During the past 20 years, teaching methods in medical education and clinical practice have shifted from a focus on factual knowledge to an emphasis on problem solving and a deeper understanding of principles. At the same time, there has been a sea change in how medical professionals develop their clinical skills, away from learning by direct patient contact toward simulated learning in which actors portray patients (standardized patients or SPs) or patient cases are reenacted electronically (virtual patients or VPs). Using SPs and virtual environments for clinical encounters reinforces principles that are best learned through tactile/experiential contact, boosts the confidence of the learner, and can enhance patient safety.

Apart from their value in teaching clinical skills, exercises using SPs and VPs can also help assess student proficiency. Most medical educators agree that assessments should cover all essential content and goals of a curriculum, often including mastering facts, practical skills, and problem solving. SP exercises have been used for more than 30 years in the U.S. to assess the ability of a student to conduct an appropriate history and physical examination. More recently, simulated environments have been used to assess a learner’s “clinical reasoning”—the ability to integrate data, create a differential diagnosis of possible explanations for a patient’s illness, and apply logic to make the best clinical decision. SP and virtual patient exercises can provide an ideal medium to test these skills. Indeed, multipronged assessments that test what a learner knows, through the use of pencil-and-paper exercises and what a learner can do by using SPs, VPs, or objective structured clinical examinations (OSCEs), provide a more comprehensive inventory of student skills than any single-assessment approach.

SP exercises and virtual patients can also be made more or less complex and so are suitable for teaching and assessing health care providers from novice to expert.

In this chapter we review the modern use of simulated environments, for both teaching and assessment purposes, at various levels of medical education. Simulation is increasingly used to teach principles and assess performance at all levels of medicine, from the beginning medical student attempting to master the medical interview, to multidisciplinary teams coordinating crisis care.

Given that the best way to replicate a human being is with a human being, many aspects of the clinical world can be evoked using specially trained actors to portray patients with particular health conditions or concerns. Because of the special training they receive to consistently reenact patient presentations, these actors have been called “standardized patients” (SPs). They are able to give a predefined account of their condition and to answer a full range of questions about themselves in a consistent way.

In a typical SP exercise, a faculty member first develops a clinical script with specific objectives in mind. For example, one may wish to test a student’s ability to obtain a focused history and perform a physical exam for a patient with abdominal pain. After the case is developed, a faculty panel reviews the script for medical accuracy. An actor is then trained to portray the medical facts of the case, including his or her character’s specific condition and relevant past history. At the conclusion of the exercise, the SP completes a checklist describing which questions were asked and which physical exam maneuvers were performed (and whether they were performed correctly). The SP also provides a more subjective assessment of the student’s communication skills. For a strictly formative exercise, training may involve memorizing a basic script over a few hours and providing direct feedback to the student. However, for “high-stakes” clinical examinations, actor training is often quite elaborate and detailed, involving multiple sessions over weeks to months, to ensure that the actors’ portrayals are standardized — that they show a certain level of internal consistency — and can appropriately determine whether a specific question was asked or a specific physical exam maneuver was performed correctly.

Standardized patients may be used for both teaching and assessment purposes in multiple, interdependent domains of clinical skills Figure 41-1. These areas include history and physical examination skills, data interpretation and clinical reasoning, patient management, and working within multidisciplinary teams. These skill domains are progressively complex, and a learner must become proficient within one area in order to develop the next. Communication skills are key skills throughout these domains. If appropriately developed and supported, SPs and VPs can add to clinical skills instruction and assessment at all of these steps of medical education.

Basic Clinical Skills: History and Physical Examination

Most medical schools now use standardized patients to help acquire and assess basic clinical skills. Although used primarily at the medical school level, SPs can also reinforce these skills throughout the duration of medical training.

The SP approach has frequently been used when first teaching basic history and physical examination skills to entry level medical students. This allows novices to practice and hone their skills before direct patient contact. At this initial level, students need not specifically know how to interpret their results. Rather, the goals may simply be to become comfortable with the parts of a medical history and the mechanics of performing a focused or comprehensive physical examination; even something as basic as laying hands on the body can be daunting for some students. As students progress in their preclinical years and learn the physiology and pathophysiology of human disease, they begin to understand not just the mechanics but also the clinical implications of their questions and findings. Practicing symptom- or diagnosis-specific exercises with direct faculty and SP feedback can be truly valuable.

At Stanford, SP exercises during the first year of medical school mainly allow students to learn and practice parts of the medical history and physical examination and are formative, including feedback directly from the SP. Therefore, by the end of the first-year curriculum, students are comfortable obtaining a medical history and performing a basic physical examination. As students progress during their medical training, they have targeted practice for specific clinical scenarios and can further refine these skills and practice more advanced topics in a safe, constructive setting. For example, we rely on SP exercises to introduce topics such as obtaining a sexual history, discussing substance abuse, and motivational interviewing (eg, advocating for smoking cessation), allowing students to become more comfortable with unfamiliar or difficult themes. Similarly, more sensitive parts of a physical exam, such as genital or pelvic examinations, are often best first learned with a trained, standardized educator; pelvic educators (or “gynecological teaching associates”) are common in medical schools and can also help clinical medical students and residents reinforce their skills.

As students master the mechanics of the history and physical examination, SP exercises developed primarily to instruct students may also be used for assessment. At Stanford we employ a series of SP-based “high-stakes” clinical examinations at various milestones in medical training. A more formative assessment at the end of the first year ensures that students have mastered basic history, physical examination, and communication skills before entering the second year. A similar, more complex examination toward the end of the second preclinical year serves as a benchmark. Having acquired additional scientific and clinical knowledge, students have learned to think in real time and ask the most salient questions and, understanding the implications of the history, then perform the most relevant maneuvers in a focused physical examination. This exam ensures that students enter their clinical clerkship training having mastered a set of essential history, physical examination, and communication skills. Finally, along with other medical schools in California, Stanford participates in a half-day clinical performance examination (CPX) after the first year of clinical training that evaluates students’ performance in clinical and interpersonal skills. Successful completion of the CPX is a Stanford University School of Medicine graduation requirement.