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Review Article

Strengths and Weaknesses of Simulated and Real Patients in the Teaching of Skills to Medical Students: A Review

Bokken, Lonneke MD; Rethans, Jan-Joost MD, PhD; Scherpbier, Albert J.J.A. MD, PhD; van der Vleuten, Cees P.M. PhD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: Fall 2008 - Volume 3 - Issue 3 - p 161-169
doi: 10.1097/SIH.0b013e318182fc56
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Abstract

Patient contacts have always been an integral part of undergraduate medical education. Early patient contacts have been recommended by the Association of American Medical Colleges and the UK General Medical Council.1 A recent review identified several positive effects of early patient contacts: they increased student motivation, taught students “things that cannot be learned from books,” increased students’ confidence to interview patients and eased the transition from preclinical to clinical training.2,3 Furthermore, patient contacts enhanced students’ feelings of empathy and responsibility toward patients and fostered their professional identity.2–4 Patient contacts also help students build integrated skills for clinical reasoning, communication, history taking, and physical examination.1–3,5 In his review, Aspegren6 found that experiential methods such as patient contacts with immediate feedback from teachers were more instructive in the teaching of communication skills to medical students than traditional methods such as lectures.

Patient contacts also help students develop “illness scripts.” Illness scripts are cognitive structures containing features of prototypical or real patients together with clinically relevant information about diseases.7 Patient contacts may supply content for illness scripts and thus help students develop their ability to handle clinical problems.

Patient contacts in medical education may involve real patients or simulated patients (SP). The role of patients in education may be passive, that is, limited to presentation of complaints and symptoms, or it may be active as when the patient actually takes on the role of the teacher. In situations, such as assessments, where repeated identical role performance is required, SPs are also referred to as standardized patients.

Although the importance of patient contacts is generally recognized, we know little about the various roles of both real patients and SPs in undergraduate medical education and their value from the perspectives of students, teachers, and patients.1

We reviewed the literature to identify the different roles of real patients and SPs in undergraduate medical education and the benefits and limitations of these roles. We were particularly interested in how the roles relate to each other. In this review we did not consider the role of patients in assessment, because we were specifically interested in the contribution of patients to teaching.

METHODS

We searched the Pubmed and Eric databases using the search terms: (real or active) patients, patient partners or instructors, patient simulation, standardized or simulated patients, and undergraduate medical education or teaching. The databases were searched from their onset throughout March 2006. Additionally, we searched the references of articles to identify relevant articles that we might have missed. Articles were selected for inclusion in the review by one of the authors (L.B.). Articles were selected based on the abstract or the full paper if the abstract was absent or did not provide sufficient information. We included all retrieved research articles and descriptive articles published in English on the subject of real patients or SPs involved in undergraduate medical education. Even though real patients and SPs are also used in graduate and postgraduate medical education, we concentrated on undergraduate medical education to define the sphere of the review. Although assessment is an important part of education, we did not include articles dealing with assessment.

We categorized the selected articles based on four types of patient roles derived from the literature: real patients as an educational resource (passive role); real patients as teachers (active role); SPs as an educational resource; and SPs as teachers. The patient role was categorized as active when real patients or SPs were actively involved in teaching. This meant that the patient had the teacher’s role, preferably in the absence of other teachers.

The aim of this review was to identify strengths and limitations of the four types of patient roles from the perspectives of students, teachers, and patients.

REAL PATIENTS AS AN EDUCATIONAL RESOURCE

Patients as educational resource are used in many different educational settings, for example in bedside teaching. Generally, this is considered a valuable method for teaching skills, such as physical examination, history taking, communication, and procedural skills.8–10 The opportunity for students to observe skill performance by experienced clinicians and the fact that the patient is at the center of teaching are perceived as beneficial.10

We found two comparative studies on the effectiveness of bedside teaching in the teaching of skills, in terms of student scores on an objective structured clinical examination (OSCE).11,12 These studies are summarized in Table 1. Bedside teaching was found to be effective in comparison with instruction and practice sessions or structured clinical teaching.

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TABLE 1:
Comparative Studies on the Effectiveness of Real Patients as an Educational Resource (Bedside Teaching)

Two studies reported on students valuing bedside teaching and considering it an effective educational method.13,14 A large majority of students considered bedside teaching an effective way to develop physical examination, history taking, and communication skills.14 Particularly feedback at the bedside was perceived as high-quality teaching by students.13

Most studies show that patients feel very positive about their participation in bedside teaching14–19 Nair et al.14 found that 77% of patients enjoyed bedside teaching, with 84% saying they would recommend it to others.

One of the limitations of patients as an educational resource is concern among students and faculty about patients’ comfort18 and concern about bedside teaching being stressful to patients.20 However, no physiological signs of stress (changes in heart rate, blood pressure, or plasma norepinephrine levels) were found in patients during bedside teaching.16 Furthermore, patients reported bedside teaching not being stressful.15–17 Many even found bedside teaching a reassuring experience which helped them understand their illness. Patient satisfaction with bedside teaching may be further improved, for instance by paying more attention to consent and confidentiality.17,19

Another limitation of bedside teaching is variability because of differences between individual clinical teachers and the uncertain availability of suitable patients.14,21–24 Patients may be too ill or their condition too complicated to participate in bedside teaching. In addition, bedside teaching is affected by reductions in inpatient beds, shorter hospital stays, and reductions in the number of faculty teachers,21,24,25 whereas increasing numbers of students, such as medical students, nursing students, and physician assistants in training, require patient contacts.22 These limitations might have contributed to the decline in bedside teaching from 75% of clinical teaching in the 1960s to an estimated less than 16% today.26 In a study using direct observation, the median time spent at the bedside during teaching rounds was much less compared with the time spent in the classroom (2.5 minutes and 69 minutes, respectively).27 Waterbury24 suggested that SPs might compensate for the limitations of bedside teaching.

In summary, the use of patients as an educational resource in bedside teaching is considered valuable and effective in the teaching of skills to undergraduate medical students, in comparison with other teaching methods such as structured clinical teaching and from the perceptions of students. Although students and teachers worry about patients’ comfort, patients were reported to enjoy bedside teaching. There are limitations of bedside teaching, such as the unpredictable availability of suitable patients and the high variability in learning experiences.

REAL PATIENTS AS TEACHERS: PATIENT-INSTRUCTORS

Real patients are increasingly fulfilling active teaching roles in undergraduate medical education.28 In most studies, patient-instructors are used to actively teach skills such as physical examination and communication skills.22,29–36 They have also been used in the teaching of factors and circumstances affecting health and health care.37

We found two comparative studies on the effectiveness of patient-instructors in the teaching of skills, in terms of student scores on an OSCE.22,34 In these studies, summarized in Table 2, patient-instructors were compared with physicians in the teaching of physical examination skills to students. Patient-instructors were found to be at least as effective as physicians. Studies comparing the teaching by patient-instructors to other teaching methods have not been found.

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TABLE 2:
Comparative Studies on the Effectiveness of Real Patients as Teachers

Studies on patients’ views show that patients value their active teaching role.28,35,37,38 They regard themselves as important contributors to medical education as experts and exemplars of their particular medical condition and as facilitators of the development of students’ professional skills and attitudes.38 Plymale et al.35 found that cancer survivors enjoyed participating in a clinical teaching course, were willing to participate in future courses and perceived their role as an important and effective part of the course. Patients appreciate the opportunity to talk and learn about their condition.28,38 Furthermore, contributing to the training of future doctors gives them a sense of empowerment.28,35

Evaluations of students with regard to teaching by patient-instructors are positive.22,28,31–35 Instruction on joint examination by patients with arthritis was rated as beneficial by 93% of the students.33 Students valued the direct feedback on their skill performance provided by patient-instructors as it helped them in identifying their strengths and weaknesses.28,31 Furthermore, teaching by patient-instructors increased students’ confidence in physical examination skills and reduced anxiety.22,28 Stillman et al.31 suggested patient-instructors enhance the integration of technical and interpersonal skills. They also suggested patient-instructors are better able than teachers to highlight the patient’s perspective and give feedback on subjective aspects of physical examination.31 Therefore, their expertise may complement that of teachers.37

There are limitations too, however. Being patient-instructor demands a great deal from patients. Some patients found it tiring, especially when they were ill.32 Stillman et al.31 developed criteria for patient-instructors: their physical findings must be evident, their physical condition must allow repeated examination, and they should be able and willing to learn about their disease. Another limitation is that of costs in terms of faculty time spent on training and maintaining the skills of patient-instructors.32 However, this investment may be worthwhile because trained patient-instructors are 50% to 75% less expensive than faculty teachers.31 In one study, the use of real patients (as opposed to SPs) reduced training time because real patients required no training in simulating physical findings.36

In summary, although there are few comparative studies on the effectiveness of patient-instructors, patients-instructors are suggested to be equally effective as physicians in the teaching of specific physical examination skills to undergraduate medical students. Students value being taught by patient-instructors. Skills can be practiced and physical abnormalities can be found in a low anxiety setting. In addition to the teaching of skills, patient-instructors are trained to give constructive feedback to the student. This is a considerable advantage of patient-instructors as opposed to patients. An active role in the teaching of students is also enjoyed by patients. A limitation of this teaching method for teachers is the extensive training time needed. In addition, only a select group of patients, for example those with stable physical findings who are not too ill, can be trained to teach.

SPS AS EDUCATIONAL RESOURCE

SPs are individuals trained to perform the role of a patient realistically and consistently. SPs were introduced by Barrows in 1964 and they have been extensively used in medical education ever since.39–41 Studies have suggested SPs being a valuable complement to real patients.21,23,42 We found only one study directly comparing the effectiveness of SPs as educational resource to real patients in the same role.21 This study, summarized in Table 3, found skills teaching with SPs is as effective as skills teaching with inpatients, in terms of student scores on an OSCE. Student evaluations showed a nonsignificant trend toward greater satisfaction with the SP encounters, especially with the feedback provided to the students.21 Other advantages of SPs over real patients, portrayed by Barrows, are that they are available, safe, adaptable to students’ learning needs and minimize variability in learning experiences between students.41 SP encounters can be arranged at any time and in any setting, unlike encounters with real patients whose presence in hospital or general practice is difficult to control. SPs offer safety, because students need not feel embarrassed if their interviewing and physical examination skills are imperfect. Mistakes are acceptable, even in difficult and sensitive situations, such as the pelvic examination or breaking bad news. SP performance can be adapted to specific educational purposes. For example, an SP encounter can be interrupted to discuss the case or give tips to the student and SPs can be examined repeatedly to perfect students’ examination techniques. Also, the difficulty of the patient encounter can be adapted to match a student’s competence level. Variability in learning can be minimized by allowing each student to question and examine an SP who is simulating the same medical problem in the same way. SPs can simulate a wide range of physical findings, for example wheezing, abdominal tenderness, muscle weakness, and tremor.41 Furthermore, SPs are easy to train and can contribute to training a variety of skills.23,40,41 People of various age groups may be SPs. For example, adolescent girls have been reported to highly value their performance in a patient role.43 SPs reported being strongly motivated and greatly enjoying their encounters with students.44

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TABLE 3:
Comparative Study on the Effectiveness of SPs as an Educational Resource

Students enjoyed workshops with SPs in which they learned about basic interviewing skills and interview challenges, such as breaking bad news.42 They considered the workshops effective and valued the realistic learning with immediate feedback from the SP, without having to worry about harming real patients.

One study suggested that students prefer real patients to SPs because of their authenticity.45 This might be a limitation of SPs. However, a recent systematic review on incognito SPs visiting practicing physicians (who do not know when they are visited by SPs) showed SPs were detected in less than 15% of the cases.46 Detection rates of even less than 1% were found. These findings suggest SPs can be very authentic.

As with the real patients, SPs may also experience negative effects of their role. In a recent study 73% of SPs reported negative effects of patient role performance, for example fatigue and dissatisfaction with their performance.47 However, a subsequent study showed that the frequency and intensity of these negative effects were minor.48

In summary, in addition to real patients SPs are considered valuable educational instruments. SPs generally enjoy their work despite some minor negative effects of performing a patient role. SPs have considerable advantages compared with real patients used as an educational resource, including their availability and flexibility. Also, SPs can be trained to provide students with feedback, which is valued by the students.

SPS AS TEACHERS: SP-TEACHERS

With additional training SPs can undertake active teaching roles. To avoid confusion with real patients in the patient-instructor role, we will use the term SP-teacher to refer to SPs who teach.

Several comparative studies have assessed the effectiveness of SP-teachers in the teaching of skills, in terms of student scores on an OSCE. These studies are summarized in Table 4. Most studies show SP-teachers are effective in the teaching of skills to medical students. Students who were taught skills, such as communication and pelvic examination skills, by SP-teachers had similar or even better OSCE scores compared with those taught by physicians or faculty teachers. Furthermore, students taught by SP-teachers performed at least equally as those taught by traditional teaching methods, such as lectures, role-playing or instruction on (plastic) models, in the teaching of skills. Three studies showed retention of skills over a longer period of time in students taught by SP-teachers.49–51 Some comparative studies also reported views of students on the instruction they had.52–54 All of these studies showed students preferred instruction by SP-teachers to teaching by physicians or to traditional teaching methods such as role-playing.

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TABLE 4:
Comparative Studies on the Effectiveness of SPs as Teachers

Several studies primarily focused on student evaluations with regard to instruction by SP-teachers. Most studies found students highly value the teaching of skills, particularly pelvic examination skills, by SPs.55–60 Students felt calmer, more secure and more confident about performing a pelvic examination after instruction by SP-teachers.55,58,60 Students also valued the ability of SP-teachers to provide feedback.55,59 Levenkron et al.61 reported students considered direct feedback from SP-teachers on behavioral counseling skills more effective than feedback from a faculty member on a videotaped SP encounter. Two studies suggested SP-teachers are better able to give feedback on certain parts of the students’ pelvic examination, for example on the gentleness of the examination and on palpation of the ovaries, as opposed to traditional teachers.56,57

A limitation of the use of SP-teachers is the time and effort required to train SPs in their role of both patient and teacher. Davidson et al.,62 however, reported considerable cost savings because of teaching by SP-teachers. Although most studies reported students preferring instruction by SP-teachers to teaching by physicians or role-playing, two did not.63,64 In these studies, student evaluations regarding a didactic lecture on appendicitis or peripheral vascular disease were compared with student evaluations regarding an instructional SP interaction on the same subject. Overall, students preferred the didactic lecture, although they evaluated the SP interaction more favorably when it was preceded by the lecture.63,64

Only few studies, summarized in Table 5, have compared real patients to SPs in the teaching of skills to medical students. Most studies found real patient encounters are comparable to SP encounters. One study, however, found that communication skills training by real patients led to a stronger focus on the psychosocial content of the medical interview, whereas training by SPs resulted in significantly better verbal skills, such as summarization.45 Based on these findings, it was suggested to use SPs in the early stages of communication skills training and real patients in later stages when students have mastered the basic interviewing skills.

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TABLE 5:
Studies Comparing Real Patients to SPs in the Teaching of Skills to Students

In summary, SP-teachers are effective in teaching communication skills and physical examination skills such as pelvic examination skills. SP-teachers are at least as effective as traditional teaching methods such as didactic lectures, use of plastic models and teaching by physicians or faculty teachers. In general, students value the teaching by SP-teachers and regard it more effective than traditional teaching methods. However, in two studies students valued didactic lectures more than the teaching by SPs. The literature suggests real patients and SPs are useful for teaching different parts of communication skills.

The advantages and disadvantages of the different roles of patients in teaching skills to medical students are summarized in Table 6.

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TABLE 6:
Advantages and Disadvantages of Different Patient Roles

DISCUSSION

Most of the studies in our review suggest that real patients and SPs make a highly valued and indispensable contribution to undergraduate medical education in passive and active roles. Simulated and real patients, the latter especially in their teaching role, provide a safe, low anxiety learning environment where students can learn from immediate feedback and their own mistakes and build their competence and confidence.

The key aspects of educational experiences with real patients appear to be the presentation of actual abnormal physical findings and unique insights from the patient’s perspective. The advantages of SPs are that they are controllable and flexible. They are available when needed, adaptable to students’ needs, offer uniformity of educational experiences across students, and enable repeated practice of skills. They also have an excellent track record for teaching related to sensitive areas, such as breaking bad news and pelvic examination.

Real patients have limitations that place restrictions on their use, however, desirable it may be deemed to be. There are fewer available and suitable patients because of changes in health care and there are concerns about the patient’s comfort and confidentiality.

A possible limitation of the use of SP-teachers might be their costs in terms of faculty time required for training. However, real patients also require training for their teaching roles and once trained, both SP-teachers and patient-instructors seem to be less expensive than faculty teachers. We believe patient contacts remain essential in medical education, even with the rapid development of realistic simulation techniques. Initiatives to integrate (simulated) patient contacts and simulation techniques are therefore highly welcomed by us. In addition, we think that both real patients and SPs should not be burdened excessively by their educational roles. Their health and well-being should be a strong concern for program directors and teachers.

Our review has some limitations. Only one researcher searched the databases and selected studies for inclusion in the review. Therefore the review was not systematic. Although we made every effort to make our searches as thorough as possible, selection bias cannot be ruled out. Furthermore, relatively few comparative studies were found in our review. Although the majority of these studies used high-quality experimental designs, many used rather small populations. Many studies in our review were descriptive in nature. This may have influenced our results. Finally, for some studies in our review the distinction between the four patient roles turned out to be somewhat artificial as a small amount of overlap was found between the roles in these studies, for example, real patients who simulated some aspects of their role or SPs who had actual findings on physical examination. Although most studies were clear on whether real patients or SPs were used, as educational resource or as teachers, this might have influenced our results.

Further research should compare the effectiveness of real patients in the role of teachers to other teaching methods such as instruction on hospitalized patients or models. The role of patient-instructors in the teaching of skills in addition to physical examination skills, such as history taking and communication skills, is another area for future research. In addition, further research is needed with regard to the comparison of real patients to SPs. Despite the considerable amount of literature we found, many gaps in knowledge about patient roles in medical education remain and should be addressed by future studies.

REFERENCES

1. Spencer J, Blackmore D, Heard S, et al. Patient-oriented learning: a review of the role of the patients in the education of medical students. Med Educ 2000;34:851–857.
2. Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: systematic review. BMJ 2005;331:387–391.
3. Dornan T, Littlewood S, Margolis SA, Scherpbier A, Spencer J, Ypinazar V. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Med Teach 2006;28:3–18.
4. Dammers J, Spencer J, Thomas M. Using real patients in problem-based learning: students’ comments on the value of using real, as opposed to paper cases, in a problem-based learning module in general practice. Med Educ 2001;35:27–34.
5. Howe A, Dagley V, Hopayian K, Lillicrap M. Patient contact in the first year of basic medical training—feasible, educational, acceptable? Med Teach 2007;29:237–245.
6. Aspegren K. BEME Guide No. 2: Teaching and learning communication skills in medicine—a review with quality grading of articles. Med Teacher 1999;21:563–570.
7. Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ 2007;41:1133–1139.
8. Janicik RW, Fletcher KE. Teaching at bedside: a new model. Med Teacher 2003;25:127–130.
9. Kroenke K, Omori DM, Landry FM, Lucey CR. Bedside teaching. South Med J 1997;90:1069–1074.
10. Fitzgerald FT. Bedside teaching. West J Med 1993;158:418–420.
11. Cooper D, Beswick W, Whelan G. Intensive bedside teaching of physical examination to medical undergraduates: evaluation including the effect of group size. Med Educ 1983;17:311–315.
12. Hill DA, Lord RS. Complementary value of traditional bedside teaching and structured clinical teaching in introductory surgical studies. Med Educ 1991;25:471–474.
13. Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: perceptions of third-year medical students during an inpatient rotation. Acad Med 2005;80:950–954.
14. Nair BR, Coughlan JL, Hensley MJ. Student and patient perspectives on bedside teaching. Med Educ 1997;31:341–346.
15. Linfors EW, Neelon FA. The case for bedside rounds. N Engl J Med 1980;303:1230–1233.
16. Simons RJ, Baily RG, Zelis R, Zwillich CW. The physiologic and psychological effects of the bedside presentation. N Engl J Med 1989;321:1273–1275.
17. Lehmann LS, Brancati FL, Chen M, Roter D, Dobs AS. The effect of bedside case presentations on patients’ perceptions of their medical care. N Engl J Med 1997;336:1150–1155.
18. Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Bedside case presentation: why patients like them but learners don’t. J Gen Intern Med 1989;4:284–287.
19. Howe A, Anderson J. Involving patients in medical education. BMJ 2003;327:326–328.
20. Hodgson H. Teaching and the patient. BMJ 1975;1:628.
21. McGraw RC, O’Conner HM. Standardized patients in the early acquisition of clinical skills. Med Educ 1999;33:572–578.
22. Anderson KK, Meyer TC. The use of instructor-patients to teach physical examination techniques. J Med Educ 1978;53:831–836.
23. Stillman PL, Swanson DB. Ensuring the clinical competence of medical school graduates through standardized patients. Arch Intern Med 1987;147:1049–1052.
24. Waterbury JT. Refuting patients’ obligations to clinical training: a critical analysis of the arguments for an obligation of patients tot participate in the clinical education of medical students. Med Educ 2001;35:286–294.
25. Farquhar D. Reducing reliance in hospitalized patients for undergraduate clinical skills teaching in internal medicine. Acad Med 2000;75:537.
26. LaCombe M. On bedside teaching. Ann Intern Med 1997;126:217–220.
27. Tremonti LP, Biddle WB. Teaching behaviors of residents and faculty members. J Med Educ 1982;57:854–859.
28. Wykurz G, Kelly D. Developing the role of patients as teachers: literature review. BMJ 2002;325:818–821.
29. Frazer NB, Miller RH. Training practical instructors (programmed patients) to teach basic physicial examination. J Med Educ 1977;52:149–151.
30. Guttman HA, Paris J. Using nonpsychiatric patients to teach medical students about psychiatry. J Med Educ 1978;53:147–149.
31. Stillman PL, Ruggill JS, Rutala PJ, Sabers DL. Patient instructors as teachers and evaluators. J Med Educ 1980;55:186–193.
32. Gall EP, Meredith KE, Stillman PL, et al. The use of trained patient instructors for teaching and assessing rheumatologic care. Arthritis Rheum 1984;27:557–563.
33. Lindsley HB, Welch KE, Bonaminio G. Using patients to teach functional assessment of patients with arthritis. Acad Med 1998;73:583
34. Hendry GD, Schrieber L, Bryce D. Patients teach students: partners in arthritis education. Med Educ 1999;33:674–677.
35. Plymale MA, Witzke DB, Sloan PA. Cancer survivors as standardized patients: an innovative program integrating cancer survivors into structures clinical reaching. J Cancer Educ 1999;14:67–71.
36. Coletta EM, Murphy JB. Using elderly disabled patients to teach history taking and physical examination. Acad Med 1993;68:901.
37. Kelly D, Wykurz G. Patients as teachers: a new perspective in medical education. Educ Health 1998;11:369–377.
38. Stacy R, Spencer J. Patients as teachers: a qualitative study of patients’ views on their role in a community-based undergraduate project. Med Educ 1999;33:688–694.
39. Barrows HS, Abrahamson S. The programmed patients: a technique for appraising student performance in clinical neurology. J Med Educ 1964;39:802–805.
40. Stillman PL, Regan MD, Philbin M, Haley HL. Results of a survey on the use of standardized patients to teach and evaluate clinical skills. Acad Med 1990;65:288–292.
41. Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Acad Med 1993;68:443–451.
42. Fortin AH, Haeseler FD, Angoff N, et al. Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors. J Gen Intern Med 2002;17:704–708.
43. Blake K, Gusella J, Greaven S, Wakefield S. The risks and benefits of being a young female adolescent standardised patient. Med Educ 2006;40:26–35.
44. Davies M. The way ahead: teaching with simulated patients. Med Teacher 1989;11:315–320.
45. Simek-Downing L, Quirk ME, Letendre AJ. Simulated versus actual patients in teaching medical interviewing. Fam Med 1986;18:358–360.
46. Rethans JJ, Gorter S, Bokken L, Morrison L. Unannounced standardised patients in real practice: a systematic literature review. Med Educ 2007;41:537–549.
47. Bokken L, Van Dalen J, Rethans JJ. Performance-related stress symptoms in simulated patients. Med Educ 2004;38:1089–1094.
48. Bokken L, Van Dalen J, Rethans JJ. The impact of simulation on simulated patients: a focus group study. Med Educ 2006;40:781–786.
49. Fletcher KE, Stern DT, White C, Gruppen LD, Oh MS, Cimmino VM. The physical examination of patients with abdominal pain: the long-term effect of adding standardized patients and small-group feedback to a lecture presentation. Teach Learn Med 2004;16:171–174.
50. Livingstone RA, Moodie PF, Ostrow DN. A follow-up study of patient-instructors who teach the pelvic examination. J Med Educ 1980;55:715–717.
51. Kleinman DE, Hage ML, Hoole AJ, Kowlowitz V. Pelvic examination instruction and experience: a comparison of laywoman-trained and physician-trained students. Acad Med 1996;71:1239–1243.
52. Livingstone RA, Ostrow DN. Professional patient-instructors in the teaching of the pelvic examination. Am J Obstet Gynecol 1978;132:64–67.
53. Papadakis MA, Croughan-Minihane M, Fromm LJ, Wilkie HA, Ernster VL. A comparison of two methods to teach smoking-cessation techniques to medical students. Acad Med 1997;72:725–727.
54. Sachdeva AK, Wolfson PJ, Gabler Blair P, Gillum DR, Gracely EJ, Friedman M. Impact of a standardized patient intervention to teach breast and abdominal examination skills to third-year medical students at two institutions. Am J Surg 1997;173:320–325.
55. Beckmann CR, Sharf BF, Barzansky BM, Spellacy WN. Student response to gynecologic teaching associates. Am J Obstet Gynecol 1986;155:301–306.
56. Johnson GH, Brown TC, Stenchever MA, Gabert HA, Poulson AM, Warenski JC. Teaching pelvic examination to second-year medical students using programmed patients. Am J Obstet Gynecol 1975;121:714–717.
57. Kretzschmar RM. Evolution of the gynecology teaching associate: an education specialist. Am J Obstet Gynecol 1978;131:367–372.
58. Wånggren K, Pettersson G, Csemiczky G, Gemzell-Danielsson K. Teaching medical students gynaecological examination using professional patients—evaluation of students’ skills and feelings. Med Teacher 2005;27:130–135.
59. Plauche WC, Baugniet-Nebrija W. Students’ and physicians’ evaluations of gynecologic teaching associate program. J Med Educ 1985;60:870–875.
60. Wallis LA, Tardiff K, Deane K. Changes in students’ attitudes following a pelvic teaching associate program. J Am Med Womens Assoc 1984;39:46–48.
61. Levenkron JC, Greenland P, Bowley N. Using patient instructors to teach behavioral counseling skills. J Med Educ 1987;62:665–672.
62. Davidson R, Duerson M, Rathe R, Pauly R, Watson RT. Using standardized patients as teachers: a concurrent controlled trial. Acad Med 2001;76:840–843.
63. Carter MB, Wesley G, Larson GM. Didactic lecture versus instructional standardized patients interaction in the surgical clerkship. Am J Surg 2005;189:243–248.
64. Carter MB, Wesley G, Larson GM. Lecture versus standardized patient interaction in the surgical clerkship: a randomized prospective cross-over study. Am J Surg 2006;191:262–267.
65. Colletti L, Gruppen L, Barclay M, Stern D. Teaching students to break bad news. Am J Surg 2001;182:20–23.
66. Vannatta JB, Smith KR, Crandall S, Fischer PC, Williams K. Comparison of standardized patients and faculty in teaching medical interviewing. Acad Med 1996;71:1360–1362.
67. Holzman GB, Singleton D, Holmes TF, Maatsch JL. Initial pelvic examination instruction: the effectiveness of three contemporary approaches. Am J Obstet Gynecol 1977;129:124–129.
68. Levenkron JC, Greenland P, Bowley N. Teaching risk-factor counseling skills: a comparison of two instructional methods. Am J Prev Med 1990;6(2 suppl):29–34.
69. Nelson LH. Use of professional patients in teaching pelvic examinations. Obstet Gynecol 1978;52:630–633.
70. Helfer RE, Black MA, Teitelbaum H. A comparison of pediatric interviewing skills using real and simulated mothers. Pediatrics 1975;55:397–400.
71. Sanson-Fisher RW, Poole AD. Simulated patients and the assessment of medical students’ interpersonal skills. Med Educ 1980;14:249–253.
72. Gilliland WR, Pangaro LN, Downing S, et al. Standardized versus real hospitalized patients to teach history-taking and physical examination skills. Teach Learn Med 2006;18:188–195.
Keywords:

Active or passive patient roles; Patient-instructors; Real patients; Review; Simulated or standardized patients; Undergraduate medical education

© 2008 Society for Simulation in Healthcare