Simulated patients and objective structured clinical examinations: review of their use in medical education

Simulated or standardised patients have been used in medical education and other medical settings for some 30 years (Box 1). Their use encompasses undergraduate and postgraduate learning, the monitoring of doctors’ performance and standardisation of clinical examinations. Simulation has been used for instruction in industry and the military for much longer (Jason et al, 1971) but the first known effective use of simulated patients was by Barrows & Abrahamson (1964), who used them to appraise students’ performance in clinical neurology examinations. The objective structured clinical examination (OSCE) was first described by Harden & Gleeson as, ‘a timed examination in which medical students interact with a series of simulated patients in stations that may involve history-taking, physical examination, counselling or patient management’ (Harden & Gleeson, 1979). Because OSCEs have been shown to be feasible and have good reliability and validity (Hodges et al, 1998) their use has become widespread as the standard for performance-based assessment, particularly in undergraduate examinations. The use of OSCEs in undergraduate examinations (‘summative’ use) occurs in every London medical college and was pioneered by the Royal London and St Bartholomew’s Hospitals. Many colleges across the UK have now adapted their examinations to include these components. In addition, there is considerable uptake in the use of simulated patients for medical student training (‘formative’ use). Several of the medical Royal Colleges have introduced an OSCE component into their postgraduate membership examinations. For example, the Royal College of Anaesthetists includes an OSCE in Part I of the fellowship examination, and the Royal College of Obstetricians and Gynaecologists has an OSCE in Part II of their examinations. The Royal College of Surgeons, London, are introducing OSCEs and a pilot is being planned for this year. The Royal College of Physicians has a Practical Assessment of Clinical Examination Skills (PACES) in their clinical examinations, part of which comprises a communication and ethics station, in which simulated patients are used. Although the preferred method of examination is with videotape of real consultations, the Royal College of General Practitioners has a ‘simulated surgery’ that about 5% of candidates use. The Royal College of Psychiatrists has recently proposed changes to the existing membership examinations with a view to increasing their reliability and validity (http://www.rcpsych.ac.uk/ traindev/exams/exam_recent.htm). The main changes are to the Part I examination, and from spring 2003 the existing individual patient assessment will Simulated patients and objective structured clinical examinations: review of their use in medical education