The Use of Standardized Patients in Medical Education

Mark H. Swartz, M.D.Mark H. Swartz, M.D.Professor of Medicine andProfessor of Medicine and

Morchand Professor of Medical EducationMorchand Professor of Medical EducationMount Sinai School of Medicine Mount Sinai School of Medicine –– New YorkNew York

Kaohsiung Medical University

Superior doctors prevent the disease.Mediocre doctors treat the disease before evident.Inferior doctors treat the full blown disease.

–Huang Dee: Nai-Ching (2600 B.C. 1st Chinese Medical Text.)

Standardized patientsHistory and Definition

First introduced by Howard Barrows, M.D. and First introduced by Howard Barrows, M.D. and Steven Abrahamson, Ph.D. in 1964Steven Abrahamson, Ph.D. in 1964A standardized patient (SP) is a A standardized patient (SP) is a nonphysiciannonphysician(actor) who has been trained to portray a specific (actor) who has been trained to portray a specific patient case in a consistent, standardized manner.patient case in a consistent, standardized manner.In this interaction with the examinee, the SP In this interaction with the examinee, the SP presents the case history in response to presents the case history in response to questioning by the examinee and undergoes a questioning by the examinee and undergoes a physical examination at the examineephysical examination at the examinee’’s direction.s direction.In addition, SPs complete checklists following the In addition, SPs complete checklists following the examineeexaminee--SP encounter, on which they document SP encounter, on which they document actions performed by the examinee. actions performed by the examinee.

Educational Usesof Standardized Patients

Teaching and evaluating interpersonal Teaching and evaluating interpersonal skillsskillsTeaching and evaluating historyTeaching and evaluating history--taking & taking & physical examination skillsphysical examination skillsClinical reasoning analysisClinical reasoning analysisAssess ability to educate the patientAssess ability to educate the patient

Educational Advantages of SPs

Available at any timeAvailable at any timeA standardized patient problemA standardized patient problemProvide clinical training for the Provide clinical training for the unexperiencedunexperiencedEliminate risks of using a real patientEliminate risks of using a real patientProvide opportunity to work in an emergency Provide opportunity to work in an emergency situationsituationOffer practice with difficult patients or sensitive Offer practice with difficult patients or sensitive situationssituationsProvide direct feedback about interpersonal skillsProvide direct feedback about interpersonal skillsOffer a flexible educational toolOffer a flexible educational toolModulate pressures of time and urgencyModulate pressures of time and urgencyTime can be telescopedTime can be telescoped

Common Misunderstandings About Standardized Patients

The standardized patient is not a realThe standardized patient is not a real--life situation; life situation; it is too artificial to use.it is too artificial to use.The standardized patient presents typical or classical The standardized patient presents typical or classical disease entities, but not the vague or complex disease entities, but not the vague or complex problems that are encountered in the real world.problems that are encountered in the real world.The range of problems that can be simulated is very The range of problems that can be simulated is very small.small.Good standardized patients are difficult and timeGood standardized patients are difficult and time--consuming to prepare.consuming to prepare.The standardized patient is too expensive.The standardized patient is too expensive.

Use of SPs in USA and Canada

Recent study conducted in the past two years Recent study conducted in the past two years showed that nearly all medical schools in the USA showed that nearly all medical schools in the USA and Canada are now using SPs in their curricula.and Canada are now using SPs in their curricula.

A number of medical licensing and specialty A number of medical licensing and specialty certifying boards in the USA and Canada are certifying boards in the USA and Canada are currently using or considering the use of SPs. currently using or considering the use of SPs. These includes:These includes:

National Board of Medical ExaminersNational Board of Medical ExaminersEducational Commission of Foreign Medical GraduatesEducational Commission of Foreign Medical GraduatesMedical Council of CanadaMedical Council of CanadaRoyal College of Physicians and Surgeons of CanadaRoyal College of Physicians and Surgeons of CanadaCorporation of Medical Professionals of QuebecCorporation of Medical Professionals of Quebec

Are standardized patients realistic?Are they accurate in portraying their roles?

A number of studies have shown that experienced A number of studies have shown that experienced physicians physicians cannot differentiate real patients from cannot differentiate real patients from SPsSPs when the latter are sent unannounced into a when the latter are sent unannounced into a physicianphysician’’s office. This finding is particularly s office. This finding is particularly impressive given that the physicians had agreed in impressive given that the physicians had agreed in advance to participate in these studies and thus advance to participate in these studies and thus knew that SPs would be coming into their offices knew that SPs would be coming into their offices unannounced in a period of the next few months.unannounced in a period of the next few months.Other studies have shown that house officers Other studies have shown that house officers clinical behaviors were quite similar whether the clinical behaviors were quite similar whether the encounter was with real patients or SPs.encounter was with real patients or SPs.

Accuracy of checklist completionAre they accurate at checklist completion?

As expected, the number of actions needed to be As expected, the number of actions needed to be recalled influenced the accuracy.recalled influenced the accuracy.

In one study, accuracies ranged from 83% for a In one study, accuracies ranged from 83% for a 55--item checklist to 76% for 30item checklist to 76% for 30--item checklistitem checklistAt The Morchand Center, accuracies average At The Morchand Center, accuracies average from from 8787--98% for a 2098% for a 20--item checklistitem checklist..

In general, 15In general, 15--item checklists appear to represent a item checklists appear to represent a good balance between recording accuracy and good balance between recording accuracy and breadth of information regarding examinee breadth of information regarding examinee performance.performance.

Test securityIs test security a potential threat to the validity of SP examinations?

Studies have shown Studies have shown no consistent, systematic no consistent, systematic increasing or decreasing trendincreasing or decreasing trend in scores in scores throughout the examination period.throughout the examination period.

OSCE

OObjectivebjective SStructured tructured CClinical linical EExaminationxaminationUses SPs to simply simulate parts of an encounter Uses SPs to simply simulate parts of an encounter to test specific tasks or technical skills, for to test specific tasks or technical skills, for example:example:

Take a BPTake a BPExamine the left retinaExamine the left retinaEvaluate the abdomenEvaluate the abdomenEducate the diabetic patient about insulin useEducate the diabetic patient about insulin use

Shorter station timeShorter station timeMay involve nonMay involve non--SP encounter, e.g. read an ECGSP encounter, e.g. read an ECGMany stations requiredMany stations required

The Morchand Center for Clinical CompetenceHistory and background information

Opened in January 1991Opened in January 1991Home of the SP program for the NYC medical Home of the SP program for the NYC medical schoolsschoolsTeach and evaluate more than 1,300 fourth year Teach and evaluate more than 1,300 fourth year students annuallystudents annuallyOver 1,500 actors on databaseOver 1,500 actors on database

The Morchand CenterThe Facility

Seven examination roomsSeven examination roomsConference roomConference roomAll equipped with closedAll equipped with closed--circuit color television circuit color television cameras and stereo microphonescameras and stereo microphonesObservation theater with eight television monitorsObservation theater with eight television monitors

The objective of medical education is to The objective of medical education is to prepare students for the effective, efficient, prepare students for the effective, efficient, and humane care of patients.and humane care of patients.

Mark H. Swartz, M.D.Mark H. Swartz, M.D.Mount Sinai School of Medicine Mount Sinai School of Medicine ––

New York CityNew York Citymark.swartz@mssm.edumark.swartz@mssm.edu

The Use of Standardized Patients in Medical Education

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