AMEE Medical Education Guide No. 13: real patients, simulated patients and simulators in clinical examinations

AbstractIn the assessment of clinical competence it is important to observe a candidate interacting with a patient. The role of the patient in this encounter will vary depending upon the level of interaction expected between the student and the patient, and whether physical signs are part of the presentation. Patients used in examinations may be real or simulated by a person who has undergone training in order to reproduce a particular scenario. Models or simulators, videotape and audiotape and computers may also be used as patient substitutes. There is a continuum between real patients with no training and simulated patients who have been extensively trained to perform the task: (1) 'real' patients presenting in clinical practice; (2) 'real' patients who have agreed to take part in a clinical examination but who are unrehearsed; (3) 'real' patients who have been rehearsed in what is expected of them; (4) 'real' patients who have been asked to modify, for the purpose of the examination, aspects of their history or presentation; (5) 'real' patients whose medical experience forms the basis for their performance in the examination but whose presentation is substantially modified for the purpose of the examination; (6) simulated patients who are given only an outline of what is expected of them; (7) simulated patients who are given a short brief or scenario with which they become familiar but beyond which they are free to respond as they wish; (8) simulated patients who are briefed extensively and who are thoroughly rehearsed prior to the examination. Simple and sophisticated simulators may be used to assess skills of physical examination and practical procedures. In only a few instances is the choice of patient representation in an examination limited to one approach. Examples where the choice is limited are the use of real patients with physical signs which cannot be simulated, the use of simulated patients in delicate or emotionally difficult areas, and the use of simulators where the use of patients would be inappropriate, for example, cardiopulmonary resuscitation. In many instances, however, there is no one correct approach. The approach adopted should be determined by the local circumstances and the needs of the examination. Factors which should influence the choice of patient representation in an examination are related to: (1) what is being assessed, including the level of abnormality and level of interaction with the patient required; (2) the level of standardization required, with greater emphasis on standardization needed for high-stakes national examinations; (3) the logistics, including the availability and costs of real patients and trained simulated patients; (4) the context, for example, practice-based or formal examinations of the OSCE type; (5) the level of realism or authenticity required. Practical steps can be taken in the clinical examination to get the maximum value from the patient whether 'real' or simulated.