Patient instructor

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Simulated patient

A simulated patient or standardized patient (SP) (also known as a patient instructor), in health care, is an individual who is trained to act as a real patient in order to simulate a set of symptoms or problems. Simulated patients have been successfully used in medical education, evaluation, and research.

History

Dr. Howard Barrows trained the first standardized patient in 1963 in University of Southern California. This SP simulated the history and examination findings of a paraplegic multiple sclerosis patient. Dr Barrows also developed a checklist that the SP could use to evaluate the performance of the trainee. Dr. Paula Stillman trained another set of standardized patients in 1970 at the University of Arizona. Her pilot program had local actors portray the "mothers" of imaginary children. The actors would describe the illness the unseen child was suffering from, requiring the medical students taking the history to develop differential diagnoses based on the mother's testimony. In 1984, a number of residency programs in the northeastern U.S. gave their residents the same examination using SPs. Medical Council of Canada was the first to use SPs in a licensure examination in 1993. The Educational Commission for Foreign Medical Graduates introduced the Clinical Skills Assessment exam in 1998 to test the clinical skills of foreign medical graduates. This exam is now the USMLE Step 2 Clinical Skills exam and is mandatory for obtaining medical licensure in the United States, for both foreign medical graduates and American medical students.

Uses

Simulated patients are extensively used in medical education to allow medical students to practice and improve their clinical and conversational skills for an actual patient encounter. SPs commonly provide feedback after such encounters. They are also useful to train medical students to learn professional conduct in potentially embarrassing situations such as pelvic or breast exams. SPs are also used extensively in testing of clinical skills of medical students, usually as a part of an Objective Structured Clinical Examination. Typically, the SP will use a checklist to record the details of the encounter.

Standardized patients have also been sent unannounced in physician practices to evaluate standards of care. They are also employed in medical informatics research.

Advantages

The use of simulated patients has several advantages.

Convenience: SPs are able to provide cases that are needed at the time they are needed. They are likely to be more reliable, and may tolerate more students than real patients.
Standardization: The use of standardized clinical scenarios allows direct comparison of the students' clinical skills, locally as well as nationally and internationally.
Compression/expansion of time: SPs can provide a longitudinal experience and enable students to follow through patients over time, even in a compressed time frame of examination. One technique employed in SP encounters is the use of information cards. When the trainee or examinee articulates the need for an examination or a laboratory test, the SP hands him/her a small card with the results of that exam/test, and the encounter can continue.
Safety: SP encounters allow students to learn about situations they may not be able to manage alone in a real clinical setting, or where the use of a real patient may be inappropriate. For example, counseling a cancer patient.
Efficiency: The monitoring of students by SPs reduces the need for supervision of medical students by physician faculty during clinical encounters.

Limitations

At the same time, SPs are case specific and are able to assess clinical competency in a limited area only. Multiple encounters may be needed for broad ranged training or testing. Also, while SPs are quite proficient in simulating the symptoms, emotional states and even certain examination findings (neurological examination, for example), they may not be able to simulate certain other signs such as heart murmurs or lung sounds. Recruitment of SPs may also be difficult, time consuming and more expensive than using 'real' patients.

Recruitment

Simulated patients are often recruited from among local amateur or professional actors, through advertisements in local newspapers, or by word of mouth. Graduate students in nearby universities may also agree to take up these roles, especially if the position is paid. SPs need to draw on their own personal experiences with physicians, conversations with healthcare professionals, talking to specific patient populations etc. They also need to be trained to accurately and reliably simulate particular clinical scenarios. Frequent quality assessment may be needed to ensure consistency in the portrayal of the patient role, especially since SPs may absorb quite a significant amount of clinical knowledge during their interactions with healthcare professionals.