M edical Teacher, V ol. 20, N o.

6, 1998

AM EE M edical Education Guide No. 13:

real patients, simulated patients
and simulators in clinical
examinations
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1 2
J. P. CO LL IN S & R . M . HA R D EN
1
F aculty of M edicine & Health Sciences, U niversity of Auckland, New Zealand; & 2 Centre for M edical E ducation, University
of D undee, D undee, U K

SU M M AR Y In the assessm ent of clinical com petence it is
im portant to observe a candidate interacting w ith a pa tient.
T he role of the pa tient in this encounter w ill va ry depending
upon the level of interaction expected betw een the student
For personal use only.
which cannot be simulated, the use of sim ulated patients in
delicate or em otionally dif® cult areas, and the use of simulators
where the use of patients w ould be inappropriate, for example,
cardiopulmonary resuscitation. In m any instances, how ever,

and the pa tient, and w hether ph ysical signs are pa rt of the
presentation. P atients used in exam inations m ay be real or
sim ulated by a person w ho has undergone training in order to
reproduce a pa rticular scenario. M odels or sim ulators,
videotape and audiotape and com puters m ay also be used as
patient substitutes.
There is a continuum betw een real patients w ith no training
and simulated patients w ho 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 m odify, for the
purpose of the exam ination, aspects of their history or
presentation;
(5) `real’ patients w hose m edical experience form s the basis for
their performance in the examination but whose presen-
tation is substantially modi® ed for the purpose of the
examination;
(6) sim ulated patients who are given only an outline of what is
expected of them ;
(7) sim ulated patients who are given a short brief or scenario
with w hich they becom e familiar but beyond w hich they are
free to respond as they w ish;
(8) sim ulated patients who are briefed extensively and w ho are
thoroughly rehearsed prior to the exam ination.
S im ple 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 exam ination limited to one approa ch. Examples w here the
choice is limited are the use of real patients with physical signs
there is no one correct approa ch. The approach adopted should
be determined by the local circumstances and the needs of the
exam ination.
F actors w hich should in¯ uence the choice of patient repre-
sentation in an examination are related to:
(1) w hat is being assessed, including the level of abnorm ality
and level of interaction with the patient required;
(2) the level of standardization required, with greater emphasis
on standardization needed for high-stakes national exam i-
nations;
(3) the logistics, including the availability and costs of real
patients and trained sim ulated patients;
(4) the context, for example, practice-based or form al examina-
tions of the OS CE type;
(5) the level of realism or authenticity required.
Practical steps can be taken in the clinical examination to
get the m axim um value from the patient whether `real’ or
simulated.
Ex am ination of clinical com petence
At a recent international m eeting on medical education, a
participant asked the question ª Is it possible to use real
patients in an Objective Structured Clinical Examin-
ation?º . The question is a surprising one. M any centres use
only real patients in the OSCE setting and som e a mixture
of both real and simulated patients. Indeed, the initial
description of the OSCE (Harden et al. , 1975) and the
subsequent ASME M edical Education booklet on the sub-
ject (Harden & Gleeson, 1979) both refer to the use of real
Correspondence: John P. C ollins, C entre for M edical Education, M iddlemore
Hospital, Private Bag 93 311, Otahuhu , Auckland 6, New Zealand. Tele:
1 649 2 704779; Fax: 1 649 276 0066; e-mail: jcollins@middlemore.co.n z

508 0142-159X /98/060508-14 $9.00 Ó 1998 C arfax Publishing Ltd

 Patients in assessm ent

patients. The question, however, is an understandable one.

The use of standardized or simulated patients has, in many
centres, become synonymous with the OSCE as an ap-
proach to the assessment of clinical competence. Little
attention has been paid to when it is appropriate to use real
patients and when standardized simulated patients should
be used.
The assessm ent of a student’ s clinical com petence
involves the m easurem ent of a wide range of interrelated
but different skills including skills of com m unication
and physical exam ination of patients. For m any years, the
bedside clinical exam ination, with the patient playing
a central role, was the pre-em inent m ethod for assess-
ing th ese skills. Its importance was recognized in the F igure 1. Three variables in the clinical exam ination.
® nal exam ination with a pass in clinical com petence be-
ing a requirem ent for a pass in the exam ination as a
whole (Stokes, 1974). Q uestions were raised, how-
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ever, about the reliability of th e traditional clinical

An account is given of the different ways in which patients
exam ination.
can be represented in the examination, including real pa-
It was recognized that wide variations in the level of
tients, simulated patients or patient substitutes. The guide
dif® culty presented by different patient challenges and
describes the factors which should be taken into account
variation in the judgem ent and objectivity of exam iners
when selecting the patient representation to be used.
m ay lead to serious psychom etric de® ciencies and
problem s of reliability (M cGuire, 1966; Pokorny &
Frazier, 1966; Foster et al. , 1969; W ilson et al. , 1969). A pproaches to patient representations in clinical
These factors led som e exam iners and exam ination exam inations
boards in the 1960s to m ove aw ay from patient-based
Three approaches to the use of patients in clinical exami-
assessm ent (Hubbard et al ., 1965), and alternative ap -
For personal use only.

nations are available:

proaches were pursued. W ritten tests of the m ultiple-
choice type offered greater reliability, were easy to score
and covered large areas of content; other written ap -
proaches adopted included the m odi® ed-essay question
(Knox, 1975), and th e patient-m anagem ent problem
(Harden, 1983).
The development of the objective structured clinical
examination (OSCE), with its emphasis on patient partici-
pation, represented a different approach which aimed to
achieve both reliability and validity. The concept of simu-
lated or programm ed patients was introduced by Barrows
& Abraham son (1964) to facilitate the learning of clinical
skills and was subsequently developed for use in assess-
m ent (Barrows, 1968; Lam ont & Hennen, 1972; Stillm an
et al. , 1976).
The use of OSCEs and simulated patients expanded
during the 1980s (Stillman et al. , 1986; Barrows et al. ,
1987; Stillman & Swanson, 1987; Newble & Swanson,
1988; Harden, 1990). There was wide agreement that it
was essential to observe candidates interacting with pa-
tients to achieve validity in assessm ent. The importance of
authentic or performance-based testing has been empha-
sized further in the 1990s with patients having a central
role in the assessment process. The Ottawa Conferences
(Hart et al. , 1986; Hart & Harden, 1987; Bender et al. ,
1990; Harden et al. , 1992; Hart et al. , 1992) re¯ ected the
growing interest in the use of patients in the assessment of
students’ clinical competence.
In the clinical examination there are three variables: the
student, the examiner and the patient (Figure 1). The aim
should be to standardize the examiner and the patient so
that the student’ s performance can be seen as a measure of
his or her clinical com petence. This booklet provides
guidelines for the use of patients in clinical examinations.
(1) `real’ patients as encountered in medical practice;
(2) simulated patientsÐ individuals trained to play the role
of patients;
(3) patient substitutes, including video or sound represen-
tations, plastic or other models, or computer simula-
tions.
The distinction between the use of `real’ and `simulated’
patients may not be as clear as it would appear from the
literature. Indeed, there is a spectrum from the real patient
who is completely unrehearsed to the simulated patient
who is extensively trained, and whose every response is
carefully though t through (Figure 2). Points in the contin-
uum include:
(1) the `real’ unrehearsed patient in clinical practice. An
example is the consultation in general practice where
the trainee’ s performance is assessed by an analysis of
the consultation skills recorded in a videotape of the
consultation (Campbell et al. , 1993).
(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. There may be a bank of such
patients who may have ® xed physical ® ndings such as
a heart murm ur or a joint problem;
(4) `real’ patients who have been asked to modify aspects
of their history or perform ance in an examination.
Patients may be asked, for example, to focus on a
particular aspect of their history or to accentuate
physical ® ndings. They may be coached in order to
modify the level of dif® culty of the examination;
(5) `real’ patients whose medical experience is used as a
basis for their perform ance in the examination but

509
 J. P. Collins & R. M . Harden
Figure 2. Continuum between the use of `real’ and `simulated’ patients in a clinical examination.
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whose presentation is substantially modi® ed for the
purpose of the examination. They may be asked to
simulate joint stiffness in arthritis, muscle rigidity in
neurological disorders or right upper abdominal ten-
derness in biliary disease;
(6) simulated patients who are given only an outline of
what is expected of them. This use of simulated pa-
tients is found in situations where the interaction in
the examination between the patient and the student is
minimal. Examples are physical examination or proce-
For personal use only.
dures such as ophthalmoloscopy where no abnorm ality
is demonstrated, and patient education in topics such
as diabetes, asthma, hypertension, ostomy care, immu-
nization and contraception. Counselling challenges
can be created around obesity, sm oking, alcoholism
and coping with cancer. Other scenarios such as gain-
ing consent for therapeutic procedures including
surgery have been used satisfactorily;
(7) simulated patients who are given a short brief or
scenario with which they become fam iliar but beyond
which they are free to respond as they wish. Baerheim
& M alterud (1995) have described the use of simu-
lated patients who were encouraged to adjust their
roles to their personal backgrounds. They were trained
to act restricted roles that had been structured as
additions to their personal experience and chosen and
modi® ed according to their own choice. The simulated
patients reported that the perform ance had been easy
and felt natural. One of them said ª It felt quite genu-
ine. To me it was especially easy because I had previ-
ously suffered from som ething similar.º The short
training of simulated patients as described by Baer-
heim & Malterud (1995) may not be enough to stan-
dardize performance. They argue that in m any exam i-
nations this is not important;
(8) simulated patients who are briefed extensively and
who are thoroughly rehearsed prior to the examina-
tions. Such patients m ay be taught to simulate abnor-
malities on exam ination such as a cough, abdominal
tenderness or more complex scenarios. Dif® cult per-
sonalities as well as the hostile, non-comm unicative or
anxious patient or relative, including psychiatric disor-
ders such as depression with or without suicidal ten-
dencies, can all be portrayed. Substance abuse,
510
confusional states, collapse or the results of severe
trauma can be simulated (Collins, 1992).
The use of real patients, simulated patients and patient
substitutes is discussed in more detail in this section of the
guide.
(1) `R eal’ patients
The traditional use of `real’ patients in clinical assessment
has included their participation as long and short cases
(Stokes, 1974; Newble, 1991). For the long-case scenario,
a patient is required who can give a clear history and who
has adequate physical signs. Short cases are usually pa-
tients with obvious physical ® ndings such as goitre or
rheumatoid arthritis.
W ith careful selection, `real’ patients can provide an
adequate opportunity to assess a candidate’ s skills. To
reduce the variability in the cases presented to students, it
is possible to recruit a small group of patients with the
same condition and similar signs, for exam ple, chronic
obstructive airways disease, polycystic kidneys or aortic
valve disease (Newble, 1992).
In many centres real patients rather than sim ulated
patients are used in O SCEs. Patients’ views of their partici-
pation in high-stakes clinical examinations have been re-
ported as favourable (Persaud & M eux, 1990; Sharma et
al. , 1994). Sharma et al. reported that over two-thirds of
patients found the examination pleasant/enjoyable and felt
helpful and important. A large m ajority said that they
would participate again, many looking forward to it as a
social occasion.
In the past, anaesthetized patients undergoing a surgi-
cal procedure have been used to teach and assess rectal
and vaginal examination often without the patient’ s per-
mission. This practice, however, is ethically unacceptable,
legally questionable and of uncertain educational value.
Endotracheal intubation techniques have also been taught
and assessed using anaesthetized patients and patients who
have recently died. This practice too has been condemned
(Tonks, 1992), although the value of intubating cadavers
has been recommended providing protocols are followed
(Hinchley, 1992; Tyrrell et al. , 1992). In a survey of the
public in Norway, Brattebo et al. (1993) found that most

people agreed that intubation technique could be practised
on patients who have recently died.
Advantages of using `real’ patients
The use of `real’ patients offers a number of advantages:
(1) they can demonstrate clearly abnormal ® ndings such
as goitre, cardiac murm urs, hypertension and preg-
nancy;
(2) they are readily available in many situations;
(3) they require no additional resources and minimum
organizational support;
(4) they may incur no cost other than travelling expenses
for outpatients;
(5) they offer a high level of acceptability to staff and
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students (Newble, 1991);
(6) if included in an examination together with simulated
patients they may make the whole experience more
credible. The use of real patients makes less necessary
the `willing suspension of disbelief’ necessary in an
examination in which only sim ulated patients partici-
pate.
D isadvantages
Using real patients also has disadvantages:
For personal use only.
(1) they may be less available in some situations;
(2) if not carefully selected, participation in an exam in-
ation may cause distress or embarrassment for the
patient;
(3) the patient may be unwilling to participate in an exam-
ination where he/she is exposed to large numbers of
students, as in an OSCE;
(4) their behaviour may be unpredictable, their physical
signs may change and their overall condition may
deteriorate. Current medications may preclude their
taking part, as m ay con¯ icting commitm ents such as
investigatory or therapeutic procedures;
(5) patients may be dif® cult to standardize with the result
that students assessed on another patient may have a
very different experience;
(6) real patients may have greater dif® culties in adjusting
their medical histories than simulated patients have in
learning new ones (Baerheim & Malterud, 1995).
(2) Sim ulated and standardized patients
Considerable differences may occur between the level of
complexity presented by different patients, the quality of
their physical signs and their ability to give an adequate or
consistent history. These factors together with, in some
cases, a lack of availability of patients led to the develop-
m ent of simulation techniques for use in assessment. Sim-
ulated patients (SPs) may be real patients or lay persons
who have undergone varying levels of training in order to
provide consistent clinical scenarios. Students interact with
simulated patients as though they were taking a history,
examining or counselling a real patient.
Considerable interest has been shown in simulated
Patients in assessm ent
patients as an assessm ent tool in medical education. In the
USA, the AAM C held a consensus conference on the use
of standardized patients in teaching and evaluation of
clinical skills and this was published in the June 1993 issue
of Academic M edicine and highlighted in Teaching and
Learning in M edicine (Anderson & Kassebaum, 1994). A
survey carried out in 1993 in US and Canadian M edical
Schools revealed that 39 of the 111 schools require stu-
dents to take, before graduation, an examination which
involves using `standardized’ patients to evaluate clinical
skills (Anderson et al. , 1994). There has been an interest in
simulated patients in other countries although to a lesser
extent. The London Initiative on Sim ulated Patients Proj-
ect (ISPP) held a conference in 1994 to explore the experi-
ence gained and future potential of simulated patients in
medical education.
The sim ulated patient, if appropriately trained, should
not be distinguishable from a real patient by experienced
clinicians (Norman et al. , 1982). Norman made a direct
com parison of resident performance with real and simu-
lated patients presenting the same problem. No signi® cant
differences emerged in the performance of residents with
the real or simulated patients. Residents correctly
identi® ed 67% of the patients they had seen as real or
simulated against a chance ® gure of 50%.
Sim ulated patients can be used to test a broad range of
skills including history taking, physical exam ination and
counselling. M ost commonly SPs are used to assess history
taking and communication skills or physical examination
where no abnormality is found.
Barrows (1993) has described a wide range of physical
® ndings that can be simulated but Stillm an (1993) has
cautioned on the need for considerable expertise if som e of
these are to be simulated realistically. Simulated patients
have also been used to evaluate the spoken English
pro® ciency of foreign medical graduates (Friedman et al. ,
1991).
Sim ulated patients can be used to assess students’
com petence in a range of settings and covering different
aspects of performance in the context of am bulatory care
(Furman et al. , 1994) and general practice (Pieters et al. ,
1994; Shahabu din et al. , 1994).
Sim ulated patients have been used in assessment in two
ways. The com monest use is in the context of a formal
examination, either an objective structured clinical exam-
ination with a series of relatively short stations (Harden &
Gleeson, 1979), or in a long-station examination (Ferrel &
Thompson, 1993). A second approach is to use a simu-
lated patient in the practice setting to assess the doctor’ s
performance (Rethans & van Boven, 1987; Tamblyn et al. ,
1992; Shahabu din et al. , 1994). This provides a measure of
the performance of general practitioners in practice.
Standardized patients and sim ulated patients
The term `standardized patient’ is increasingly used to
indicate that the person has been trained to play the role of
the patient consistently and according to speci® c criteria.
The term was introduced by Geoff Norman from M cMas-
ter. It recognized the need in some circumstances for a
high degree of reproducibility over a large number of
students with each student facing the same test situation in
511
 J. P. Collins & R. M . Harden
F igure 3. Standardized patients may be `real’ or `simulated’ .
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the examination. Van der Vleuten & Swanson (1990)
reviewed published studies of the psychom etric character-
istics of tests using standardized patients. They found that
relatively little m easurement error is introduced if multiple
standardized patients are trained to play the sam e patient
role. Vu & Barrows (1994), updated this earlier review and
concluded that ª use of live SP technology in large-scale
perform ance assessments in the health professions has
dem onstrated that, at least at the institutional level, such
For personal use only.
assessments not only are feasible but also can be standard-
ized and scored in an objective mannerº .
The terms standardized patient and simulated patients
are som etimes used interchangeably (see for example
Pololi, 1995) and the abbreviation SP has been used to
refer to both. This is, however, m isleading. The simulated
patient as de® ned by Barrows (1985) is ª a normal person
who has been carefully coached to present the symptoms
and signs of an actual patientº . The emphasis is on the
simulation of reality. Standardized patients, in contrast, are
ª people with or without actual disease who have been
trained to portray a medical case in a consistent fashion.
These people may portray their own problem(s) or ones
based on those of other patientsº (RCSA, 1993). The
emphasis is on consistency of presentation. Standardized
patients can be simulated or real and may need little or
considerable training (Figure 3). A real patient with a
m urmur of aortic stenosis can be used as a standardized
patient in an OSCE with little or no training. A simulated
patient m ay need considerable training to portray a com-
plex situation. In contrast, a simulated patient may need
little training to sim ulate a patient on whom the student’ s
use of the sphyg momanometer is being tested. A real
patient may be coached to m odify his/her history and to
present this in a considered way.
The trend to replace the use of the term `simulated
patients’ with `standardized patients’ re¯ ects the emphasis
on ª the need to provide a standard patient problem that
will not vary from student to studentº (Barrows, 1993).
The term `standardized patient’ is a broader term which
covers both real and simulated patients. It does not indi-
cate whether the patient being dealt with or discussed is a
real or simulated one. This has both advantages and disad-
vantages.
512
The training and recruitment of SPs
Simulated patients can be recruited in a variety of ways. In
Dundee we have found that an effective approach is
through an advertisement in the local paper. This may
produce more than a hundred responses, with many prov-
ing suitable for recruiting as SPs. Some prefer to target
particular groups such as amateur actors, students, rela-
tives of staff and school teachers.
The brie® ng and training of SPs is critical to the
success of the programme. The extent of training required
will vary with the use to which the SP is to be put.
Simulated patients need to be motivated, integrated in
medical education and available, and according to Stillman
(1993), very sm art. ª W e can train them to portray all
different degrees of sm artness, but the basic substrata has
to be a high degree of smartness. It is important that they
are not bitter against the medical profession and that they
have com munication skillsº . Smee (1996) reported that six
of the 16 Canadian medical schools had a full-time staff
person responsible for coordinating a standardized patient
program me and several more have a part-timer.
Howard Barrows describes, in an introduction to a
series of videotapes which provides guidance on training
simulated patients (published by the Health Sciences Con-
sortium, Chapel Hill, NC 27514-1517 USA), the simu-
lated patient as a ª person who has been carefully coached
to simulate an actual patient so accurately that the simu-
lation cannot be detected by a skilled clinician. In perform-
ing the simulation the SP presents the gestalt of the patient
being simulated; not just the history.º SPs, he suggests,
can be trained in three one-hour coaching sessions with
simple problems taking even less time. Barrows describes
three com ponents of training of the simulated patientÐ the
history, the physical ® ndings and the dress rehearsal. The
SP is ® rst given a thorough history and outline of the
patient’ s problem . The SP’ s own experience and back-
ground are used as much as possible. This, Barrows sug-
gests, makes it easier for the SP’ s performance to seem
natural and unrehearsed. The patient’ s symptom s are then
explained to the SP avoiding medical term inology. For
many SPs no further training is required and one can
proceed to a dress rehearsal in which a doctor unfamiliar

with the patient exam ines the SP. This is observed by the
trainer. Feedback is given to the SP by the doctor and the
trainer. The SP m ay also learn to simulate physical
® ndings. In a case of pneumothorax, the SP can learn to
m anipulate his/her body so that asym metric breathing is
apparent during gross observation and when the doctor
examines him/her with a stethoscope. The coaching
m ethod for patient simulation as described by Barrows
(1985) is an adaptation of what is comm only referred to as
`method acting’ .
Thew & Worrall (1998) have described the Leicester
approach to training SPs, which is based on videotapes of
actual general practice consultations. The training process
used is as follows:
(1) Consultations are recorded during a normal surgery
where the patient characteristics appear to match the
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age and sex of the simulator.
(2) The video recording is ® rst seen by the sim ulator who
decides whether it is possible to identify suf® ciently
with the patient.
(3) The consultation is then discussed exhaustively at a
mutual viewing with the doctor who recorded the
consultation, the originating doctor. The simulator is
encouraged to enquire from the patient’ s perspective
about issues relevant to the consultation. Factual in-
formation about the patient which is not known by the
trainer can be hypothesized by the simulator as long as
For personal use only.
this is then incorporated into the patient’ s character, a
process described as `creative consistency’ . Such addi-
tions, which are never medical, are only made to
sustain credibility.
(4) It is left to the simulator to decide how to present the
patient. For some cases the sym ptoms, body language
and voice are telling enough. In others credibility is
helped by attention to hair style, dress or distinctive
items such as spectacles or a handbag. Personal effects
are often necessary to help the simulator become the
patient.
(5) The patient sim ulator has `® rst time’ consultations
with at least four other trainer doctors.
(6) The SP and the originating doctor decide which issues
are to be assessed in the consultation. These are incor-
porated into a checklist.
O n what criteria can SPs be assessed? This can be done on
the basis of:
· accuracyÐ how clearly does the SP replicate the picture?
· consistencyÐ how reproducible is the representation by
the SP?
· replicabilityÐ can several patients trained at the same
site produce the same simulation?
· portabilityÐ can the simulation be produced at different
sites?
Simulated patients are a valuable resource and once
trained it is important to keep them in a programme
(Stillman, 1993). It helps to:
(1) work them interm ittently througho ut the year. If you
only use them one to two days in a year you may lose
them;
Patients in assessm ent
(2) allow them to teach or give feedback to students. This
maintains their interest in the programme;
(3) provide ongoing positive reinforcement to them about
their contribution.
Advantages of using sim ulated patients
(1) The SP can be trained to respond more consistently in
the examination than the real patient, can be dupli-
cated to allow multiple examinations to be adminis-
tered and is more standardized for use in different
centres and internationally (Sutnick et al. , 1994).
(2) The com plexity of the presentation can be more easily
controlled and matched to the stage of training of the
student.
(3) The risk that the perform ance by the student during
the examination may be disturbing to the real patient
is not a problem with SPs.
(4) SPs may be more readily available than real patients
and can be relied upon to be present at an examin-
ation.
(5) SPs can be used in situations where the use of a real
patient would be inappropriate, e.g. counselling of a
patient with cancer.
(6) SPs can be trained to assess the student’ s performance
and to provide feedback to the student.
(7) SPs may tolerate more students in an examination
than a real patient would. In an OSCE, for example,
one SP m ay serve one station but two matched real
patients, used alternately, m ay be required for the
same station.
(8) The recruitment of SPs from the com munity con-
tributes to the development of a working partnership
and good relations between the community and the
medical school.
D isadvantages of using SP s
(1) Recruiting, training and organization of SPs is time
consuming. Many schools with an SP program me ® nd
they need a member of staff to undertake this responsi-
bility full time.
(2) The cost of SPs may be substantially higher than that
of `real patients’ . This may be com pensated in some
situations by using SPs instead of clinicians to assess
the student’ s performance.
(3) SPs do not duplicate the `real patient’ . ª We do not
believeº said Stillm an et al. (1990), ª that SPs can ever
replace the rich encounter that occurs between a stu-
dent, a faculty member and an actual patientº .
(4) It is not possible to simulate many physical signs, for
example, heart sounds, oedema or a goitre.
(5) O pposition to the use of SPs m ay be voiced by
som e exam iners and clinicians and the credibility
of the exam ination m ay be questioned. The sugges-
tion that sim ulated patients be used in the U K to
assess doctors against whom com plaints have been
m ade led to th e headline in the S unday T im es (18
A ugust 1996) `D octors to be tested by bogus pa-
tients’ . A G P was quoted as saying ª There are m uch
better ways of assessing people’ s perform ance than
using joke patients. It is an insult to the whole
professionº .
513
 J. P. Collins & R. M . Harden
Scepticism to the use of SPs is usually quickly
erased, however, by personal exposure to the concept
in action (Miller, 1990). Examiners ® nd that SPs are
clinically realistic and that they can interrelate with
them as they do with real patients. We found in
Dundee that experienced clinicians in a ® nal exam in-
ation were unable to differentiate SPs from real pa-
tients. Nor are SPs detected when they are sent into
doctors’ practices unannounced (Owen & Winkler,
1974; Norman et al. , 1985).
(3) Patient substitutes
In some situations in a clinical examination, neither a real
patient nor a simulated patient is appropriate and a patient
substitute has to be used. These include:
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· video or sound recordings of a patient;
· sim ulators;
· a computer simulation.
V ideo and sound recordings
Video recordings of patient interviews were initially intro-
duced to enhance the learning of interview techniques
and com m unication skills (M aguire et al. , 1978). Such
recordings also provide a convenient m ethod for assessing
these skills, particularly in dif® cult areas such as be-
For personal use only.
havioural science, paediatrics, geriatrics and psychiatry
(Jolly, 1981; Fenton & O ’ G orm an, 1984). The recording
provides each candidate with a consistent scenario and
enables important aspects of clinical com petence to be
assessed.
In Dundee, videotapes have been used in O SCEs in the
® nal examination and in early phases of the curriculum, to
represent a clinical situation where it was not possible to
use real patients or simulated patients. Examples are the
m anagement of a patient with a wound and a patient with
depression. Audio recordings of heart sounds and m ur-
m urs may be used in an exam ination, to assess a candi-
date’ s knowledge and ability to interpret cardiac sounds.
Such recordings have been used successfully during the
® nal m edical examination in Auckland over several years
(Collins & Gamble, 1996).
S im ulators
The value of sim ulators as an adjunct to clinical teaching
with patients has been recognized (McLeod & Harden,
1985). Such simulators have a place in the assessm ent of
clinical skills. They can be used at OSCE stations to assess
physical examination techniques or practical procedures.
Simulators to assess cardiopulm onary resuscitation are in
comm on use.
Som e m odels are static and perm it exam ination and
m anipulation by the student, but do not respond to what
the student is doing. O thers are interactive in som e way
with students. In the ® rst catego ry are m odels for breast
exam ination, m odels for exam ination of the ear and the
eye, and m odels of the fem ale pelvis for vaginal exam in-
ation and the m ale pelvis for rectal exam ination. Simula-
tors are available to assess procedural and practical skills
514
including m inor surgery. Sim ulators can be used to assess
the insertion of intravenous lines, the catheterization of
the m ale and fem ale bladder and endoscopy technique. A
range of abnorm alities can be inserted into the m odels.
M acintosh & C hard (1997), in an assessm ent of pelvic
trainers, concluded th at th e sim ulators were suitable
for assessing the technique of pelvic exam ination but
unsuitable for assessing the recognition of abnorm al
® ndings. They found th at som e of the conditions
emulated were m issed by experienced gynaecologists. If
such m odels are used, it is important to appreciate their
lim itations.
Sim ulators can be used to assess surgical ability in
simple wound closure including suture tension and accu-
racy of placement (Platt et al. , 1997). A model which
closely mimics an in¯ am ed toe is available which allows a
range of procedures to be assessed, including ring block
with local anaesthetic and wedge excision of the nail bed
and total ablation of the nail. Other sim ulators can be used
to assess anastam otic technique, injection of a joint and
laparoscopic surgery.
`Harvey’ is an example of a more sophisticated model.
It was developed by Michael Gordon at the M edical Train-
ing and Simulation Laboratory in the University of M iami
and offers a technology-based approach to assessment.
This lifelike cardiac simulator can be used to assess the
student’ s physical examination technique including the
interpretation of venous pulsations, respiratory and pulse
rates and rhythm, praecordial movem ents, heart sounds
and murmurs. It can be program med to represent a range
of conditions (Sajid et al. , 1990).
The ® rst tested com puter controlled patient sim ula-
tor, `Sim O ne’ , a lifelike anaesthetic training m odel, was
developed by the U niversity of Southern California
School of M edicine in 1967 (Abraham son et al. , 1969).
Sim O ne behaved like a real patient and could be used to
assess an anaesthetist’ s com petence in routine procedures
and in anaesthetic emergencies. Later developm ents of
this m odel are now used for training and assessm ent of
anaesthetists.
W hile simulators have played a key role in competence
assessment of other workers, notably aircraft pilots, such
simulators have been slow to make an impact in medicine.
This situation is changing rapidly and the future is likely to
see such devices playing a prominent role in clinical assess-
ment.
Com puter-based simulations
Com puter-based simulation of patients can be used as an
assessment tool and has been developed for use in both
formative and summative assessment (Clyman & Orr,
1990).
ª Efforts to develop computer-based clinical simulations
have been progressing for 25 yearsº suggest Swanson et al.
(1996) ª Early simulations were little more than PM Ps
delivered via com puter terminals. M ore recently, simula-
tions have included high-® delity models of the patient care
environment, requiring examinees, in an uncued fashion,
to select from the full range of diagnostic and therapeutic
modalities available in clinical settings. The simulations
can be based upon dynamic models of disease pro-

cesses; as a result, computer-sim ulated patients can
respond appropriately to the therapeutic efforts of
examinees.
C hoice of patient representation
W e have reviewed in the previous section the different
approaches to using patients in clinical examinations. In
this section, we look at the factors which should be taken
into account when choosing between the different options
available. These include:
· the role expected of the patient;
· the level of standardization required;
· local logistics including experience of using the different
approaches, availability of the different options and cost;
· the context for the assessment;
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· the requirement for realism or authenticity.
The role expected of the patient
An important factor in the choice of approach is the role
expected of the patient in the examination. This varies
with:
· the aspect of clinical competence to be tested, and
whether the emphasis is on the norm al or the abnormal;
· the level of interaction expected between the student and
For personal use only.
the patient;
· whether the patient is expected to contribute to the
rating of the students’ performance.
The aspect of competence to be tested. The ability of a
clinician to obtain accurate and complete inform ation by
interview and physical examination of a patient is the basis
on which a clinical diagnosis is made. Students may be
expected to dem onstrate a range of competences in an
examination. This may include competence in comm uni-
cation skills and skills in physical exam ination and practical
procedures. Some aspects of physical examination of the
patient and som e procedures such as vaginal examination
and endotracheal intubation are seen as particularly sensi-
tive or invasive and present particular problems for the
assessment of a student’ s competence. Characteristics such
as empathy are recognized as important attributes of a
good physician and may be tested in a clinical examination
(Colliver et al. , 1998). Problem solving has been a major
T able 1. Different levels of patient interactivity.
Level of interactivity
Aspect of
com petence tested Less interactive
History taking Gives history only
Physical examination Inspection
Patient education Patient listens only
Practice procedures M easurement of BP
Patients in assessm ent
focus of medical education and may be assessed in a
clinical examination (Solomon et al. , 1994).
Some competences are m ore easily assessed using sim-
ulated patients whereas others require real patients. His-
tory taking and the technique of physical examination can
be assessed using simulated patients. Some physical signs
are relatively easy to simulate while others are more
dif® cult. Signs such as cyanosis and jaundice may be
simulated, but many examiners would prefer to use real
patients with these conditions. W here the purpose of the
assessment is to measure a candidate’ s ability to elicit or
demonstrate important physical signs then real patients
with these conditions will be required. Common examples
are rheum atoid arthritis of the hands and peripheral vascu-
lar disease of the legs. If the technique of physical examin-
ation is being assessed, then the observation of a candidate
examining a sim ulated patient, or a real patient without
physical signs, is adequate. M easurement of a person’ s
blood pressure, exam ination of a joint or a neurological
examination of the limbs are exam ples.
Participation by patient and level of interactivity required. The
role of the patient varies with the level of interactivity
required. Different components of the examination require
different levels of interactivity and patient participation
(Table 1). During a patient education station in an OSCE
the patient may simply listen to the student. An example is
a station where the student has to advise a patient about
rehabilitation after a myocardial infarction having been
briefed about the patient at the previous station. The
patient, however, may be programmed to play a more
inter-active role. This may include asking questions, pro-
viding additional information about themselves or demon-
strating emotional reactions and behaviours such as rude-
ness or crying.
The level of patient interaction may be high or low in
patients exhibiting both norm al and abnormal ® ndings
(Figure 4). The greater the interaction with the patient in
the examination, the more important is training of the
simulated patient. Real patients m ay be expected to re-
spond without training but m ay do so in a non-standard
way.
The patient as an assessor. Considerable experience has been
gained using the SP to evaluate students’ performance
(Stillman et al. , 1986, 1990; Vu et al. , 1992). ª The SPsº ,
suggested Vu et al. , ª not only have to portray accurately
M ore interactive
Responds to questions
O ther aspects of
examination
Patient listens and
asks questions
Venepuncture
515
Med Teach Downloaded from informahealthcare.com by University of California Irvine on 10/26/14 J. P. Collins & R. M . Harden
F igure 4. Level of patient abnormality and interaction required in different assessm ent scenarios.
the patient problem they are trained to simulate, but also
have to record accurately on a check list the precise actions
perform ed by the examinees during the encounter.º The
accuracy of SPs in recording check list items has been
found to be good or very good and to be consistent over a
one-day or a longer exam ination. Vu et al. (1992) suggest
that SPs can be used as a valid and cost-effective recorder
For personal use only.
of information. Training of SPs for this important role may
be highly effective (Van der Vleuten et al. , 1989). In the
recently introduced ECFM G test of clinical competence,
information about students’ performance is collected en-
tirely by SPs. The role of recorder, however, should not be
confused with the role of evaluator where judgements have
to be passed on a candidate’ s competence or lack of
competence.
There are signi® cant bene® ts to be gained from physi-
cians watching their own students in an examination in
order to motivate them and to provide them with imm edi-
ate feedback about their teaching (Collins et al. , 1998). It
is unfortunate if the use of SPs as assessors prevents this.
The level of standardization required
A second factor to be considered when choosing the type
of patient representation is the level of standardization
required. Real patients differ one from another and may
present a varying picture on separate occasions with no two
students facing the identical clinical task. Varying levels of
dif® culty or inaccuracies in a patient’ s presentations in an
examination may have a m ajor impact on an examinee’ s
perform ance. This may be critical where pass/fail decisions
are required, but is less important in formative assessment
where the emphasis is on enhancing learning by appropri-
ate individualized feedback in the exam ination (Black &
Harden, 1986).
The extent to which simulated patients have an advan-
tage over real patients is in¯ uenced by the level of stan-
dardization required by the chosen format of the exam in-
ation (Ainsworth et al. , 1991). Standardization becomes an
important issue in high-stakes examinations administered
516
to a large num ber of students. In this situation, the need is
for standardized patients who will consistently and repro-
ducibly offer to students the same clinical presentation.
The need for standardization will vary with the number of
candidates, the examination sites involved, and the time
over which the exam ination will take place.
Sim ulated patients are reproducible and can present
students with the same challenge at different sites and at
different times at the same site. This is useful if large
numbers of students have to be assessed on the same tasks
at the same degree of dif® culty.
A real patient may be useful if few students are to be
assessed. Adjustments may be needed in the check list with
real patients to individualize it to each patient. If students
are assessed on different patients, possible variations in the
degree of dif® culty can be addressed by comparing the
mean m arks of the groups examined on each patient.
Scores can be equated to achieve standardization.
Logistics
A third important factor in the choice of patient represen-
tation in a clinical exam ination is the logistics. These
include:
· availability of `real’ patients;
· availability and experience with simulated patients;
· availability of simulators;
· costs.
Availability of `real’ patients. The availability of real
patients in the num bers required to run a clinical examin-
ation varies between different cities and countries. The
lack of availability of such patients reported from North
AmericaÐ a factor in the rapid development of sim ulated
patients thereÐ m ay be unheard of in other places.
A shortage of patients for use in clinical examinations
may be the result of the ethical issues involved, changes in
the attitude of patients and changes in the delivery of
health care. Advances in medical technology and the in-
creased number of diagnostic and therapeutic procedures

perform ed in ambulatory or day-stay clinics have reduced
the number of patients admitted to hospital as well as
shortening the stay of those who are admitted. M oreover,
clinicians responsible for the organization of examinations
m ay have less personal contact with suitable patients and
this will affect recruitment of patients. At the same time,
publicity of medical misadventures and a greater awareness
of ethical issues involved in utilizing sick people in exam i-
nations have affected the attitudes of patients towards
participating in educational exercises. For those patients
who are in employm ent, getting time off work m ay also
have unacceptable ® nancial and workplace implications,
particularly at tim es of econom ic restraint.
Availability of sim ulated patients. Simulated patients have
to be recruited, trained and organized. Preparation of the
fully trained patient may require considerable expertise
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and time, although only m inim al training is necessary for
som e purposes. The fully trained person enables a wide
range of scenarios to be successfully sim ulated. Poor simu-
lation creates major dif® culties both for the candidate and
the m arker and has to be avoided.
Not all centres have the expertise and resources to
administer a simulated patient program me. A high level of
expertise with the selection and training of simulated pa-
tients has been accumulated in some schools. A bank of
such patients may be available. In such an environment,
advantage should be taken of this expertise and simulated
For personal use only.
patients used where appropriate in clinical assessment.
If there is a lack of trainers or suitable persons to be
trained, real patients, particularly those who are briefed,
m ay be more appropriate in a clinical examination, es-
pecially if the standardization procedure m entioned earlier
is followed.
Availability of approp riate simulators and other patient substi-
tutes. Simulators, if available, can play an important part
in student assessment. This is particularly true for import-
ant procedures such as cardiopulmonary resuscitation, and
in physical examination of the heart. Not all institutions,
however, have a cardiac simulator such as `Harvey’ which
provides authentic representation of heart sounds and may
be used instead of real patients with the cardiac signs.
C ost. An overriding factor may be cost. In som e centres
the cheapest option may be the use of real patients. The
cost of simulated patients varies from centre to centre. In
som e instances SP volunteers are paid only travelling ex-
penses, in others payment covers the time spent by the SP
participating in the assessment. The use of paid trained
simulated patients as recorders, however, may be cost-ef-
fective if the result is that less time is required of clinical
teachers for the assessment process. The difference in cost
m ay be substantial in a situation such as the ECFM G
clinical assessment where the clinical examination is run
throughout the year, ® ve days a week.
C ontext of the assessment
The assessment of a student’ s clinical competence has
been discussed, for the most part, in the context of a
formal exam ination. Newer approaches to assessment us-
Patients in assessm ent
ing portfolios (Snadden & Thomas, 1998) place a greater
role on the student’ s experience with real patients seen in
the community as well as in the hospital context. For
reaccredidation purposes, ª on-the-jobº assessment with
real patients is generally considered m ore appropriate than
formal traditional examinations. Sim ulated patients have,
however, been used in this situation (Rethans & van
Boven, 1987). The exam ination or submission of
videotapes of consultations conducted in general practice
with real patients has been used as an assessment tool to
evaluate general practitioner trainees’ consultation skills.
Requirem ent for realism or authenticity
The extent to which the patient representation is indis-
tinguishable from reality may or may not be important,
depending on what is being tested. A plastic m odel for
vaginal examination may be realistic enough to assess
aspects of the vaginal examination technique (excluding
com munication with the patient), but may be insuf® ciently
realistic to assess the student’ s ability to differentiate be-
tween different gynaecological pathologies (Macintosh &
Chard, 1997).
In general, the more realistic the patient representation,
the more likely will the examination assess what the stu-
dent will do in practice. Expecting students to com muni-
cate with a simulated patient whom they recognize as
simulated m ay inhibit their performance. In computer
simulations, the realism created by the scenarios and the
student’ s interaction with the patient and the patient’ s
response to the student’ s actions m ay be m ore important
than a multimedia representation with less interaction.
Hints on using patients in clinical assess m ent
This guide has reviewed the different types of patient
representation in assessment and the factors that might
affect the choice between the range of options. In this ® nal
section, we present som e additional guidelines or hints on
using patients in the assessment of students. Som e apply to
both real and simulated patients. Some are speci® c to real
patients and some to simulated patients. M any of the
guidelines may appear obvious to the reader and to rep-
resent standard routine practice. Experience has shown,
however, that many of the dif® culties encountered with
clinical assessm ent can be attributed to their neglect.
Issues relating to real or sim ulated patients
(1) Do not leave the selection of patients too late. Early
selection allows the time needed for preparation and
contributes to the success of the examination.
(2) Explain to patients what is expected of them in the
examination and obtain their consent.
(3) Provide the patients with clear instructions regarding
the site of the examination, the time of arrival and
departure, transport and parking arrangem ents and
any reim bursement which will be made.
(4) Advise the patients about appropriate dress.
(5) Provide the patients with the contact num ber of a
517
 J. P. Collins & R. M . Harden
nam ed member of staff which they can use if for some
reason they are unable to attend the examination.
(6) Arrange reserve patients in case a patient is unable to
participate. Duplicate patients may be advisable where
it is felt that not all students can examine one patient.
(7) Simple courtesy and kindness to patients, with a wel-
come when they arrive and tim ely refreshments, will
do much to ensure patients will participate in a relaxed
and cooperative manner.
(8) At the end of the exam ination thank all patients for
their help.
(9) Ask patients for any comments they might have on the
conduct of the exam ination and on their own partici-
pation in it.
Issues speci® c to real patients
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(1) The doctor responsible for the care of the patient will
usually be in the best position to recruit suitable pa-
tients.
(2) For each patient, produce a case pre cis which should
include details of the patient’ s ability to give a clear
history and the degree of certainty of their physical
signs. Comments should be included on their home
circumstances, personal fears and problem s (W eather-
all, 1991).
(3) Copies of X-rays, CT scans, photographs of endo-
For personal use only.
scopic ® ndings and the results of laboratory or other
investigations required for the examination must be
prepared early.
(4) Do not use in the examination, patients who either
through the severity of their illness or their personality
are unsuitable.
(5) Current medications such as diuretics or frequent in-
jections usually preclude patient involvement in the
examination.
(6) Check that arrangements made for patient investiga-
tions and procedures do not con¯ ict with the exam in-
ation. Patient care should take priority over the exam-
ination.
(7) The use of outpatients has advantages and keeps ward
disruption to a minimum .
(8) Communication with ward nursing staff is essential
when using inpatients.
(9) Recon® rm the absence or presence of physical signs
and the patient’ s history before the examination com-
mences.
Issues related to sim ulated patients
(1) Recruit simulated patients from comm unity volun-
teers, students, colleagues, acting groups or other
groups such as teachers.
(2) Recruit sim ulated patients by word of m outh,
through existing patients, from personal contacts and
by advertising in the local paper.
(3) Select individuals who have the ability to portray the
important clinical features of a patient’ s problem.
The characteristics of the individual are as important
as the training they receive (Tamblyn et al. , 1991).
(4) Recruit trainers of simulated patients from healthcare
518
professionals, particularly those with an interest in
education.
(5) Trainers themselves should receive appropriate train-
ing and will bene® t from observing experienced train-
ers in action. The ability of trainers to select and
prepare simulated patients will increase as their ex-
perience increases.
(6) Arrange the training of simulated patients in individ-
ual or group sessions. A written brief of the scenario
to be sim ulated should be supplied and opportunities
given for the person to practise the role. This brie® ng
sheet should be given again to the sim ulated patient
immediately prior to the exam ination to help refresh
his/her memory.
(7) Direct observation of other trained patients or of real
patients in live encounters, or videotape recordings of
such events, can assist with training (Stillm an et al.
1990).
(8) M eeting and talking to real patients with problems
similar to those to be simulated is helpful and worth
the effort needed.
(9) Simulated patients should be the same age and gen-
der as the person they are expected to portray.
(10) Simulated patients may be encouraged to answer the
less critical questions from their own experience and
be allowed to be inventive. Exam ples are the location
of a holiday, or family responsibilities.
(11) The duration of training will vary with the task to be
perform ed and the background of the person playing
this role. Brie® ng for simple tasks takes little time
whereas more complex roles will require 3 hours or
m ore.
(12) Before a simulated patient is used in a high-stakes
examination, a doctor who is unfamiliar with the case
should take a history from or examine the patient.
Conclusions
De® ciencies in the bedside clinical examination of stu-
dentsÐ mainly in respect of reliabilityÐ led m any schools
and examination boards to move to written tests, largely of
the multiple-choice type. In time these tests were also
found to have their own lim itations, particularly relating to
the problem of validity. The need for some form of clinical
examination is now widely accepted. No single test, how-
ever, assesses all the com ponents of clinical competence
and a com bination of different methods is required.
Central to the clinical examination is the observation of
a candidate interacting with a patient and every effort
should be made to retain and improve the validity and
reliability of this process. The appropriate use of real
patients, or simulated patients and simulators, will do
much to achieve this goal.
The approach to the use of real patients, sim ulated
patients or other patient representations using simulators
or computers should be determ ined by the local circum-
stances and needs of the exam ination.
In some cases, the answer is clear cut, for example:
· To assess the exam ination of a patient with a goitre and
exophth alm os, a real patient is required.

T ab le 2. Factors in¯ uencing the choice of the appropriate point on the
continuum between real and sim ulated patients.
Factors Real patient
Simulation Physical signs to be
assessed are not easily
simulated
Availability Real patients readily
available
Standardization Standardization
less important
Frequency Occasional or
intermittent clinical
examination
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Context Assessment on the job,
in practice
Cost Real patient inexpensive
· To assess communication with a disturbed psychiatric
patient, a simulated patient is required.
· To assess cardiopulmonary resuscitation, a sim ulator is
required.
For personal use only.
In many cases, however, the situation is less clear cut and
the answer will depend on the local circumstances. There
m ay be a trade-off between the need for standardization
and the choice of real or sim ulated patients. The term
`standardized patient’ is often wrongly equated with `simu-
lated patient’ . Real patients can be standardized to an
extent as described above, but standardization is easier to
achieve with simulated patients.
The most appropriate choice of patient representation
in a clinical examination can be identi® ed somewhere on
the continuum between the real patient with no brie® ng
and the sim ulated patient with extensive training. Factors
m oving the decision to one or the other end of the contin-
uum are sum marized in Table 2. The decision as to the use
of real patients, sim ulated patients or simulators in a
clinical examination must be taken based on the nature of
the examination and the local context.
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