Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review

Are simulated patients effective in facilitating development of clinical competence for healthcare students? A scoping review

Background

The need to evaluate the effectiveness of SPs in improving clinical competence has attracted a heightened interest across the healthcare professions, with some prevailing gaps in their evidence. Using a scoping review approach, this study aims to provide an overview on the effectiveness of SPs in facilitating the development of clinical competence for healthcare students.

Methods

This scoping review applied the first five out of the six-stage methodological framework developed by Levac et al. (Implementation Science 5:69), as follows: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The search was performed on four databases, including Medline, EMBASE, CINAHL and Scopus.

Results

A total of 33 articles were included in this study (out of 968 identified), comprising of 20 cross-sectional studies, eight randomised controlled trials and five longitudinal studies. The studies were examined and categorised for further discussion in the three domains of clinical competence; technical, non-technical and cognitive skills. Overall, 24 out of 33 studies showed effectiveness of SPs in facilitating students’ clinical competence.

Conclusion

This scoping review serves to provide guidance for future healthcare education development, by illustrating the effectiveness of SPs in improving students’ clinical competence as evidenced in the literature. In doing so, it highlights the potential of SPs in facilitating students’ acquisition of the necessary skills for clinical practice.

Introducing simulation-based education to healthcare professionals: exploring the challenge of integrating theory into educational practice

BACKGROUND

Introducing simulation-based education to the curricular programme of healthcare professionals can be challenging. This study explored the early experiences of healthcare professionals in the use of simulation. This was in the context of the Kuwait-Scotland transformational health innovation network programme.

METHODS

Two cohorts of healthcare professionals undertook a simulation module as part of faculty development programme in Kuwait. Participants' initial perceptions of simulators were gathered using a structured questionnaire in the clinical skills centre. Their subsequent ability to demonstrate the application of simulation was evaluated through analyses of the video-recordings of teaching sessions they undertook and written reflections of their experiences of using simulation.

RESULTS

In theory, participants were able to identify simulators' classification and fidelity. They also recognised some of the challenges of using simulators. In their teaching sessions, most participants focused on using part-task trainers to teach procedural skills. In their written reflections, they did not articulate a justification for their choice of simulator or its limitations.

CONCLUSION

This study demonstrated a theory-to-practice gap in the early use of simulation by healthcare educators. The findings highlight the need for deliberate practice and adequate mentorship for educators to develop confidence and competence in the use of simulation as part of their educational practice.

Perception of Simulation-based Learning among Medical Students in South India

Background:

Traditional methods of educating medical students are no longer sufficient in the current era largely influenced by multimedia. Simulation-based techniques may play a pivotal role in bridging this educational gap.

Aim:

This study was conducted to explore the perception of medical students towards simulation based learning (SBL).

Subjects and Methods:

This cross-sectional study was conducted in May 2013 in a private medical college in Mangalore, Karnataka, India. A total of 247 participants from fourth, sixth, eighth semester and internship were chosen by convenience sampling method. Attitudinal data on perception towards SBL were collected using a self-administered questionnaire with responses in a 5-point Likert's scale.

Results:

The mean age of students was 21.3 (standard deviation 1.9) years, and males constituted 55.5% (137/247). Most participants 72.5% (179/247) had favorable perceptions of SBL, with scores of92–118 out of a possible 118 points. Favorable perception towards SBL was seen significantly more among female students (P = 0.04) and senior MBBS students of sixth and eighth semesters (P = 0.05). Nearly, all students (90.7%; 224/247) agreed that simulation supports the development of clinical skills. As many as 29.6% (73/247) agreed that real patients might be replaced with simulated patients in practical examinations.

Conclusion:

SBL was perceived as favorable by a large number of participants in this study indicating a bright prospect for its implementation in the medical curriculum.

Presence with purpose: attitudes of people with developmental disability towards health care students

CONTEXT

Early clinical encounters help medical and nursing students build professional competencies. However, there is a necessary emphasis on patient autonomy and appropriate consent. Although most individuals do not object to student involvement in clinical encounters, there are occasions when personal preference and health care education conflict. Many studies have evaluated patient attitudes towards students across a variety of specialties.

OBJECTIVES

The purpose of this study was to identify the attitudes, comfort level and preferences of individuals with developmental disability (DD) towards the presence and involvement of medical and nursing students during clinical encounters.

METHODS

Adults with DD across the Hamilton-Niagara region were invited to participate. Focus groups were moderated by two students with a health care facilitator and physician-educator. Participants were provided with focus group questions in advance and encouraged to bring communication aids or care providers. Data were analysed for emerging themes by two independent reviewers, who then compared results.

RESULTS

Twenty-two individuals participated. A wide range of opinions were expressed. Some participants were positively disposed towards students and perceived better care and improved communication with the health care team. Others were indifferent to students in a clinical setting. The final group was opposed to the presence of health care students, expressing confusion over their role and purpose, uneasiness with deviation from the norm, and concerns about confidentiality. Informative introductions with confidentiality statements and the presence of a supervising clinician were seen as helpful.

CONCLUSIONS

People with DD are affected by above-average health care needs. Their input into health care planning has been limited. Their opinions on health care learners varied considerably. Themes relating to attitudes, comfort and preferences about student involvement provide impetus for health care training practices that promote person-centred approaches and improvements to the quality of care received by people with DD.

Engaging Students: Using Video Clips of Authentic Client Interactions in Pre-Clinical Veterinary Medical Education

The present study evaluated third-year veterinary medical students' perceptions of a communication lab protocol. The protocol used clips of fourth-year veterinary medical students working with authentic clients. These clips supplemented course material. Clips showed examples of proficient communication as well as times of struggle for fourth-year students. Third-year students were asked to critique interactions during class. One hundred and eight third-year students provided feedback about the communication lab. While initial interest in communication proved low, interest in communication training at the end of the course increased substantially. The majority of students cited watching videos clips of authentic client interactions as being an important teaching tool.

Study of the impacts of patient-educators on the course of basic sciences in dental studies

Ever since 2006, Nantes University dental educators have started organising lectures led by the mother of a young patient suffering from ectodermic dysplasia (patient-educator) to help second-year students to better understand how important it is for their future dental work to better understand basic sciences. In this study, we have analysed this training experience on students' motivation. For this purpose, students were asked to complete questionnaires 10 days after the patient-educator's lecture (early assessment; n = 193) and 4 years later, during the last year of their dental studies (delayed assessment; n = 47). Moreover, 3 years after the first lecture, we analysed the ability of students to diagnose a mother carrying the ectodermic dysplasia genetic disorder, using a case-based learning exercise with a patient showing dental features similar to those exposed by the patient-educator (measure of knowledge; n = 42). Ten days after the lecture, the early assessment shows that all the students were interested in the lecture and 59% of the students declared being motivated to find out more about genetics whilst 54% declared the same thing about embryology courses. Moreover, 4 years later, 67% of the students remembered the patient-educator's lecture a little or very well. Three years after the course, 83% of the students diagnosed ectodermal dysplasia whilst studying the case-based example that listed typical dental phenotypes. In conclusion, this study shows that this original educational approach enhances dental students' motivation in learning basic sciences and that patient-educators could offer many benefits for students and patients.

Managing the complexity of doing it all: an exploratory study on students' experiences when trained stepwise in conducting consultations

BACKGROUND

At most medical schools the components required to conduct a consultation, medical knowledge, communication, clinical reasoning and physical examination skills, are trained separately. Afterwards, all the knowledge and skills students acquired must be integrated into complete consultations, an art that lies at the heart of the medical profession. Inevitably, students experience conducting consultations as complex and challenging. Literature emphasizes the importance of three didactic course principles: moving from partial tasks to whole task learning, diminishing supervisors' support and gradually increasing students' responsibility. This study explores students' experiences of an integrated consultation course using these three didactic principles to support them in this difficult task.

METHODS

Six focus groups were conducted with 20 pre-clerkship and 19 clerkship students in total. Discussions were audiotaped, transcribed and analysed by Nvivo using the constant comparative strategy within a thematic analysis.

RESULTS

Conducting complete consultations motivated students in their learning process as future physician. Initially, students were very much focused on medical problem solving. Completing the whole task of a consultation obligated them to transfer their theoretical medical knowledge into applicable clinical knowledge on the spot. Furthermore, diminishing the support of a supervisor triggered students to reflect on their own actions but contrasted with their increased appreciation of critical feedback. Increasing students' responsibility stimulated their active learning but made some students feel overloaded. These students were anxious to miss patient information or not being able to take the right decisions or to answer patients' questions, which sometimes resulted in evasive coping techniques, such as talking faster to prevent the patient asking questions.

CONCLUSION

The complex task of conducting complete consultations should be implemented early within medical curricula because students need time to organize their medical knowledge into applicable clinical knowledge. An integrated consultation course should comprise a step-by-step teaching strategy with a variety of supervisors' feedback modi, adapted to students' competence. Finally, students should be guided in formulating achievable standards to prevent them from feeling overloaded in practicing complete consultations with simulated or real patients.

The educational value of improvisational actors to teach communication and relational skills: perspectives of interprofessional learners, faculty, and actors

OBJECTIVE

To assess the educational value of improvisational actors in difficult conversation simulations to teach communication and relational skills to interprofessional learners.

METHODS

Surveys of 192 interprofessional health care professionals, and 33 teaching faculty, and semi-structured interviews of 10 actors. Descriptive statistics, Fisher's exact test and chi-square test were used for quantitative analyses, and the Crabtree and Miller approach was used for qualitative analyses.

RESULTS

191/192 (99.5%) interprofessional learners (L), and 31/33 (94%) teaching faculty (F) responded to surveys. All 10/10 actors completed interviews. Nearly all participants found the actors realistic (98%L, 96%F), and valuable to the learning (97%L, 100%F). Most felt that role-play with another clinician would not have been as valuable as learning with actors (80%L, 97%F). There were no statistically significant differences in perceived value between learners who participated in the simulations (47%) versus those who observed (53%), or between doctors, nurses, or psychosocial professionals. Qualitative assessment yielded five actor value themes: Realism, Actor Feedback, Layperson Perspective, Depth of Emotion, and Role of Improvisation in Education. Actors independently identified similar themes as goals of their work.

CONCLUSIONS

The value attributed to actors was nearly universal among interprofessional learners and faculty, and independent of enactment participation versus observation. Authenticity, feedback from actors, patient/family perspectives, emotion, and improvisation were key educational elements.

Teaching communication skills in clinical settings: comparing two applications of a comprehensive program with standardized and real patients

BACKGROUND

Communication is important for the quality of clinical practice, and programs have been implemented to improve healthcare providers' communication skills. However, the consistency of programs teaching communication skills has received little attention, and debate exists about the application of acquired skills to real patients. This study inspects whether (1) results from a communication program are replicated with different samples, and (2) results with standardized patients apply to interviews with real patients.

METHODS

A structured, nine-month communication program was applied in two consecutive years to two different samples of healthcare professionals (25 in the first year, 20 in the second year). Results were assessed at four different points in time, each year, regarding participants' confidence levels (self-rated), basic communication skills in interviews with standardized patients, and basic communication skills in interviews with real patients. Data were analyzed using GLM Repeated-Measures procedures.

RESULTS

Improvements were statistically significant in both years in all measures except in simulated patients' assessment of the 2008 group. Differences between the two samples were non-significant. Differences between interviews with standardized and with real patients were also non-significant.

CONCLUSIONS

The program's positive outcomes were replicated in different samples, and acquired skills were successfully applied to real-patient interviews. This reinforces this type of program structure as a valuable training tool, with results translating into real situations. It also adds to the reliability of the assessment instruments employed, though these may need adaptation in the case of real patients.

Bedside teaching in medical education: a literature review

Bedside teaching is seen as one of the most important modalities in teaching a variety of skills important for the medical profession, but its use is declining. A literature review was conducted to reveal its strengths, the causes of its decline and future perspectives, the evidence with regard to learning clinical skills and patient/student/teacher satisfaction. PubMed, Embase and the Cochrane library were systematically searched with regard to terms related to bedside teaching. Articles regarding the above-mentioned subjects were included. Bedside teaching has shown to improve certain clinical diagnostic skills in medical students and residents. Patients, students/residents and teachers all seem to favour bedside teaching, for varying reasons. Despite this, the practice of bedside teaching is declining. Reasons to explain this decline include the increased patient turnover in hospitals, the assumed violation of patients' privacy and an increased reliance on technology in the diagnostic process. Solutions vary from increasingly using residents and interns as bedside teachers to actively educating staff members regarding the importance of bedside teaching and providing them with practical essentials. Impediments to bedside teaching need to be overcome if this teaching modality is to remain a valuable educational method for durable clinical skills.

Patient-centred education: what do students think?

CONTEXT

Medical educators endeavour to foster patient-centred learning. Although studies of patient-educators report general increases in patient-centredness, no formal review of students' reflections on the role of patients in their education has yet been undertaken. Our research questions were: (i) What themes might be identified through a qualitative analysis of students' reflective writing on patient-centred education? (ii) What are common students' perceptions regarding patients as educators?

METHODS

For two academic years, Year 2 pre-clinical students (189 and 167 students, respectively, in each academic year) submitted a 250-word writing assignment in response to one of four questions meant to promote reflection on the role of patients in their education. Using a grounded theory approach, we performed a qualitative analysis of these written reflections for emerging themes. A synthesis of these themes was prepared and was presented for validation and discussion by two focus groups of six and three students, respectively. We analysed the transcripts of the focus group discussions and compared them with results from the analysis of written reflections and used them to further inform and refine our initial thematic framework.

RESULTS

A total of 356 reflective writing assignments were analysed. The major themes were: (i) students seeing the condition within the context of patients' lives; (ii) patients supporting students' learning; (iii) students recognising patients' needs; (iv) students seeing the patient as a capable part of the team, and (v) students recognising the complexity of practising medicine. The two focus group discussions confirmed these main themes, but placed greater emphasis on the first and second themes. These themes mapped closely to the conceptualisation of patient-centred care defined by the International Alliance of Patients' Organizations.

CONCLUSIONS

Students' reflections on their experiences of patient-educators cover an important and broad range of key concepts in patient-centred care that are well aligned with patient-generated conceptualisations of patient-centred care.

Simulation in healthcare: a taxonomy and a conceptual framework for instructional design and media selection

BACKGROUND

Simulation in healthcare lacks a dedicated framework and supporting taxonomy for instructional design (ID) to assist educators in creating appropriate simulation learning experiences.

AIMS

This article aims to fill the identified gap. It provides a conceptual framework for ID of healthcare simulation.

METHODS

The work is based on published literature and authors' experience with simulation-based education.

RESULTS

The framework for ID itself presents four progressive levels describing the educational intervention. Medium is the mode of delivery of instruction. Simulation modality is the broad description of the simulation experience and includes four modalities (computer-based simulation, simulated patient (SP), simulated clinical immersion, and procedural simulation) in addition to mixed, hybrid simulations. Instructional method describes the techniques used for learning. Presentation describes the detailed characteristics of the intervention. The choice of simulation as a learning medium is based on a matrix of simulation relating acuity (severity) to opportunity (frequency) of events, with a corresponding zone of simulation. An accompanying chart assists in the selection of appropriate media and simulation modalities based on learning outcomes.

CONCLUSION

This framework should help educators incorporate simulation in their ID efforts. It also provides a taxonomy to streamline future research and ID efforts in simulation.

Minding the gap between communication skills simulation and authentic experience

CONTEXT

Concurrent exposure to simulated and authentic experiences during undergraduate medical education is increasing. The impact of gaps or differences between contemporaneous experiences has not been adequately considered. We address two questions. How do new undergraduate medical students understand contemporaneous interactions with simulated and authentic patients? How and why do student perceptions of differences between simulated and authentic patient interactions shape their learning?

METHODS

We conducted an interpretative thematic secondary analysis of research data comprising individual interviews (n = 23), focus groups (three groups, n = 16), and discussion groups (four groups, n = 26) with participants drawn from two different year cohorts of Year 1 medical students. These methods generated data from 48 different participants, of whom 17 provided longitudinal data. In addition, data from routinely collected written evaluations of three whole Year 1 cohorts (response rates ≥ 88%, n = 378) were incorporated into our secondary analysis dataset. The primary studies and our secondary analysis were conducted in a single UK medical school with an integrated curriculum.

RESULTS

Our analysis identified that students generate knowledge and meaning from their simulated and authentic experiences relative to each other and that the resultant learning differs in quality according to meaning created by comparing and contrasting contemporaneous experiences. Three themes were identified that clarify how and why the contrasting of differences is an important process for learning outcomes. These are preparedness, responsibility for safety, and perceptions of a gap between theory and practice.

CONCLUSIONS

We propose a conceptual framework generated by reframing common metaphors that refer to the concept of the gap to develop educational strategies that might maximise useful learning from perceived differences. Educators need to 'mind' gaps in collaboration with students if synergistic learning is to be constructed from contemporaneous exposure to simulated and authentic patient interactions. The strategies need to be tested in practice by teachers and learners for utility. Further research is needed to understand gaps in other contexts.

Using authentic client interactions in communication skills training: predictors of proficiency

Communication training has become a focus of concern in recent years in veterinary medicine. Existing literature to date indicates that Colleges of Veterinary Medicine (CVMs) have implemented various communication training protocols. The present study focused on the evaluation of a communication training protocol implemented in 2007 at Kansas State University (KSU) in a sample of veterinary medical students (N=415) across five cohorts. The protocol includes video review of authentic client interactions, feedback from authentic clients, and small-group communication training. Findings indicate that targeted communication skills improved through video-review feedback and small-group communication training. Communication scores were particularly affected by students' attention to improving communication deficiencies during a second student-client video. Baseline scores from the first student-client video in four specific areas (using nonverbal communication, setting expectations, building rapport, and being able to clarify) were predictive of overall performance during the second evaluation. Based on the results of the present study, using videos of authentic client interactions is recommended as a valuable communication training teaching tool.

Comparative effectiveness of instructional design features in simulation-based education: systematic review and meta-analysis

BACKGROUND

Although technology-enhanced simulation is increasingly used in health professions education, features of effective simulation-based instructional design remain uncertain.

AIMS

Evaluate the effectiveness of instructional design features through a systematic review of studies comparing different simulation-based interventions.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. We included original research studies that compared one simulation intervention with another and involved health professions learners. Working in duplicate, we evaluated study quality and abstracted information on learners, outcomes, and instructional design features. We pooled results using random effects meta-analysis.

RESULTS

From a pool of 10,903 articles we identified 289 eligible studies enrolling 18,971 trainees, including 208 randomized trials. Inconsistency was usually large (I2 > 50%). For skills outcomes, pooled effect sizes (positive numbers favoring the instructional design feature) were 0.68 for range of difficulty (20 studies; p < 0.001), 0.68 for repetitive practice (7 studies; p = 0.06), 0.66 for distributed practice (6 studies; p = 0.03), 0.65 for interactivity (89 studies; p < 0.001), 0.62 for multiple learning strategies (70 studies; p < 0.001), 0.52 for individualized learning (59 studies; p < 0.001), 0.45 for mastery learning (3 studies; p = 0.57), 0.44 for feedback (80 studies; p < 0.001), 0.34 for longer time (23 studies; p = 0.005), 0.20 for clinical variation (16 studies; p = 0.24), and -0.22 for group training (8 studies; p = 0.09).

CONCLUSIONS

These results confirm quantitatively the effectiveness of several instructional design features in simulation-based education.

Longitudinal training and assessing consultation competence, a role for self reflection on performance

Medical consultation (patient-doctor encounter), consisting of history taking, physical examination and treatment, is the starting point of any contact between doctor and patient. Learning to conduct a consultation is a complex skill. Both communicative and medical contents need to be applied and integrated. Conducting an adequate consultation is a skill which is gradually learned and perfected during training and career. This article discusses the background and implementation of a longitudinal integrated consultation training programme in clerkships. In the programme, the student's reflection on the consultation plays an important role in education and assessment.

The simulated patient's view on teaching: results from a think aloud study

PURPOSE

This study explored third-year clinical teaching encounters from the perspective of the simulated patient (SP) participants.

METHOD

In August through December 2008, to obtain data from SPs, the authors used retrospective Think Aloud (rTA) methodology on video recordings of teaching sessions in which the respective SPs had participated. While watching the video, SPs were instructed to speak aloud their thoughts in response to the question "What made you feel comfortable or uncomfortable during the session?" Recordings of rTA exercises were analyzed by qualitative content analysis.

RESULTS

From 27 teaching sessions with 23 different teachers, 269 relevant comments were extracted and categorized. SPs felt comfortable if the atmosphere was calm (10 comments), appropriate physical contact was established (8), the student attended to the patient (8), the student acted in a well-structured manner (7), and the role-play was well structured by the clinical teacher (7). SPs felt uncomfortable if they were excluded from communication (16), actions were not properly explained (14), students did not attend to the patient (10), students did not stay in their role (10), and everyone talked at the same time (8).

CONCLUSIONS

SPs highly valued a clear structure of the teaching setting and appropriate preparation and good communication skills on the students' part. Many of the aspects of teaching quality were found to be under the influence of the clinical teacher and may, therefore, be important for teacher training.

A failing medical educational model: a self-assessment by physicians at all levels of training of ability and comfort to deliver bad news

OBJECTIVE

Patient surveys consistently show physician communication remains less than ideal. While previous studies have demonstrated a lack of trainee confidence in delivering bad news, our study explores communication skills at all levels of practice and highlights potential barriers to improvement.

METHODS

Pediatric residents, fellows, and attendings involved in direct patient care at a major academic center participated in a voluntary questionnaire, consisting of self-assessed scales of comfort level, knowledge level, amount of training, and attitudes towards communication education. We also elicited barriers to learning and teaching as well as significant experiences.

RESULTS

Eligible responses (n = 253) were evenly divided between trainees and faculty. Almost half of attendings and two thirds of fellows did not feel sufficiently knowledgeable to deliver bad news. Many attendings felt disproportionately more comfortable than they felt knowledgeable. All trainees felt insufficiently knowledgeable for independent practice of this skill. Educational barriers centered on time constraints, a deemphasis, a lack of positive modeling, and minimal awareness of existing resources. Poor experiences revolved around inappropriate language and settings as well as insufficient empathy or preparedness. Positive anecdotes highlighted the importance of education and the impact of role models.

CONCLUSION

Independent of level of training, this study reveals a lack of self-assessed preparedness from many responsible for delivering bad news to patients and families. A significant barrier to improvement is the disproportionate level of self-assessed comfort versus knowledge level. Educational models should include both didactics to learn the skills and practice-based learning to refine the techniques.

A review of standardized patients in clinical education: Implications for speech-language pathology programs

The use of standardized patients has been reported as a viable addition to traditional models of professional practice education in medicine, nursing and allied health programs. Educational programs rely on the inclusion of work-integrated learning components in order to graduate competent practitioners. Allied health programs world-wide have reported increasing difficulty in attaining sufficient traditional placements for students within the workplace. In response to this, allied health professionals are challenged to be innovative and problem-solving in the development and maintenance of clinical education placements and to consider potential alternative learning opportunities for students. Whilst there is a bank of literature describing the use of standardized patients in medicine and nursing, reports of its use in speech-language pathology clinical education are limited. Therefore, this paper aims to (1) provide a review of literature reporting on the use of standardized patients within medical and allied health professions with particular reference to use in speech-language pathology, (2) discuss methodological and practical issues involved in establishing and maintaining a standardized patient program and (3) identify future directions for research and clinical programs using standardized patients to build foundation clinical skills such as communication, interpersonal interaction and interviewing.

Instructiveness of real patients and simulated patients in undergraduate medical education: a randomized experiment

PURPOSE

Few studies have compared the instructiveness of real patient contacts with simulated patient (SP) contacts. Although most of these studies found no difference, students often comment that the instructiveness of both encounters is dissimilar. The aims of this study were to evaluate which contact (real patient or SP) is perceived as most instructive by students and which variables contribute to this.

METHOD

The authors performed an experiment involving 163 first-year medical students, randomized to having a real patient contact (n = 61) or SP contact (n = 102). Quantitative (questionnaires) and qualitative (focus groups) methods were used to evaluate the perceived instructiveness of the contact.

RESULTS

The general instructiveness of both real patient contacts and SP contacts was marked high. Several differences between the evaluations of real patient contacts and SP contacts were found. For example, students considered real patient contacts less helpful in practicing communication skills and considered the real patients' feedback less relevant. The focus group interviews yielded explanations for many of the differences found. Students regarded real patients as more authentic. However, SPs were better informed about the purpose of the consultation and provided the student with more specific feedback.

CONCLUSIONS

Students consider authenticity an important advantage of real patients. Their difficult recruitment is an important disadvantage, however, SPs have important advantages compared with real patients--for example, their feedback. The choice of real patient contacts or SP contacts for medical education depends on factors like the phase of the curriculum and the aim of the encounter.

The use of standardized patients to teach medical students clinical skills in ambulatory care settings

BACKGROUND

Ambulatory medicine is being increasingly emphasized in undergraduate medical education. Because of the limited availability of real patients, we introduced a standardized patient (SP) encounter program in an ambulatory care setting.

AIMS

This study was undertaken to assess the usefulness of SPs for teaching undergraduate students clinical skills in ambulatory settings.

METHOD

Third-year medical students met two different SPs, who presented common authentic problems, during internal medicine clerkship. Each SP encounter of 30 min was followed by SP and a tutor's feedback, using a video recording of the SP encounter. We surveyed students for program evaluation purposes at the end of their three-year internal medicine clerkships (from 2006 to 2008).

RESULTS

Most students found that the consecutive SP sessions were instructive and helpful. Video recordings of clinical encounters allowed students to reflect on their behavior and receive feedback from tutors. However, students identified several weaknesses of these SP encounters. For example, pre-exposure to the SP scenario reduced tension of the experience and inconsistent feedback from tutors caused confusion.

CONCLUSIONS

SP encounters in an ambulatory care setting, followed by tutor's feedback based on a video recording, can be used for teaching basic clinical ambulatory care skills.

Students' views on the use of real patients and simulated patients in undergraduate medical education

PURPOSE

To determine students' views about the strengths and weaknesses of real patient interactions as opposed to simulated patient (SP) interactions in the undergraduate medical curriculum in order to evaluate how their strengths can be optimally used and weaknesses remedied.

METHOD

Five focus-group interviews were conducted among fourth- and fifth-year medical students at Maastricht University in 2007, using a preestablished interview guide. The interviews were recorded, transcribed, and analyzed using qualitative methods.

RESULTS

In general, the 38 participants considered real patient encounters more instructive and more authentic than SP encounters. However, students identified several strengths of SP encounters compared with real patient encounters. For example, SP interactions were helpful in preparing students for real patient interactions (particularly with regard to communication skills and self-confidence), in the teaching of "intimate" physical examination skills, such as gynecological examination skills, and in giving constructive feedback on communication skills. In contrast to what we had anticipated, taking a time-out was considered easier in real patient interactions.

CONCLUSIONS

Both real patient interactions and SP interactions are considered indispensable to undergraduate medical education. Each encounter has unique strengths and weaknesses from the perspectives of students. On the basis of strengths and weaknesses that were identified, suggestions were made for the use of real patients and SPs in undergraduate medical education.