Simulated patients in undergraduate education in psychiatry

This paper describes the use of simulated patients in medical education and how actors have been deployed with medical students in Aberdeen. The advantages and disadvantages of using actors for student education are summarised and we conclude with some possible future developments. At the outset, it may be helpful to outline some definitions, as in the review by Barrows (1993). A ‘standardised patient’ is an umbrella term for both an actual patient who is trained to present his or her own illness in a standardised way and also for a simulated patient who is a well person trained to portray an illness in a standardised way. This paper will use these terms but will relate mainly to the use of professional actors (not volunteers from the general public, who are often deployed by medical teachers) as simulated psychiatric patients.

Historical synopsis

Ainsworth et al (1991), Barrows (1993) and Wallace (1997) have provided accounts of the development of standardised patient programmes in North America. Howard Barrows is credited with using the first simulated patient in Los Angeles in 1963; this was an artist’s model who posed as a patient with multiple sclerosis. Barrows (1993) has described the progressive use of simulated patients in portraying a wider range of neurological and other physical symptoms. However, his innovations were greeted with general scepticism, often being regarded as ‘too touchy-feely, too expensive, too Hollywood’ (Wallace, 1997). Barrows moved to McMaster University in 1971 and, here and elsewhere, the use of simulated patients gradually evolved. In the 1970s, difficult patients who might be hostile, seductive or hate doctors were used to teach students in Michigan, and the use of simulated patients grew to teaching interview skills in general. ‘Unannounced’ simulated patients were introduced, and doubts about their realism were reduced when they went undetected during out-patient clinics. Their first use in medical student assessments was probably by Ronald Harden and colleagues in Dundee who used them in objective structured clinical examinations (OSCEs; Harden et al, 1975). The use of simulated patients in both undergraduate and postgraduate assessments of clinical skills, as well as in diverse areas of medical education, has since become progressively widespread.

Advantages and disadvantages of simulated patients

At a time of increased attention to confidentiality and patient privacy, which can render participation in teaching less likely, the recent international charter on medical professionalism (Jotkowitz et al, 2004) has called for increased use of simulated patients in undergraduate education. The use of simulated patients avoids the potential mistreatment of real patients and protects them against ‘novice practice’ (Du Boulay & Medway, 1999), but reassures students, particularly when the teaching relates to an emotionally sensitive area. Indeed, it can permit students access to clinical situations that they would otherwise be unlikely to encounter, for example domestic violence, HIV counselling and emotionally difficult psychotherapy patients (Trudel, 1996; Haist et al, 2003; Haist et al, 2004).