Experiential learning is a key component in teaching clinical and communication skills to medical students. A UK report stated the following about the role of patients in medical education:
There are a number of challenges that arise from patient involvement in medical education. These range from practical considerations relating to the organization of clinical placements to patient concerns about consent and confidentiality. As many of these challenges are an unintended consequence of changes to medical education and healthcare service delivery, they will require flexible and innovative solutions.1
It is challenging for tutors to structure learning events for their students with patients. We have several anecdotal accounts of preclerkship medical students going to the wards unsupervised to practise their clinical skills—a practice no longer considered ethical by today’s standards. As such, an awareness of and ability to recruit different patient resources and to be available to teach and assess students has become part of the teacher’s mandate.
In this article, we discuss various types of patients as “educational resources,” including standardized patients (also called simulated patients), real inpatients or outpatients, patients who volunteer for educational purposes, and virtual patients. It is important that both teachers and learners be mindful that, with the exception of virtual patients, these resources are human beings and not mere educational objects.2
Standardized and simulated patients
To address the difficulties of finding real patients for teaching medical students on a consistent basis and also to provide a fair learning and assessment environment, Barrows introduced simulated patients in 1963.3 A simulated patient is usually a person who has been carefully coached to simulate an actual patient, such that the simulation would not be detectable by a skilled clinician.3 Simulated patients can be real patients coached to modify their presentations, lay volunteers, faculty members, students, trained actors, high-fidelity mannequins, and, more recently, virtual patients.
The terms simulated patients and standardized patients are often used interchangeably; however, the emphasis for simulated patients is in portraying the signs and symptoms of real patients, whereas the emphasis for standardized patients is on consistency.4 For the purpose of our discussion, we will use the term standardized patient (SP).
Standardized patients can be indistinguishable from real patients when they are sent unannounced into clinical practice.5 However, the students are well aware that they are not real patients when SPs are used for teaching and testing. As consistency is important in testing students, SPs are the norm in examination settings across North America.
Real patients
Family physicians have access to real patients in their offices, in clinics, or on the wards. Often in preclerkship training the inpatient units are where the students meet real patients to practise their clinical skills. These patients are often very frail; there might be language barriers; or they are unavailable. It is fair to say that in current times, if a patient is well enough to endure 1 to 2 hours of a first-year medical student interview and examination, then he or she might be too well to be in hospital. Students learning clinical skills on inpatient units is not only unfair to the inpatients, but also to the medical students, as their learning becomes a suboptimal experience because patients might be too fatigued for them to finish their assessments. For example, a student might be unable to perform a required musculoskeletal examination and observe the patient’s gait if the patient is too sick.
Outpatient volunteer programs are burgeoning across Canada (eg, Patients Playing a Part program at the Mississauga Academy of Medicine at the University of Toronto6). Organization and maintenance of such programs can prove to be a challenge, requiring administrative resources. Teaching intimate examination requires specialized patient partners or associates, and many schools work in collaboration with such programs. Access to such teaching resources might be found through SP programs or midwifery programs. Teaching with a hybrid combination of SPs and task training pelvic models is becoming more and more common.
Virtual patients
Virtual patients in online tools are also being used in clinical skills medical education. Often there are blended approaches with patient resources such as combining a live patient visit with online clinical resource tools; for example, the student might examine a patient’s heart and then augment his or her learning afterward with online auscultation modules.
Comparing patient types
Studies have found that there is generally a high level of satisfaction expressed by medical trainees working with various patient types. However, there are challenges with this type of research. Most studies that examined the equivalence of SPs and real patients for teaching had no standardized evaluation tools and were based on attitude or satisfaction surveys developed for each individual study.4 Reporting standards were also inconsistent, as demonstrated in a review that specifically looked at the quality of research on SPs; the review randomly selected 21 articles from a total of 177 articles published from 1993 to 2005 and found no defined standards for reporting the use of SPs in research.7 Some examples of studies from the literature are demonstrated in Table 1.8–13
The literature supports the use of SPs in teaching medical students how to conduct interviews, develop communication skills, and perform physical examinations; however, no superiority in use of either SPs or real patients has been consistently demonstrated. Working with SPs in medical education appears to have no effect on student performance, and differences in perceptions among students and faculty members are inconsistent. As some of the recent original studies have illustrated, there is evidence to support involving real patients as educational resources.14
Using patient resources
Available patient resources vary according to the geographic location, medical school, and curricular programs. The clinical skills teacher needs to be aware of the options in their local community. Simulated patients cost money, but so do the patient volunteers or real patients in the sense that running the programs to use these resources requires coordination and time on the part of the medical education office.
Selecting, obtaining consent from, and preparing real patients and patient volunteers are integral to the success of a session. Unlike SPs, real patients or patient volunteers are not trained in a specific role for teaching. Patients might have a personal agenda regarding how best to educate medical students. They might reveal too much information, making it too easy for the students, or they might withhold information, trying to make it more challenging for the students. For example, an eager patient might reveal his or her entire medical history within the first 5 minutes, diminishing the student’s ability to practise questioning techniques. Patients might feel pressured to volunteer in order to please their personal health providers. Real patients are authentic, which might be preferable for some types of teaching sessions, as in the example of demonstrating palpation of an enlarged liver. Additionally, some real patients or patient volunteers are amenable to coaching. One can offer the patient suggestions about which part of the history to reveal or withhold until he or she is asked the correct question.
Standardized patients are often trained to provide constructive feedback to the students about their communication skills and behaviour. Real patients or patient volunteers often appreciate being asked for feedback. Sometimes patients will provide unsolicited feedback about the student’s attire or behaviour, which can lead to valuable discussions. Feedback about SP programs maintains high-quality performance; for example, the SP might have forgotten to portray a key part of the history that was critical to the diagnosis. Clinical teachers will likely work with all patient types, so being aware of and knowledgeable about various patient resources will serve to enhance their competency in teaching. In Box 1 we discuss factors to consider when working with various patient types.
Factors to consider when working with all patient types
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SP—standardized patient.
Teaching learners
The teacher needs to be prepared with regards to the clinical skills session’s objectives, content, and role of the patient for each session. For example, a teaching session on “breaking bad news” would involve SPs who could provide the learners with a “safe” environment for them to develop their approach before they face the real-life circumstances. Whereas learning how to obtain a patient’s medical history might be more appropriate with a real patient.
Using patient resources to teach learners clinical skills is also a golden opportunity for teachers to model respectful behaviour toward the patient—regardless of whether he or she is a real patient, a volunteer, or an SP—who essentially represents the voice of the real patient as in real life. Students quickly notice this respectful behaviour; thanking and speaking directly to the patient volunteer, real patient, or SP is paramount to the tutor’s role modeling.
While the teacher and students talk about the patient’s health in front of the patient during a teaching session, they can unwittingly cause the patient anxiety, leading to follow-up patient medical visits to address these concerns. Ideally, when possible, the teacher needs to observe the patient-student encounter and provide specific feedback immediately. Standardized patient programs should offer faculty members suggestions and sessions on how to improve the quality of teaching encounters when working with SPs.4 In Box 2 we present factors for teachers to consider when using patient resources to teach clinical skills.
Factors to consider when using patient resources to teach learners clinical skills
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SP—standardized patient.
Conclusion
Studies have shown that both real patients and SPs are suitable to facilitate medical students’ education in clinical skills. There is no evidence of the superiority of one patient type over another in teaching clinical skills to preclerkship medical students. Instead, local circumstances and expertise will ultimately guide selection of patients for educational sessions. Factors such as the knowledge or skill being taught or assessed, the availability of real patients, and the costs involved with either SPs or patient volunteers will have an effect on the choice of patient resources.
Acknowledgments
We thank Diana Tabak for her assistance in writing this paper.
Notes
TEACHING TIPS
Both simulated patients (SPs) and real patients are suitable resources to use when teaching clinical skills. When deciding which patient type to use, consider the resources available at your site, costs, and logistics.
Align the patient type with the goals of the teaching session; for example, if the teaching session is about difficult communication, it might be preferable to use an SP.
Clinical teachers are role models and must model professional behaviour toward all patients regardless of what patient type (ie, SP, real patient, or volunteer patient) is being used.
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Miriam Lacasse, Teaching Moment Coordinator, at Miriam.Lacasse{at}fmed.ulaval.ca.
Footnotes
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de juillet 2014 à la page e373.
Competing interests
None declared
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