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 ...