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 were introduced into the medical education literature in a detailed format by Barrows (1971). For Barrows, a simulated patient is a healthy person who has been trained to portray the historical, physical and emotional features of an actual patient. Simulated patients are based on actual case histories, not an amalgam or ‘ideal’ case developed for teaching or assessment purposes. Lay people, often with prior theatrical experience, are trained to portray all aspects of a real case. After training, the simulated patients are checked for accuracy by an experienced clinician before being used with students. Once trained, simulated patients are used in a structured way in student education, most commonly as a bridge into working in clinics, or in assessment.
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).
In developing our simulated patient programme we adhered closely to the Barrows model. Other users have modified the original concept, often altering the case, training or presentation to suit their philosophy or circumstances. Recently, excellent innovations with simulated patients have emerged. Kneebone et al (2005) described a successful quasi-clinical education experience for medical students whereby invasive clinical procedures (e.g. insertion of a catheter) were rehearsed with a simulated patient (for the communication and interpersonal skills component) who had an inanimate model attached (for the technical/motor skill component).
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.
The most important reason for teachers to use simulated patients is to manage and control aspects of the clinical learning environment, including programming, level of content, environment, ethics and safety, economy and reproducibility. The process of ‘time out’ and feedback from the simulated patients improves the educational experience for students. Enormous pressure is placed on university programmes to ensure their students meet high preclinical standards (Rose 2005) in the face of reduction in the number of clinical education opportunities for students and the stress of the clinical education role and workplace. Our rationales for developing a simulated patients programme were to better prepare students for clinical settings and to reduce the variability and lack of control in clinical teaching.
Using simulated patients enables teachers to programme student/patient interactions to suit the curriculum. Teachers can select a particular case, nominate the time to study that case, and be reasonably assured that the interaction will actually occur at the scheduled time and with the designated case. The teacher can predetermine the level of clinical reasoning involved in the learning activity. In real clinics, plans are frequently disrupted by reality (for example, the patient has disappeared to the X-ray department!). Using simulated patients results in efficient and effective use of teachers’ and students’ time.
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.
Using simulated patients allows teachers to be prescriptive and to use educational theory to select an encounter that best suits the students’ learning needs. Such prescription is in stark contrast to real clinical situations where learning is often haphazard. By manipulating variables, clinical reasoning can be taught in appropriately small chunks, at a pace that matches students’ learning and level of experience. Students are still expected to cope with and adapt to the unexpected and to be flexible in the clinical setting, but with simulated patients the teacher can control when and how students have to be flexible.
Simulated encounters allow control over the type of environment in which clinical encounters take place. Thus at certain times teachers may wish students to have to deal with noisy, distracting or threatening environments, while at other times teachers may create an environment as conducive as possible to a successful encounter. Teachers can set up hospital-like environments, outpatient clinics, home based situations and so on, to best meet the learning goal. By comparison, in the real clinical setting, teachers must deal with whatever happens to be present.
The use of simulated patients simplifies some aspects of ethics and safety in clinical practice. Since simulated patients do not really have the conditions for which they are being assessed or treated, they can be used for long sessions or exposed to many repetitions of the same procedure, neither of which would be ethical or practical with real patients. It is possible to have a number of students working with one simulated patient, an economic use of time that may reduce expenditure. Teachers can have greater confidence that every student working with a particular simulated patient is receiving the same kind of clinical experience. Simulated patients are trained to accurately reproduce their symptoms, case histories and psychosocial backgrounds across different encounters. They are therefore predictable and consistent over time. Real patients are far from this!
Using time out in working with simulated patients is of great benefit when teaching clinical reasoning. Students or teachers can call ‘time out’ at any point during an encounter with a simulated patient, to break from the interaction and seek assistance/feedback/reassurance from peers or the facilitator. During time out the simulated patient freezes, staying in role but not interacting with the student until ‘time in’ is called. At that point the encounter resumes as though there had been no break in the interaction. Time out is used for discussion, group input, problem solving and reviewing performance. Students are often able to reason creatively about the current situation, resume with new strategies and then complete a more successful encounter, thereby increasing their confidence.
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).