Psychiatric Bulletin (2007) 31: 187-190. doi: 10.1192/pb.bp.106.010793
© 2007 The Royal College of Psychiatrists
Simulated patients in undergraduate education in psychiatry
John M. Eagles, Consultant Psychiatrist
Royal Cornhill Hospital, Cornhill Road, Aberdeen AB25 2ZH, email:
john.eagles{at}gpct.grampian.scot.nhs.uk
Sheila A. Calder, Consultant Psychiatrist
Royal Cornhill Hospital, Aberdeen
Sam Wilson, Clinical Teaching Fellow
Medical Education Unit, University of Aberdeen
Jane M. Murdoch, Lecturer in Old Age Psychiatry
University of Aberdeen
Paul D. Sclare, Consultant Psychiatrist
Royal Cornhill Hospital, Aberdeen
Declaration of interest
None.

Introduction
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 artists 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.

Contemporary uses of simulated patients
Teaching
Simulated patients are now deployed for teaching purposes in
almost all
areas of medicine where students and healthcare
professionals interact with
conscious patients. Some of the
more innovative uses, and those more relevant
to psychiatric
practice, are summarised in Box 1. This shows simulated patient
teaching often relates more to attitudinal and interactive
areas of medicine,
rather than to more specific acquisition
of knowledge. As such, it is perhaps
surprising that psychiatry
has not had a more leading role in its development,
but this
may relate to the relative complexities involved in training
a
simulated patient to portray a psychiatric role convincingly.
Assessment
Since the 1970s, the use of standardised patients in OSCEs has steadily
evolved and has been reviewed by Adamo
(2003). Videotaped OSCEs can
also provide a valuable teaching opportunity through feedback from teachers
and peers (Rose & Wilkerson,
2001; Brazeau et al,
2002). Standardised patients have been used progressively in more
wide-ranging types of examinations, this development arising through
disenchantment with ineffective and inequitable methods of learner assessment
(Kassebaum & Eaglen,
1999); real patients differ greatly from each other and the same
real patient may present very differently to each examinee. Standardised
patients provide consistency within examination centres and even permit the
possibility of national standardisation
(Barzansky & Etzel, 2004).
Furthermore, trained standardised patients can participate helpfully and
reliably in the assessment process (Luck
& Peabody, 2002; Van
Zanten et al, 2005).
| Box 1. Some teaching uses of simulated patients
Psychiatry
- Introduction to psychotherapy with emotionally difficult patients
(Trudel, 1996)
- Consulting with patients seeking benzodiazepines or opiates
(Taverner et al,
2000)
- Simulated patients with schizophrenia for whole class teaching of mental
state examination (Birndorf & Kaye,
2002)
- Introduction of junior medical students to delirium to aid integration of
psychiatric, physical and psychosocial concepts
(Chur-Hansen & Koopowitz,
2002)
- International videoconferencing to illustrate transcultural psychiatry
(Ekblad et al,
2004)
Other areas of medicine
|
Research
Medical teaching is under-researched; this is partly because such research
is often methodologically complex. Some of these complexities can be reduced
by the use of standardised patients; for example, real patients, videotaped
interviews and simulated patients can be compared to investigate optimal
teaching methods (Eagles et al,
2001a; Knowles et
al, 2001). To understand biases in assessments and management
plans, patients can be standardised in their presentations but differ in age,
race or gender (Wilson et al,
2002; Kales et al,
2005). Unannounced simulated patients can be deployed to research
the skills acquired by practitioners exposed to different teaching strategies
(Luck & Peabody, 2002). If
medical education techniques are to be further refined, simulated patients are
likely to play a major role in researching appropriate developments.

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).
Developing a bank of simulated patients (as described by
Ker et al, 2005) is
time-consuming but, once established, such patients are available at
any time and available in any setting
(Barrows, 1993). Moreover, one
person can simulate a wide range of different presentations. Teaching
techniques can be deployed which would be problematic with real patients. The
interview can be frozen, with the tutor calling time out, during
which the teacher and students can reflect on what has been occurring and
debate where the consultation might proceed before time in is
called (Barrows, 1993).
Experienced simulated patients can step out of role and provide valuable
structured feedback to students (Eagles
et al, 2001a;
Rose & Wilkerson, 2001;
Wettach, 2003).
Simulated patients can be stressed by the roles they portray
(Bokken et al, 2004),
which is probably a reason for using professional actors in psychiatric
teaching, where roles may well be more emotionally demanding than in other
areas of medicine. A positive aspect of the simulated patient role is that the
simulators become more knowledgeable about their own health
(Wallach et al,
2001).
Simulated patient programmes have cost implications. Costs diminish once a
programme is established, and overall may actually prove to be cheaper given
the staff time saved in teaching and assessment
(Ainsworth et al,
1991; Kelly & Murphy,
2004). Examinees may be justifiably disappointed if the costs of
using standardised patients are passed directly to them
(Wettach, 2003).

Psychiatric teaching with actors in Aberdeen
We have been using actors in our undergraduate psychiatry teaching
with
Aberdeen students since 1996, and we started to do so
for three principle
reasons. First, the new curriculum required
in response to the General Medical
Councils (
1993)
publication
of
Tomorrows Doctors prompted a fundamental review
of
psychiatric teaching. Second, our shrinking in-patient population
had
become overexposed to students and less inclined to agree
to see them. Third,
our in-patients had become progressively
unrepresentative of the spectrum of
psychiatric disorders that
students would be seeing in other areas of medical
practice.
Contact was made with Aberdeen Actors, a professional group who had already
done some similar role-playing with social workers. Detailed life histories
and scripts were prepared for actors. Discussions and rehearsals led into live
performances with students, and ongoing feedback and refinement followed
continuing exchanges between actors and tutors. Some interviews between actors
and psychiatrists have been videotaped for regular use with more junior
students. Psychiatric conditions presented by actors have included depression,
anxiety, alcohol misuse/dependence, hypomania, schizophrenia, psychosis with
aggression, obsessive-compulsive disorder, overdose in an adolescent and early
dementia. In their final year, students have a week of joint teaching from
psychiatrists and general practitioners, during which actors portray
somatisation, life crisis/depression, the spouse of a dementia sufferer,
adolescent crisis and alcohol misuse. Actors play scenes separated in time,
while students interview as general practitioners or psychiatrists,
emphasising inter-specialty links and demonstrating the longitudinal course of
a disorder, for example early alcohol misuse in primary care evolving to
hospitalisation with delirium tremens.
Many of the advantages of using actors in our teaching programme are the
generic ones outlined above. The costs are not prohibitive; in the academic
year 2004-2005, a total of 107 live actor sessions and 6 understudy rehearsals
cost under £8000. This constitutes a tiny proportion (less than 0.5%) of
the additional cost of teaching monies received by Aberdeen psychiatry. Our
actors portray a wide range of presentations with flair and professionalism,
and students generally find that they can not distinguish them from
real patients.
A very significant advantage is that actors can be trained to portray
patients who would, in real life, decline to see students but are common and
typical (Eagles et al,
2001b). An example would comprise a person with an
alcohol problem who gives information about his drinking in a guarded and
defensive manner. We have also been impressed by the constructive feedback
provided to students by actors when they come out of role at the end of an
interview. It was this component of the teaching session that seemed to give
rise to our students rating actors as superior to other methods of teaching
about alcohol misuse in the specific area of improvement in interview skills
(Eagles et al,
2001a).
Perhaps partly because the majority of the literature on simulated patients
is published by enthusiasts, less has been written about their disadvantages.
Although our experiences have also been very predominantly positive, we have
observed a few problems locally. Once actors have been trained, it is
sometimes tempting not to tinker with their script or performance, so that
teaching sessions may become outdated or repetitive. Actors may draw,
inappropriately, on their own experiences and embellish their roles outside
the scope intended by the scriptwriter. Occasionally, overacting may occur;
for example, simulated patients may be just too depressed or too hopeless.
Actors are often encouraged to present challenging scenarios to students and
they may not always appreciate the point at which their presentation becomes a
little too difficult and challenging.

Future developments
In psychiatry, and in other areas of medicine, it seems highly
probable
that the use of simulated patients will continue to
increase both for teaching
and for assessments. This may be
coupled with an increasing national
uniformity in curricula
and in assessments. There could be more collaborative
use of
actors and videotaped simulated patients between teaching centres.
It
is to be hoped that research into medical education will
receive the attention
it merits and will be facilitated by
the use of simulated patients.

Acknowledgments
The Royal College of Psychiatrists Scottish Division Undergraduate
Student
Teaching And Recruitment Group (S-DUSTARG) coordinated
the writing of this
paper and the others in this series on
undergraduate education in psychiatry.
Bill Dick of Aberdeen
Actors has been a very constructive, innovative and
helpful
collaborator. The secretarial work for this paper was done by
Lana
Hadden and Lindsay Thomson gave helpful comments on the
first draft.

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