Chapter 40 Using simulated patients to teach clinical reasoning
In this chapter we describe how and why we have used simulated patients to teach clinical reasoning. We focus on the reality for teachers and for students of using simulated patients, and on the processes required to make a simulated patient programme work.
Simulated patients have been used in a range of healthcare professions to teach and assess a wide variety of clinical skills – interviewing and counselling, data gathering, performing physical examinations, conducting psychosocial assessments and developing skills in clinical reasoning and decision making. The American Medical Association reported in 2001 that simulated/standardized patients were used in instruction in US medical schools for history taking (106 schools), doctor–patient communication (104), general physical examination skills (93) and specialized physical exams (e.g. gynaecological) (114) (Williams et al 2001). Other examples worldwide include assessing Finnish general practitioners’ abilities to conduct first contraception consultations (Peremans et al 2005); educating American medical students to recognize biopsychosocial issues (e.g. family violence) during patient interviews (Elman et al 2004); teaching communication skills to British undergraduate medical students (Rees et al 2004); assessing the professional performance of Scottish community pharmacists (Watson et al 2004); and developing the cultural competence of medical students working with French speaking minority groups in Canada (Drouin & Rivet 2003).
REASONS FOR USING SIMULATED PATIENTS
The use of simulated patients has been supported in the literature over many years. Gordon et al (1988) reported that experienced clinicians could not differentiate between real and simulated patients during history taking or physical examination. Students relate well to simulated patients (Sanson-Fisher & Poole 1980). Reporting on a comprehensive assessment programme at Southern Illinois School of Medicine, Vu et al (1992) concluded that the use of simulated patients increased the feasibility, validity, reliability and utility of performance based examinations. Ainsworth et al (1991) used simulated patients in all years of the medical course at the University of Texas for teaching and assessment, in introduction to patient evaluation, history taking and physical examination skills, integrating clinical skills, clinical clerkship, demonstration of competence, senior assessment and during the postgraduate medicine residency. Wallace et al (2002) focused on use of simulated patients in objective structured clinical examinations and psychiatry. Although papers such as these convince us of the value of simulated patients, it needs to be emphasized that simulated patients are not a replacement for real patients. Rather, simulated patients are an educational tool used to develop and refine students’ clinical skills, as they progress to becoming competent practising clinicians.
MANIPULATING PROGRAMMES AND CONTENT
Teachers using simulated patients can be specific about the type of encounter offered to students. This is achieved by manipulating the type and complexity of disorder to be studied, the level of interpersonal and reasoning skill required for a successful interaction, the complexity of the therapeutic/assessment task, the duration of the encounter, and whether the student deals with a part of or the whole of a treatment or assessment session. Novice students can be given a theoretically less complex disorder in their early encounters with clinical reasoning, in order to build confidence. Teachers can match levels of theory acquisition to practice. Rehearsal of specific skills such as interviewing can be achieved without overwhelming students by the complexity of patients’ disorders. Teachers may wish to specifically challenge students’ interpersonal skills, for example offering them an encounter that will test their ability to keep a patient motivated.
SIMULATED PATIENTS IN ACTION
Time out
Students can also trial various interventions, call time out, receive some feedback or have time to reflect, and then try again with a different approach. Time out is a rich opportunity for developing clinical reasoning. Details are fresh in students’ minds, there is space to reflect and there is the opportunity to resume immediately and try again, rather than having to wait until the next real patient encounter (and perhaps develop some performance or anticipation anxiety in the meantime).
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