuCH may mCHH5Q ImHCmCoHumHmm mCHxHOB m mCHCHmuCHmz ch mCHCmHHnmumm .H N mmmm .m EHom H©.HCOUV z chCmmmm 387 .30H> IHmuCH mHCH m0 uxmucoo 0C» CH umCmHCQ Cmmn m>mn ©H500 COHsz mm5mmH m>HHHmCmm cmcH0>m .mUmOC HMCoHuofim m.quHumm 0C» 0» UCOQmmH u0C 0H0 H0 omHOCmH .mvmmC HMUHm»Cm m.quHumm may 0» GCOQmmH HOC UHC H0 omHOCmH .HmmCHHmmH gown mUHOC .onou mmmCmno .quammHmmch 005CHHC00 ..m.mv CoHuommH quHumm »n ©00C00H>m mm 0>HHH0mm5mIC0C mm3 H0 H.0um .C0HH0C5H COmHmm H0 mmOH HmmH ..m.m .»HMHH IC00 mCH 0H mon©H>m muHmmmv =.m.o ma HHH3 mcHnuNum>m= awn» quHumm mHHmuv mCHH5mmmmH mas m N H H.00Hm>oo mHm CHmoCoo H0 mmmHm w>HuHmCmm COHns um mHMH 0C» umm 0H HCmHumm any mHHEHmm ..m.0v mmmHm m>HuHmCmm u5n HCm>mHmH um »HHCmm omQOHm .4 “HCmGCHm 03H .30H>H0HCH may mCHH5o CoHumuHOHHm mama .HH .mome HMCoHuoam m.HCmHumm 0:» 0H UmcCommmH .m .mommC HMUHm»Cm m.uC0Huma 0:» 0H vmeommmH .0 .H50» HHmu 0H mCH»HH Cmmn mm: 0: pass oooum IHm©C5 ch onwn m>mn 50» HmCH HCmHHmm may 0» mmumo IHC5EEOU ..m.HV quHumm map »n 00mmmmem mm3 Hommmm CmC3 H0 omumm5me C033 0>HHH0mm5m mm3 .m m mmmm .m EHom HU.HCOUV z xHCCmmmé 388 .30H>HmuCH may m0 COHuomHHv H0 30HH 0:» HQCHch 0» mm HmCCmE m C05m CH mCoHummCU mCH»mHHMH0 mxmm .mCoHumm5U mCH»HHHMHo cmommC xmm HOC mmoo .HCmHHmm map »n nmqum IMHQ HMHHmumE 0>HuomHHmIC0C .HM5H0MH may CHH3 NHCO HHmmv HmmCommmH 0C H0 mm» m mCHHHCva mCoHumm5U ..m.wv mCoHHm05U »H0HMH0memIC0C »HC0 ©0m5 .HCmHumm 0:» 0H ©0H5H00H “mmH500mHv mCoH CH annEmH .mmon 0>HHHmCmm CHH3 mCHHmmU CH Hump H0 xomH m CHHB cmnmmUOHm Anmum5mcm mHmomV m Homumchm mHmomv m v v m m N N .30H>HmuCH 0:» H0 CoHuomHHv m0 30Hm may mCHum5HHmuCH HCOCHH3 mCoHumm5v mxmm .mCHmoCoo quHumm »HHHMH0 0H HmEmuHm CUHC3 mCOHumm5w mxmm .mmCHHmmm m.HC0Humm 0C» HCOQM mCoHumm5U OCmem mquHHmm »n cmHCwmmHm HMHHmumE m>HH00HHm CHH3 NHCo uHmmv .HmCOHumva UmchICmmo H0 wm5 »n HCmHumm 0:» »n Conm50mH© H0CHH5H mmmm IH500C0 ..0.Hv mCoHHmm5w »H0HMH0mem »HC0 omm5 .uaHom ms» 0H CCM »HH0HHQ mHCmEEOU mama va mCoHumva cmxmm .mmem 0>HuHmC0m CHH3 mCHHmmU CH HUMH CHH3 vwommUOHm .m H 00mm .m EHom HU.HCOUV z xHUCmmm< 389 N0>HHU$MMO #mOE mm3 H00“ 50% 0.0 Umflmflfl HOH>M£0Q “Mg .H mH0H>mCmm m>HuomHHmCH va m>HuommHm .30H>HmuCH 0H »mmm »Hm> mm3 quHHmm H m m H m N H .mmHuH5oHHHHU mHQMHmUHmCoo ammom quHumm umHmom mCH30HH0m 0:» C0 30H>HmuCH 0:» H0 »HH50HHHH© 0C» wumm NuH50HHHHQ 30H>H0HCH H0 quEmmmmmC m.Hmem .»H0umHC HMUvae 0Humfimum»m m CHmuno HOC mmon .mmCHwCHH Hm0Hm»£m mmHOCmH .quHumm muommwm EmHQOHm mCHHCmmmHm 30: C0 mumc umm HOC mwov .mHCHMHm I800 HmHCU H0 mmH500 va HmmCo 0C» H0 »H0HmHC HmoHomE UHHmEmum»m m mCHmuno .HCmHumm H0 mCHmoCoo HMUHm»Cm 0H UmHmHmH mumc mCHmuno .mHHH mucmHumm ms» wwuomwmm mm: EmHQOHQ 02H 30: OmHm H53 HHCHMHQEOU AmeCUV mCHqummHm »HC0 HOC muom .>H .HHH .h .m m mmmm .m EHom A@.uC00v 2 xHUCmmmd 390 .... umHH .mumsuo HH .m mm>HuomHH0 HmmmH mmz Hmmw 50» 06 @mHmHH H0H>mnmn Hmnz .N m 00mm .m EHom H©.HCOUV 2 vaCmmm< 391 Appendix M (Cont'd) Form 6 NEUROLOGICAL PRACTICAL EXAMINATION OF PSYCHOMOTOR TECHNIQUES AND SKILLS GRADING FORM Each test will be evaluated in the three following areas: A. Patient rapport with emphasis on accuracy_of instructions given to patient before and during each test. B. Proper positioning of patient. C. Proper technique in performing the test. Each of the above categories will be graded as follows: 1 = Excellent 2 = Adequate 3 = Fail The three categories are combined for a total score. The total score represents the students psychomotor skill or technique in performing the various neurological tests. 5/5/72 392 HHHHeouuxm “mamas mzoa mHosz mHmmz H¢H24mo m>mmz HflHZfiMU m>mmz 44HZ4MU m>mmz H¢H2 mawzmmew mHUmDE mBUZHmBm mAUmDZ u m 4 H4909 umUHCCUmB quHumm mCOHuo5HHmCH HO HO mCHCOHHHmom »00H5oo¢ mfiwzmmam mHUmDZ m mwmm .m EHOH Ho.HCoov z xHoCmmmd 394 mmOUm H4909 U m C 44909 mmeCCoo9 quHumm mCoHHo5HHmCH H0 H0 mCHCoHHHmom »0~H5004 «NHHEwHuxm HosoHv H»HHEwHuxm Hm3oHv H»HH60Hme Hmmm5v HHwHEmexm Humane onaozsm CHHHmmmmmo v mmmm .0 EHom Ho.uCouvHH xHoCmmmd 395 MZQZ BZNQDBm lg] mHuamu Cwsom »Hm> mHuuHH d HCHmHmo »HCMC0mmmm mHquUINHm> m H m N H HCmIov "mm3 Houoon may .CoHHMCHmem HMUHm»Cm 0C» mCHHCQ .HH AmHmm ou mCHHmo HmHmm 0p m50HxC¢ CCm uoz I uConmmHoCH HmHom ou omHH9 UCm 0: EHmz »HHmCH5CmU 0: H000 memmmV‘ .NH woummHmuCH cmemmmw OMICOHquHHC cmmmv omummHoHCHCD »Hm> pmumoHouCH NHQMCOmmmm omumonuCH »H0> m H m N H HHHCIUV HquuHmmm HomHMHmm HquoHHCou oCm UCM pmHun5mV »HCMC0mmmmv oomeom »Hm>v 0H500mCH mmmHm>C 0H500m m H m N H HHHCImV HmCHon max 0: HmCHoa mmz umC3 30Cx uoz oHov om Hon: 30CMV AuCoHHm »Ho>v quuumaooCH mmMHm>< quumeou m H m N H Hmooudv "mm3 CoHHmCHmem mCu mCHop Houooa 0C» HMCH HHmH H .omumHmaoo HmCH CoHHMCHmem HMUHm»CQ oCm »H0HmHC 0:» CH .H wzH94m MO9