Simulated/standardized patients
Introduction
Lay people who have been trained to portray patients have come under many names since the 1960s. Initially they were called programmed patients, followed by simulated patients in the 1970s. When used for assessment of medical students, they came to be known as standardized patients and then, in good medical acronym fashion, came the term SP. The term ‘standardized’ eventually replaced the original term ‘simulated’ to reinforce the fact that the patient’s situation can be made fundamentally the same for every student encounter. This terminology is attributed to Canadian psychometrician Geoffrey Norman (Wallace 1997). People who are portraying parents or relatives of a patient, or other healthcare members in a clinical situation who are not the patient, are termed standardized participants (Monaghan et al 1997).
A standardized patient is always simulating, but a simulated patient is not always standardized.In this chapter, SP will be used interchangeably to mean standardized patient, simulated patient or standardized participant.
SPs are particularly useful for teaching beginning students who are developing their interviewing and examination skills in preparation for interactions with real patients. Medical students often lack clinical experience with real patients. By learning through realistic SP scenarios, they increase their experience, and faculty are able to see how students practically use their new knowledge. With SPs, students can learn to take a patient history and perform a physical exam in a structured and efficient manner. Students learn to ask questions about medical, surgical and social histories in a systematic way. SPs are also helpful with upper-level students, assuring that what has been taught in the curriculum has been integrated by students ready to go out into practice.
In what areas of your curriculum would SPs enhance a student’s understanding and proficiency?What can an SP do?
“An SP is defined as a person who has been carefully coached to simulate an actual patient so accurately that the simulation cannot be detected by a skilled clinician.”The best way to see if a medical student can perform a medical interview or physical exam in a correct way is to observe them as they interview or examine a patient. Any student who works with patients will behave in the same way with an SP as they do in the actual clinic setting. This accurate reflection of their actions, decisions and behaviours has been thoroughly researched and validated by many professionals (Barrows 1993). Since it can be difficult to find real patients with the diseases and findings necessary for students to see, using SPs guarantees that students study the preferred patient cases. An added benefit of using SP cases is the ability to schedule them as needed.
The SP can also score a communication checklist based on his or her experience during the encounter with the student. For example, the SP can comment on a student’s degree of caring or lack of eye contact, based on the SP’s experience during the encounter.
In general, the use of SPs allows faculty control of clinical content and assurance that patients are available on schedule. In addition, using SP cases is:
• Convenient: available anytime, any place
• Reliable: cases are standardized and reproducible
• Valid: comparable to real patients
• Controllable: faculty can adjust the learning objectives
• Realistic: faculty can integrate psychosocial issues into a case
• Corrective: learner can receive feedback immediately
• Practical: learners can practise invasive exams (pelvic or breast exams)
• Repeatable: learners can rehearse clinical situations they are not ready to manage alone
• Measurable: learners’ performances can be compared
• Safe: inconvenience, discomfort or potential harm to real patients are limited
• Efficient: may provide a longitudinal experience in a compressed time frame and reduce time demands on physician teaching faculty.
SPs are used in many medical schools around the world as well as other healthcare educational programmes including pharmacy, nursing and dentistry. Any healthcare team members who interact with patients can benefit from working with an SP in order to evaluate how they actually work with patients in their field.
If an institution has an SP programme, then a valuable resource is already available. Contacting the institution’s SP educator can save time and make case and curriculum development a much easier process.
If the institution does not have an SP programme, it is still worth the time and effort to use an SP to teach medical students how to conduct an interview, communicate with a patient or family member and examine a patient. It is also helpful to teach clinical reasoning and can take a student through an entire disease state from diagnosis to treatment and follow-up. This can all be completed in 2 hours instead of 2 weeks, 2 months or longer.
What kind of patient cases would translate to SP methodology?How to use an SP
Finding a person who becomes a successful SP is not always easy. Recruitment requires imagination! Most programmes start small and gradually build a pool of well-trained and dependable SPs. It is necessary to find people who are intelligent and can understand that this work is educational. The use of people from outside the institution creates a better outcome of a realistic encounter for the learner. When students know the SP, whether a colleague or the staff secretary, they are less likely to take the simulation seriously. People outside of the medical profession can easily be trained to portray cases without having an understanding of medical knowledge. Friends, neighbours and family members who are interested in the programme’s success are often a good initial source for recruitment.
Retired teachers and educators make excellent SPs because they understand educational objectives. Other reliable SPs have been homemakers, students in undergraduate non-medical programmes, health club members, part-time teachers, waiting staff and actors. Use caution when using actors as SPs. This work is not about their ego or applause, but is strictly about education. Actors working as SPs must clearly understand that their role is in the field of education, not theatre.
A good SP is intelligent and can understand that SP work is about education, not entertainment.
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