M.
Abid Bashir
Faisalabad, Pakistan
Medical Education
STANDARDIZED/SIMULATED PATIENT
S tandardized and simulated patients
(SPs) are being used in medical
education for about 40 years1. Both
terms are used interchangeably but
there is difference between the two.
Simulated patient is a person who has
been carefully coached to simulate an
actual patient so accurately that the
simulation cannot be detected by a
skilled physician. Simulated patients
are role players who effectively train
healthcare professionals in communi-
cation and diagnostic skills2.
Standardized patient is a simulated or
real patient who is used for assessment
of medical students. He is a person
who has been trained to present his
illness consistently and in a standard-
ized way3.
History
The idea of simulated patient was
4
presented by Barrows in 1968 . He
argued that why simulation cannot be
used in medical education when it was
already being used for training of a
variety of high stake jobs like pilots and
military.
The first simulated patient was used in
the Department of Neurology,
University of Southern California
School of Medicine3. A model for Art
Department of the same school was
coached to have paraplegia, bilateral
Babinski's, dissociated sensory loss
and a blind eye. Her main role was to
report on performance of students
198 April to June, 2010
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following all encounters. This was a
substitute of what David Seegal, Head
of Columbia-Prebyterian Research
Unit used to do himself; watching every
clinical resident taking history and
performing clinical examination for
more than two hours in order to correct
his mistakes. Dr Barrow being the only
neurologist to look after 100 bedded
(plus additional beds in the corridor)
department, did not have enough time
to sit that long with every resident
giving him the idea of using that art
model for the same purpose. This is
contrary to the misconception that
standardized patients are used only
when real patients are lacking as
neurology service at the said hospital
had the largest number of neurological
patients in whole of United States of
3
America at that time .
Originally they were called program-
med patients, then simulated and
finally standardized patients3. With the
introduction of objective structured
clinical examination (OSCE) in 1979 ,
5
the use of SPs gained further popu-
larity. In a survey conducted in 1989,
70% of American and Canadian medi-
cal schools were using SPs for training
or evaluation of students6. The wides-
pread use of SPs led to formulation of
guidelines for recruitment and training
of SPs as well as development of
centralized SP programs and staffing,
faculty development and association
of standardized patient educators7.
INDEPENDENT REVIEWS
Rationale
There is no substitute of real patients for
the training of clinical skills but SPs
have their place in special circum-
stances like counseling and standard-
ization of high stake examinations.
There is no intent that standardized
patients should replace real patients,
the intent is to enhance the value of real
patients in learning of students3.
Advantages
SPs have a number of advantages over
random real patients. These are3:
1. SPs make it possible to provide
students with equivalent
patient experiences instead of
random experiences.
2. The SPs provide a chance for
development of core compe-
tencies
3. Faculty can determine what
should be taught during the
educational program and can
use SPs to ensure that agreed
upon themes and issues are
covered
4. Faculty members can control
the context, content, domain,
sampling, emphasis and level
of clinical problem
5. SPs provide a transition phase
as students can practice in a
less threatening environment
without embarrassment about
their novice status before they
go to actual patients
6. The use of SPs allows interrup-
tions and restarting of encoun-
ter to allow feedback and
practice
7. The timeline can also be
controlled with SPs. An SP can
present an emergency situa-
tion, and the progress can be
April to June, 2010 INDEPENDENT
mimicked in a short span of
time by training SP to role play
differently in different situations
8. SPs provide students with
opportunity to practice comm-
unication skills with difficult
patients and learn how to
handle difficult patients
9. SPs are helpful in providing
formative feedback so that
students can improve their
shortcomings
10. A single SP can be trained for
learning of different diseases
11. SPs are available whenever
8
they are required
12. They offer high level of accep-
8
tance to staff and students
13. Scenarios that are disturbing to
real patients can be simulated
like life threatening emergency
situations and counseling of
cancer patients.
14. In assessment of competence,
stations can be tailored to
match the level of students.
15. Patient variable is uniform
across trainees to ensure
unbiased, just and fair assess-
ment specially in high stake
examinations.
16. Avoids mistreatment of real
patients when a number of
students have to examine
17. Real patients may be unwilling
to participate in an exami-
nation where they are exposed
to large number of students.
18 The behavior of real patients is
unpredictable. Their physical
signs may change and condi-
tion may deteriorate while SPs
are trained to respond more
consistently and can be
duplicated to allow multiple
examinations at different
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 centers.
19. Real patients may have greater
difficulty in adjusting their
medical histories than simu-
lated patients have in learning
new ones.
Uses of SPs
SPs can be used for teaching, training,
examination and monitoring.
They have established role in teaching
of communication skills, history taking,
physical examination specially breast,
urogenital and pelvic examination,
counseling, ethical issues and handling
of difficult patients.
They can also be trained to provide
formative feedback to students
enhancing their learning.
In examination, SPs have definitive
edge over real patients especially in
high stake examinations where objec-
tive standardization is required and
when a large number of students are
appearing in exams.
They can also be used for monitoring of
the doctors in their clinics.
Disadvantages and limitations
Where there are so many advantages,
SPs are not without disadvantages and
limitations. The following are a few of
them;
1. SPs do not duplicate “real
8.
patients”
2. SPs may not allow assessment
of complex problems.
3. Real life problems are not
standardized but present with
variety of sets of problems.
200 April to June, 2010
4. It is not possible to simulate
many clinical signs like mur-
murs, goiter, heart sounds,
edema, dehydration, cyanosis
etc.
5. Long training is required for
high quality simulation.
6. The cost of SPs may be
substantially higher than real
patients.
7. Opposition to the use of Sps
by examiners may question
credibility of the examination.
Characteristics of SPs
Sps can be selected from general
public, volunteers, attendants of the
patients and paramedical staff. They
should have good communication
skills and a pleasant personality. They
should be good actors, motivated and
intelligent enough to understand the
significance of their role. Their age and
gender should match disease process
to be simulated. Professional actors
may not be good simulators as some-
times they overreact demonstrating
their acting skills rather than focusing
on the objectives of the exercise.
Recruitment and training
They may be recruited through per-
sonal communication, patients'
visitors, friends, hospital bulletins and
media.
Individuals with ability to portray
important clinical features of a patient's
problems should be carefully selected.
Similarly trainers of simulated patients
should also be very carefully selected
from healthcare professionals inter-
ested in medical education. The
trainers themselves should be trained
first.
INDEPENDENT REVIEWS

The duration of training vary according
to the complexity of the task and ability
of the role player. The simulator should
be encouraged to observe and interact
with the real patient. Whenever such
interaction is not possible, videotapes
of events to be simulated may be used.
Simulated patients may be encouraged
to answer less critical questions from
their own experience. In high stake
examination, new SP should be
examined by an unfamiliar doctor
before he is presented to students.
Real standardized patients should be
selected for examination quite in
advance and their availability should
be ensured. The attending doctor is the
References
1. Wallace J, Rao R, Haslam R.
Simulated patients and objective
structured clinical examination:
review of their use in medical
education. Advances in Psychiatric
Treatment. 2002; 8:342-50.
2. Simulated patient homepage
[internet] no date [cited March 22,
2010] available at http://www.simu
latedpatients.co.uk/pages/.
3. Barrows HS. An overview of the uses
of standardized patient for teaching
and evaluating clinical skills. Acad.
Med. 1993; 68:448-51
4. Barrows HS. Simulated patient in
medical teaching. Canad. Med.Ass.J.
1968; 98:674-6
5. Cuschieri A, Gleeson FA, Harden RM,
Wood RAB. A new approach to a final
April to June, 2010 INDEPENDENT
best person to convince and train
patient for the role play. He should be
clearly explained about the procedure
of examination, number of students
and what is expected from him and
informed consent be taken. It is
important to reconfirm physical
findings on the morning of the exami-
nation.
Conclusion
The role of SPs is well established in
medical education. They may be real
or simulated patients and are used for
training, assessment and monitoring.
They have their limitations as well. They
should be carefully selected and
properly trained. They do not replace
real patients but are important tool to
enhance learning.
exami-nation in surgery; use of the
objective structured clinical
examination. Annals of the RCS
of England. 1979; 61:400-5
6. Stillman PL, Regan MB, Philbin M,
Haley H. Results of a survey on the use
of standardized patients to teach and
evaluate clinical skills. Acad.Med.
1990; 65:288-92.
7. Adamo G. Simulated and
standardized patients in OSCE:
achievements and challenges 1992-
2003. Medical Teacher. 2003;
35(3):262-70.
8. Collins JP, Harden RM. The use of real The author :
patients, simulated patients and Muhammad Abid Bashir,
simulators in clinical examination.
AMEE medical education guide No
FCPS
13. Medical Teacher. 1998;
is associate professor in
20(6):508-21 department of Surgery at
Independent Medical
College Faisalabad and
®
instructor of ATLS .
abidbashir@hotmail.com
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