Interviewing Teen Parents: Simulated Patient Experience for Clinical Education and Outreach

Introduction: Many medical students’ initial experience obtaining a history from a pediatric patient happens in their clerkship years. There is a shift in medical education to provide early clinical experiences to train physicians. To increase the exposure to pediatric history in the pre-clinical years, we developed this simulation-based session involving students in their second year of medical school. They are tasked with eliciting a history from a baby provided by a teenager who functions both as a standardized patient (SP) and the parent of the infant. Our goal was to have second-year medical students learn and practice interviewing an adolescent while obtaining history about an infant to assist in the transition to Year three Pediatric clerkship. Approach: Collaborating with the Office of Diversity at our medical school, we recruited students registered in medical academies in public middle and high schools in our county and asked them to be part of this simulation-based activity. A majority of these medical academy students are underrepresented in medicine (URiM). The students functioned as SPs for pre-clerkship medical students while gaining exposure to a career in medicine and the medical school environment. The medical students obtained a history, with faculty providing formative feedback, followed by documentation of the encounter. Outcomes: Medical students felt they gained skills to communicate with caregivers of pediatric patients. They also practiced the skill of eliciting a pediatric history from an infant whose parent is a teenager. The middle and high school students that functioned as SPs gained a better appreciation for the medical education system and felt that the experience was valuable for all parties involved. Discussion: This session exposed pre-clerkship medical students to the nuances of eliciting a pediatric history from pediatric caregivers while also engaging URiM from middle and high school in the medical education process. This session could be used at other institutions to expand diversity in the medical field while also providing pre-clerkship medical students with pediatric experiences. This article was previously presented as an oral presentation at the AAMC Group on Education Affairs (GEA) Virtual Regional Spring Meeting on April 21, 2021.


Introduction
Simulation is an active learning approach, and is used in pre-clerkship medical school curricula to teach clinical skills [1]. In addition, simulation supports cognitive integration by providing an explicit, practical application of basic science knowledge in a relevant clinical context [2]. This exposure then serves as a reference point to guide actions that lead to improved patient care delivery and outcomes [3]. During simulation, educators employ standardized patients (SP), people who may or may not be professional actors, and they are instructed on how to act as if they have a particular disease or condition in a health care setting [4]. A recent systematic review suggests that the involvement of children and adolescents in simulation as SP for education and assessment purposes is valuable and feasible [5]. Minors have functioned as SPs in pediatric clinical skills assessments for residents [6] and in third and fourth year of medical school [7], but is less common in the undergraduate medical education curriculum, especially in the pre-clerkship phase.
Pediatrics is a specialized field in medicine, and learners with limited personal experience or exposure to children can find communication, interaction, assessment, and the provision of developmentally appropriate care difficult [8]. The ability to elicit a diagnostically relevant and accurate history is a crucial skill for medical trainees [9]. Medical students are taught clinical skills in their pre-clerkship years of medical school either via modules and videos or on adult patients functioning as SPs [8,10,11]. The few pediatric SP sessions currently published are for clerkship or post-clerkship students [6,7] and other healthcare professional schools [12]. Our medical students attend pre-clerkship preceptor experiences where they see adult patients in their practices. As a result, they get very limited pediatric patient exposure during these real-life experiences. As recommended by other authors, this simulation-based activity was utilized as an adjunct to patient care experiences, and its integration into the curriculum was planned and outcomedriven [13]. In addition, previous groups of second-year medical students requested to include more pediatric topics in their pre-clinical curriculum to help them transition to Pediatric Clerkship in their third year of medical school.
This technical report describes a simulation-based teaching session created for pre-clerkship medical students in the first semester of the second year of medical school to learn how to elicit a pediatric history of a baby where the caregiver is an adolescent SP. These medical students learned how to elicit a complete medical history from an adult during their first year of medical school using adult SP. Eliciting the history from a historian, instead of the patient, is a skill that the pre-clerkship students also must learn. The purpose of our study is to: (1) have second-year medical students obtain a pediatric history, (2) obtain a history from a secondary source, in this case, a parent, and (3) provide exposure to middle and high school students to what happens in medical school.
This article was previously presented as an Oral Presentation at the AAMC Group on Education Affairs (GEA) Virtual Regional Spring Meeting on April 21, 2021.

Technical Report
This simulation session uses middle and high school students as SPs. Recruitment of middle and high school students was done in collaboration with the Office of Diversity at our medical school. This office implements the Community Engagement & Pathway Program at medical academies in middle and high schools in our county. Medical academies in these middle and high schools are designed to provide their students an opportunity to develop the skills needed to compete for, enter, and graduate from health professions schools once they finish high school. Pathway programs have demonstrated increased engagement of high school students from diverse backgrounds in the healthcare professions [14,15]. Similar programs in the US have demonstrated that pathway initiatives that seek to diversify the health professions by providing academic enrichment in the medical sciences and college admissions support to very low-income high school students have been highly successful in reaching low-income students and preparing them for medical and other careers [16]. We approached the members of the Community Engagement and Pathway Program to identify 8 to 10 students from one of the middle or high schools to serve as SPs for our case scenario. The students chosen for this activity were female and proficient in English.
We created an SP scenario ( Table 1) to mimic an interaction between the learner and a parent of a onemonth-old baby with nasal congestion. We developed the simulated scenario for medical students to gain concrete and in-depth knowledge about a specific real-world situation. Our simulated scenario and the involvement of middle and high school students provide several perspectives. First, it enhances the learning experience of the pre-clerkship medical students by obtaining the medical history of an infant from a historian to learn the differences when eliciting a pediatric medical history as compared to an adult history. Second, it provides an opportunity to obtain a history from a caregiver who is not the patient, in this case, a parent. Third, it presents the opportunity for the medical student to demonstrate empathy, especially when dealing with a common chief concern that is usually benign like nasal congestion, which could be easily dismissed by healthcare professionals. Fourth, it illustrates an interactive way to include middle and high school students in the medical school curriculum and, at the same time, enhance their exposure to a medical school environment while functioning as SPs to possibly increase their interest in pursuing a career in medicine.

CASE INFORMATION -Provided by the standardized patient (SP) and only answer if the students asks the specific question.
Setting the interview "The name of the baby is John." You can state your name as the mother or provide another name that you would like to be called.
Establishes patient's comfort You agree to proceed with the interview and medical history of your baby.
Assesses patient's needs You have no time constraint at this time and do not need an interpreter.

Initial information &
identifying data "The name of the baby is John."; "He is one month old." Chief Complaint: The patient's primary reason for seeking care.
"The baby has nasal congestion.", "I was supposed to return for follow up in a few days, but came today because my baby is having congestion, and I thought that something is wrong with him." Other concerns the patient has. "None"

History of Present Illness (HPI):
The SP will be asked about the attributes of a symptom.
You will answer the following for each attribute: "I haven't noticed any rashes or coughing. I noticed clear secretions from the nose for the last week. Nobody at home is sick. He is otherwise acting, eating, sleeping, peeing, and pooping as his usual self."

Review of systems:
No other symptoms noted.

Past medical history
Prenatal and birth history The baby is one month old, and the mother is 16 years old. The baby was born vaginally with no problems. He was born head first and was in labor for about 10 hours. Mother was at home and noticed that water broke after about 8 months of pregnancy.
The fluid was clear, and a lot of it came out. The mother of the SP took her to the hospital. The SP's mother was surprised because she did not know SP was pregnant. Pregnancy was not planned. If female SP: "My periods started when I was 12 years old, and they are regular every 28 days."; "Because the periods are so regular, I suspected that I was pregnant when I missed one. I went to the pharmacy and bought a pregnancy test, and it was positive." Mother had a lot of pain during delivery, and it was bad so they gave her some medicine (epidural) in her back (spine = epidural). No illnesses during pregnancy.
Pregnancy was hidden because the mother did not gain a lot of weight (about 12 pounds) and wore big shirts/sweaters. No alcohol consumption, tobacco or vaping use, or drug use during pregnancy. No prenatal care/did not go to the doctor during pregnancy. They did STD tests were done during labor and were negative. The baby did not require the use of forceps, CPR, or other medical procedures and was born healthy. I don't know what an APGAR score is. The baby was discharged two days after birth and was to see the doctor when the baby was two weeks old. Everything went well at that two-week-old visit. The blood type of the baby is unknown. SP has is type B and a positive Rh factor. The birth weight of the baby was 5lbs and 6 oz., I don't know of any illnesses in the family.

Social history
Birthplace, Marital Status & Living

Conditions
The baby was born in Florida at St. Mary's Hospital one month ago. The mother of the baby is single. The baby lives with the mother and the maternal grandparents of the baby in a house. There are no other adults in the house. John's mother has one younger sister that also lives in the house, who is 11 years old and likes to help care and play with John. The house has three bedrooms, so the baby sleeps in my room in a crib. No pets in the house. No one smokes in the house. Maternal grandparents and help take care of the baby. An aunt of the mother also lives nearby and helps take care of the baby. Maternal grandmother does not work right now and takes care of the baby when the mother attends school during the weekdays. The father of the baby and his parents also come to visit frequently since they also live close by. At the beginning, all grandparents were not very happy about the pregnancy, but now they accepted the situation and are very supportive.
Relationship and education of father and mother The father of the baby goes to the same high school as the mother, and this is how they met. The father of the baby lives with his parents and comes to visit the baby frequently. He is 17 years old, and he is supportive. The father and the mother of the baby are in a relationship.

Diet (describe)
The baby is fed formula and no breast milk. The baby takes 3 to 4 ounces of formula every three hours. We wake the baby up every three hours to feed him. We get WIC (Women, Infants and Children) vouchers, so which helps us cover the cost of the formula.

Exercise (describe) None
Educational and employment history The baby stays with maternal grandmother at home during the day while the mom goes to school.

Personal habits
The baby is eating, sleeping, peeing and pooping as his usual self.

Activities of Daily
Living Baby does not roll over yet, but does move head towards loud noises. Mother has been under stress. She returned to school, so John has been staying at home with the maternal grandmother during the day. It has been hard to adjust because of the school work and the baby waking up at night because he is hungry and wants to be fed.

Physical exam:
The physical exam of the baby or the SP will not be performed in this session.

Differential diagnosis:
For faculty to discuss with the students during the debrief section.

TABLE 1: SP case
Prior to organizing this learning activity, we submitted and received approval from our University's Institutional Review Board. Parental consent and child assent were sought with training as per project protocol. As part of our planning process, the parent(s) of the middle or high school students received a copy of the SP scenario prior to the activity for them to review it and provide consent for their child to participate as an SP. We had two sets of parents who declined to consent due to concerns of sexual history. Once parental consent and child assent were obtained, the SPs received a copy of the scenario and initial training from their school teacher. On the day of the simulation, the students arrived at our institution for additional training. Female students played the role of the SPs in our activity, but the scenario could be converted to having a male parent as the historian. Each SP was asked to carry a baby mannequin wrapped in a blanket to mimic a real-world situation.
We planned and completed the activity in two afternoons, with half of the class of second-year medical students attending each session. We reviewed the checklist ( Table 2) that was provided to the medical students that highlighted the items to be asked of a pediatric patient and their caregivers. They were able to refer to that checklist during the interaction with the SP once inside the exam room. We utilized eight exam rooms, each with one SP. Two medical students were assigned to each room. A faculty member was present in every exam room to observe the interaction of the medical students with the SP.

Inputs and processes
In order to complete this activity, we needed the following resources: Physical Space: Simulation center with eight standardized patient exam rooms, eight infant mannequins, lecture hall Documents: Checklist of benchmarks, SP story, lecture PowerPoint reviewing the pediatric history checklist, "chart" documents for the students to review in advance Staff and Faculty: Staff to recruit and train SPs, partnerships with community public schools, SPs from local middle and high schools, eight faculty to supervise each SP room, one faculty to present the lecture and debrief the session, staff member to run the activity and movements of students and faculty

Pre-briefing
A 30-minute pre-brief session was organized on the day of the session before the interaction with the SP with an MS PowerPoint (Redmond, USA) presentation for the second-year medical students to learn the difference in eliciting a pediatric history and to review the questions in the checklist that the student will be using with the SPs in the exam room. During this time, medical students and faculty were made aware that SPs were adolescent minors with parental consent for the interview process but will not perform a physical exam on the mother or the baby in this simulated case. In addition, each medical student was provided with a "chart" document that has written instructions ( Table 3) before entering the exam room to provide previous medical information about the baby, objectives for the activity and instructions as to how to proceed once inside the exam room were also given. Objectives: By the end of the session, the student should be able to: Identify the differences between eliciting the medical history in pediatric patients as compared to adult patients. Obtain a medical history of an infant from a guardian (teen parent) professionally and respectfully. Incorporate feedback from faculty, peers, and standardized patients to create personal learning/improvement goals for the future.
Instructions: You will be taking a history from a mother who reports that her baby has nasal congestion. The mother, who is the standardized patient, is a middle or high school student. You can use the Pediatric history benchmarks to proceed with the medical history. No physical exam will be conducted in this session.

Case
The simulation-based activity involves a teen mom who brings her baby to be seen at the outpatient pediatric clinic. Two medical students were assigned to enter each exam room to interview the SP who provided the medical history of their baby in the role of a parent/caregiver. Thirty minutes were allotted for the medical student to complete the interview with the SP inside the exam room. The students were given this extended amount of time because it was the first time they had elicited a history from someone other than the patient and their first time obtaining a pediatric history. Instructions were given for one student to elicit the chief complaint, history of present illness, and review of systems, and the second student to elicit the remainder of the history, including past medical history, prenatal history, and social and family history. A faculty member was present in every exam room to observe the interaction of the medical students with the SP. The faculty avoided interrupting their interaction for the first 30 minutes and provided formative feedback to medical students in the last 15 minutes of the activity inside the exam room. The students' performance was assessed with a formative evaluation by the faculty using the Yes or No checkboxes on the checklist. The SP did not provide feedback to the medical students. After 45 minutes, all medical students and faculty returned to the main lecture room to debrief the activity and answer any questions.

Debrief
In debrief, we established a safe and confidential space for students and faculty to present their experiences during the simulation-based activity. The debrief process aimed to solicit the experience of the medical students when interacting with an adolescent, eliciting information from a caregiver, and the differences in obtaining a medical history in a pediatric experience compared to an adult. These debrief also allowed the identification of the impact of the experience, gaps in knowledge, and process errors.

Outcomes
The second-year medical students that participated in the activity completed an evaluation of eight questions utilizing a 5-point Likert scale and one qualitative question for students to write additional feedback. To evaluate the experience of the SPs, one of the authors met with all SPs after the completion of each session to debrief. As mentioned in the literature, group debriefing may benefit adolescents [17]. Their teacher also accompanied the SPs during this period. A group of 64 pre-clerkship medical students completed the activity. Fifty-one students (80%) completed the evaluation form. The activity was well received, as noted in Table 4.
Rate the extent that:

Average score
The objectives of the clinical skills session were clear.

4.30
The clinical skill session helped me refine my history taking skills.

4.22
The introduction to the pediatric history was relevant to my medical education.

4.20
The time allotted to the clinical skills encounter was sufficient.

4.16
The online resources were helpful for this session. 4.08 The clinical skills faculty provided helpful feedback.

4.42
The structure and organization of the session was appropriate for practicing history taking from a pediatric patient.

4.00
This session has improved my understanding of the pediatric history. 4.00  The qualitative question provided positive responses, including: "I learned how to take the history of a newborn pediatric patient via the mother or guardian. I also learned to make sure to focus on the newborn instead of the mother as the patient." "It was good to have middle school students be our SPs for today's session because it gave some perspective in terms of the expected medical literacy and also the experience of talking to someone younger." The meeting with the SPs at the end of the activity resulted in three main topics: 1. They enjoyed the field trip to the College of Medicine and exposure to the facility, being an SP, the learning environment that mimics a medical office, and the interaction with the medical students, staff, and faculty.
2. They agreed that training medical students on how to elicit a history of a pediatric patient are imperative and that the use of SPs as a vehicle to accomplish that goal makes it engaging and memorable before meeting a real adolescent in the clinical years.
3. They realized that pregnancy and parenting as a teenager can create a significant lifestyle change.
Middle and high school students were used as caregiver SPs to enhance the training of medical students in the pre-clerkship years. The benefits to the middle and high school students that functioned as SPs included learning outside the standard classroom environment and exposure to a medical school environment, which could lead to an interest in pursuing a career in the healthcare professions. We included middle and high school students from underrepresented groups in public schools in our simulation-based activity, but students from different backgrounds or other schools (private or charter schools) could be asked to be the SPs.

Discussion
We began this study wanting to prepare a simulation-based activity with the goal of (1) having students obtain a pediatric history, (2) obtaining a history from a secondary source, in this case, a parent, and (3) providing exposure to middle and high school students to what happens in medical school. As demonstrated in our results, students found this session to be helpful to their understanding of pediatric history and felt that the experience was relevant to their medical education. They also felt the format and use of middle and high school students helped meet the learning objectives. The SPs also felt that the session was worthwhile. However, there were some limitations to the session: (1) Parental consent. A larger group of middle and high school students must be available to account for the situation when parents may not consent to the script; (2) As middle and high school students are not professional SPs, it requires a relatively simple story/scenario to which they can relate easily; (3) The physical exam was not performed in this activity to avoid issues with examining minors;