Simulated patients in undergraduate education in psychiatry

This paper describes the use of simulated patients in medicaleducation and how actors have been deployed with medical studentsin Aberdeen. The advantages and disadvantages of using actorsfor student education are summarised and we conclude with somepossible future developments. At the outset, it may be helpfulto outline some definitions, as in the review by Barrows (1993).A ‘standardised patient’ is an umbrella term forboth an actual patient who is trained to present his or herown illness in a standardised way and also for a simulatedpatient who is a well person trained to portray an illnessin a standardised way. This paper will use these terms but willrelate mainly to the use of professional actors (not volunteersfrom the general public, who are often deployed by medicalteachers) as simulated psychiatric patients.

Historical synopsis

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Historical synopsis

Ainsworth et al (1991), Barrows (1993) and Wallace (1997)have provided accounts of the development of standardised patientprogrammes in North America. Howard Barrows is credited withusing the first simulated patient in Los Angeles in 1963; thiswas an artist’s model who posed as a patient with multiple sclerosis. Barrows (1993) has described the progressive useof simulated patients in portraying a wider range of neurologicaland other physical symptoms. However, his innovations weregreeted 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 andelsewhere, the use of simulated patients gradually evolved.In the 1970s, difficult patients who might be hostile, seductiveor hate doctors were used to teach students in Michigan, andthe use of simulated patients grew to teaching interview skillsin general. ‘Unannounced’ simulated patients wereintroduced, and doubts about their realism were reduced whenthey went undetected during out-patient clinics. Their firstuse in medical student assessments was probably by Ronald Hardenand colleagues in Dundee who used them in objective structuredclinical examinations (OSCEs; Harden et al, 1975). The useof simulated patients in both undergraduate and postgraduate assessments of clinical skills, as well as in diverse areasof medical education, has since become progressively widespread.

Contemporary uses of simulated patients

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Contemporary uses of simulated...

Teaching
Simulated patients are now deployed for teaching purposes inalmost all areas of medicine where students and healthcareprofessionals interact with conscious patients. Some of themore innovative uses, and those more relevant to psychiatricpractice, are summarised in Box 1. This shows simulated patient teaching often relates more to attitudinal and interactiveareas of medicine, rather than to more specific acquisitionof knowledge. As such, it is perhaps surprising that psychiatryhas not had a more leading role in its development, but thismay relate to the relative complexities involved in traininga simulated patient to portray a psychiatric role convincingly.

Assessment
Since the 1970s, the use of standardised patients in OSCEs hassteadily evolved and has been reviewed by Adamo (2003). VideotapedOSCEs can also provide a valuable teaching opportunity throughfeedback from teachers and peers (Rose & Wilkerson, 2001;Brazeau et al, 2002). Standardised patients have been usedprogressively in more wide-ranging types of examinations, thisdevelopment arising through disenchantment with ineffectiveand inequitable methods of learner assessment (Kassebaum & Eaglen, 1999);real patients differ greatly from each other and the same realpatient may present very differently to each examinee. Standardised patients provide consistency within examination centres andeven permit the possibility of national standardisation (Barzansky & Etzel, 2004). Furthermore, trained standardised patients can participatehelpfully and reliably in the assessment process (Luck & Peabody, 2002;Van Zanten et al, 2005).

Box 1. Some teaching uses of simulated patients
Psychiatry

Introductionto psychotherapy with emotionally difficult patients (Trudel, 1996)

Consultingwith patients seeking benzodiazepines or opiates (Taverner et al, 2000)

Simulatedpatients with schizophrenia for whole class teaching of mental state examination (Birndorf & Kaye, 2002)

Introductionof junior medical students to delirium to aid integration of psychiatric, physical and psychosocial concepts (Chur-Hansen & Koopowitz, 2002)

Internationalvideoconferencing to illustrate transcultural psychiatry (Ekblad et al, 2004)

Otherareas of medicine

Presenting and discussing a medical errorwith a simulated patient (Halbach & Sullivan, 2005)

Empathicand effective death disclosure (Quest et al, 2002)

Illustrationof ethical dilemmas (Tysinger et al, 1997)

Sexual history-takingand HIV counselling (Haist et al, 2004)

Addressing domesticviolence (Haist et al, 2003)

A ‘standardised family’to aid understanding of family dynamics and community orientation(Clay et al, 2000)

A standardised hospitalisation experiencefor medical students (Wilkes et al, 2002)

Research
Medical teaching is under-researched; this is partly becausesuch research is often methodologically complex. Some of thesecomplexities can be reduced by the use of standardised patients;for example, real patients, videotaped interviews and simulatedpatients can be compared to investigate optimal teaching methods(Eagles et al, 2001a; Knowles et al, 2001). To understandbiases in assessments and management plans, patients can bestandardised in their presentations but differ in age, raceor gender (Wilson et al, 2002; Kales et al, 2005). Unannouncedsimulated patients can be deployed to research the skills acquiredby 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 researchingappropriate developments.

Advantages and disadvantages of simulated patients

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Advantages and disadvantages of...

At a time of increased attention to confidentiality and patientprivacy, 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 simulatedpatients in undergraduate education. The use of simulated patientsavoids the potential mistreatment of real patients and protectsthem against ‘novice practice’ (Du Boulay & Medway, 1999),but reassures students, particularly when the teaching relatesto an emotionally sensitive area. Indeed, it can permit students access to clinical situations that they would otherwise beunlikely to encounter, for example domestic violence, HIV counsellingand 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 widerange of different presentations. Teaching techniques can bedeployed which would be problematic with real patients. The interview can be frozen, with the tutor calling ‘timeout’, during which the teacher and students can reflecton what has been occurring and debate where the consultationmight proceed before ‘time in’ is called (Barrows, 1993). Experienced simulated patients can step out of role and providevaluable 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 usingprofessional actors in psychiatric teaching, where roles maywell 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 diminishonce a programme is established, and overall may actually proveto be cheaper given the staff time saved in teaching and assessment (Ainsworth et al, 1991; Kelly & Murphy, 2004). Examineesmay be justifiably disappointed if the costs of using standardisedpatients are passed directly to them (Wettach, 2003).

Psychiatric teaching with actors in Aberdeen

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Psychiatric teaching with actors...

We have been using actors in our undergraduate psychiatry teachingwith Aberdeen students since 1996, and we started to do sofor three principle reasons. First, the new curriculum requiredin response to the General Medical Council’s (1993) publicationof Tomorrow’s Doctors prompted a fundamental review ofpsychiatric teaching. Second, our shrinking in-patient populationhad become overexposed to students and less inclined to agreeto see them. Third, our in-patients had become progressivelyunrepresentative of the spectrum of psychiatric disorders thatstudents would be seeing in other areas of medical practice.

Contact was made with Aberdeen Actors, a professional groupwho had already done some similar role-playing with socialworkers. Detailed life histories and scripts were preparedfor actors. Discussions and rehearsals led into live performanceswith students, and ongoing feedback and refinement followed continuing exchanges between actors and tutors. Some interviewsbetween actors and psychiatrists have been videotaped for regularuse with more junior students. Psychiatric conditions presentedby actors have included depression, anxiety, alcohol misuse/dependence,hypomania, schizophrenia, psychosis with aggression, obsessive-compulsivedisorder, overdose in an adolescent and early dementia. Intheir final year, students have a week of joint teaching from psychiatrists and general practitioners, during which actorsportray somatisation, life crisis/depression, the spouse ofa dementia sufferer, adolescent crisis and alcohol misuse.Actors play scenes separated in time, while students interviewas general practitioners or psychiatrists, emphasising inter-specialtylinks 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 programmeare the generic ones outlined above. The costs are not prohibitive;in the academic year 2004-2005, a total of 107 live actor sessionsand 6 understudy rehearsals cost under £8000. This constitutesa tiny proportion (less than 0.5%) of the additional cost ofteaching monies received by Aberdeen psychiatry. Our actorsportray a wide range of presentations with flair and professionalism, and students generally find that they can not distinguish themfrom ‘real’ patients.

A very significant advantage is that actors can be trained toportray patients who would, in real life, decline to see studentsbut are common and typical (Eagles et al, 2001b). An examplewould comprise a person with an alcohol problem who gives informationabout his drinking in a guarded and defensive manner. We havealso been impressed by the constructive feedback provided tostudents by actors when they come out of role at the end ofan interview. It was this component of the teaching sessionthat seemed to give rise to our students rating actors as superiorto other methods of teaching about alcohol misuse in the specificarea of improvement in interview skills (Eagles et al, 2001a).

Perhaps partly because the majority of the literature on simulatedpatients is published by enthusiasts, less has been writtenabout their disadvantages. Although our experiences have alsobeen very predominantly positive, we have observed a few problemslocally. Once actors have been trained, it is sometimes temptingnot to tinker with their script or performance, so that teachingsessions may become outdated or repetitive. Actors may draw, inappropriately, on their own experiences and embellish theirroles outside the scope intended by the scriptwriter. Occasionally,overacting may occur; for example, simulated patients may bejust too depressed or too hopeless. Actors are often encouragedto present challenging scenarios to students and they may notalways appreciate the point at which their presentation becomesa little too difficult and challenging.

Future developments

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Future developments

In psychiatry, and in other areas of medicine, it seems highlyprobable that the use of simulated patients will continue toincrease both for teaching and for assessments. This may becoupled with an increasing national uniformity in curriculaand in assessments. There could be more collaborative use ofactors and videotaped simulated patients between teaching centres.It is to be hoped that research into medical education willreceive the attention it merits and will be facilitated bythe use of simulated patients.

Acknowledgments

The Royal College of Psychiatrists Scottish Division UndergraduateStudent Teaching And Recruitment Group (S-DUSTARG) coordinatedthe writing of this paper and the others in this series onundergraduate education in psychiatry. Bill Dick of AberdeenActors has been a very constructive, innovative and helpfulcollaborator. The secretarial work for this paper was done byLana Hadden and Lindsay Thomson gave helpful comments on thefirst draft.

References

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