what do you think about standardized patients?

[Justin4563]

hey just a question as to what you guys think of standardized patients? Im finishing my residency and when i was graduating they just started to put that in. I think its not a good thing because as good as the actors are they are still fake.. Practice on real patients not on fake ones.. there are plenty of patients practice on in a hospital, why drive the cost of medical education up more on standardized patients.. this is stupid.

I heard you have to go to philly to do a clinical exam on fake patients. Why are they doing this? I thought thats what medical school was

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[NateatUC]

You've really brought up 2 issues here: standardized patients in general, and Step 2CS.

As far as standardized patients in general go, we use them extensively. I think they're great for practicing the history taking and the normal physical exam during 1st and 2nd years. Their training allows them to provide feedback about what you're doing well and not so well. They don't generally get mad when you screw up, as we all do when we're learning. I know when I actually go in with real patients, I'm glad I've had the practice and feedback from standardized patients.

Step 2CS is another story. My understanding is that it was put in place to make sure that we know how to interact with and examine patients. As far as I'm concerned its a total waste of time and money. Our school at least has a very similar exam that we're required to pass anyway during 4th year before we graduate. And its not just Philly where they're going to give it - also Atlanta, Chicago, and a couple other cities. The whole thing remains a great unknown, though, since this year's graduating class will be the first to take it.

 

[southerndoc]

Standardized patients are a good idea. As you point out, they shouldn't be used as replacement for real patients. When combined with real patients, SP's are really good at teaching certain points.

My school used SP's. During our first two years, we routinely encounter SP's for clinical skills, and during the last two years we encountered them for various exams. My school requires a OSCE, and even after implementation of Step 2B (Step 2CS, whatever they call it now), the school still requires their own OSCE.

 

[pikachu]

I think they're a waste of time. What's the point of getting clinical instruction in 3rd and 4th years if you're not going to learn how to do a good H&P? Also, the "feedback" that I have gotten from standardized patients has often directly contradicted the correct way to examine a patient. I got a bad evaluation from one of them because I pushed on her belly "too hard." The standardized patients are actors who know next to nothing about medicine and the proper way to do an exam. Another point - no patient is "standard" so practicing on people who are faking the classic signs and symptoms is not going to improve your diagnostic ability. Let's face it, if you get through 4 years of medical school, and your instructors haven't figured out that you can't recognize rebound tenderness, there was an irremediable problem with your medical education - one that 100 standardized patients and a $1000 OSCE addition to Step 2 is not going to fix. What a colossal waste of time, effort, and money.

 

[Justin4563]

exactly my point pikachu...

take a history on a real patient with your preceptor watching you for your final.. and do your physical like that as well.

waste of time and money...

 

[NateatUC]

exactly my point pikachu...

take a history on a real patient with your preceptor watching you for your final.. and do your physical like that as well.

waste of time and money...

And how, then, does one learn how to take a history or do a physical BEFORE the final? Practice on mannequins? And how many real, hospitalized patients are going to be willing to let you, who has absolutely NOTHING to contribute to their care, come in and do it just to do it? Or, how many outpatients would be willing to contribute EXTRA time out of their day just to let you practice on them?

The way I see it, and the way it works here, is that you LEARN on standardized patients, who, I might add, are (here at least) pretty darn well trained. This happens FIRST and SECOND year here, so we don't look like total buffoons going into the clinical years.

That aside, I do still think Step 2B or 2CS, or whatever you call it, is a waste of time and money. Like I said, we're already tested on these skills here anyway, both formally with SP's and informally in the fact that we pass our rotations. As far as I'm concerned, if you can't do a good H&P, you shouldn't pass your IM, Peds, or Surgery rotations.

 

[Stinger86]

Although SPs are an important part of learning the ropes, I definitely prefer the real patient to the actor. Few things were more frustrating than asking a standardized patient "tell me what happened" only to have him/her respond with some specific 5-word answer, and then sit there and stare at you, waiting for you to ask a more specific question, i.e., one that is on the checklist. I've seen quite a few real patients in my short time as a med student, and EVERY single one practically told me their whole life story with only a simple cue from me as "so tell me what happened".

 

[Stinger86]

And as far as the CS exam goes...

If the powers that be would pay my way, I'd take the exam in a heartbeat. Screw you for charging me a grand to take an exam identical to the one I already have to take at my med school to graduate.

 

[lindyloohoo]

we've been lucky enough to have real pts as standardized pts at some points. Pts with carotid bruits in our cardiac unit, pts with COPD in resp, pts with upgoint babinski's for neuro...granted there was only 2 or 3 so we had to go in as 3 person teams, we still had real findings with some patients in addition to the SPs. these SPs were the best learning I've had in med school so far. What I want to know is how will the step 2 CS simulate real pts...if we dont get findings on a piece of paper, that means the findings have to be real. there are only so many conditions where a hx, negative physical, and tests will give you a diagnosis.

 

[southerndoc]

SP's should NEVER be a substitute for real patient encounters.

SP encounters are designed to teach you interviewing and examination skills before encountering real patients, or they're designed to test you on interviewing and counseling skills (not so much on examination skills).

SP's coupled with real patients is the way to go.

 

[pikachu]

And how, then, does one learn how to take a history or do a physical BEFORE the final? Practice on mannequins? And how many real, hospitalized patients are going to be willing to let you, who has absolutely NOTHING to contribute to their care, come in and do it just to do it? Or, how many outpatients would be willing to contribute EXTRA time out of their day just to let you practice on them?

Chill out, Dr. Sarcasmo. Most of my clinical teaching first and second year, while I was learning to do H&P's, was in fact on real-life hospitalized patients. They are asked beforehand if they are willing to have 1st-2nd year med students interview them - and guess what, they have "ACTUAL" histories of illness and physical findings so you can experience what things look and sound like in the real world. Besides, many of these patients told me that they liked talking to someone who actually had the time to sit and listen to their story and complaints (rather than an intern or resident who tends to be more rushed) - even if you aren't contributing anything to their care. Technically, you don't contribute to care as a 3rd year either - would you suggest not having clinical teaching on real patients in third year either?

The way I see it, and the way it works here, is that you LEARN on standardized patients, who, I might add, are (here at least) pretty darn well trained.

I'm guessing you haven't entered clinical years yet. No matter how "well trained" one of the actors is, they still can't fake rhonchi. You will see how vapid these encounters in fact are when you transfer from them into reality. My contention is that it's difficult if not impossible to learn from these standardized patients because the situations are so damn artificial. You might as well practice, as you said above, on a mannequin as on one of them. I can't imagine that the learning experience would be much different.

 

[Wednesday]

While I think that standardized patients can be a little forced, (one of my friends says that while she is nice to real patients she has so much trouble helping the SP up from a chair, etc, because she knows that they are faking), I think that a mix of standardized patients and real patients is fine and not a waste of money. At my school we jump right into history taking with real patients but learn physical exam with a standardized patient first. The thing I liked about it was that I got to actually try everything on the standardized patient. Often the patients we see in the hospital (we get to practice physical exams on them too) are so sick that large parts of the exam cannot be done. You guys that are fourth years forget how scary it was to actually touch a patient for the first time, push on their belly, lift their breast aside to find the PMI, etc. The first time you do something, you want to be able to say, "am I doing that right?" not necessarily to the SP but even to the other student in the room, or to the instructor. It's a lot easier to ask questions when you are in a pure teaching situation and not making an actual sick person uncomfortable. Obviously you can't avoid patients and we're all going to have to "practice" on real sick people a lot, but for the very first time I don't think it hurts to get a little practice on a "fake" patient.

PS We also had patients with real findings come in and I found that amazingly helpful.

 

[NateatUC]

OK, maybe I came off a bit sarcastic in that last post. My bad. I guess I'm trying to play devil's advocate a bit here, since I and many of my classmates felt that our experiences with standardized patients actually were helpful and instructive. That said, I am, in fact in the clinical years (just a bit into third year, granted, but clinical nonetheless). And our first and second year curriculum did have us working with real hospitalized patients, so I do understand the value of practicing on real hospitalized patients. The course coordinators did exactly as you said, and asked the patients beforehand if they were willing to work with us. Even some of them though, were not the greatest models, like the patient with acute pancreatitis and a j-tube who basically wouldn't let us near her belly and could barely lean forward to let us hear her lungs, or the other patient who didn't really know why he was in the hospital and actually didn't care to talk to us once he found out we couldn't give him any more answers.

I guess what I was trying to get across, and apparently I didn't do a great job of, was that I think the SP's are a good for learning the process of H&P. Yes, nobody can fake ronchi or a murmur. But before you can here ronchi or a murmur, you have to know where and how to listen for them. I contend that this is the purpose of the standardized patient - they give you a sense of what is "normal", and how to ellicit normal findings - the sound of heart and lungs, feel of the abdomen, range of motion of joints, responses of reflexes, etc., so that when you do encounter a real / hospitalized patient with abnormalities, you can say to yourself "The SP didn't feel / sound / act / react like that." And occasionally some of our SP's actually do have pathology - I had one that had about a 3/6 systolic ejection murmur, another that had a weird looking TM from an old cholesteatoma removal, and there is a story floating around (not sure how much urban legend) that there used to be one that actually had situs inversus. Never mind the SP's that actually volunteer to be paid to let you learn how to do prostate and pelvic exams. I think I'd be at least a little bit uncomfortable doing those for the very first time on a real clinic patient, not knowing what to look / feel for.

I still maintain that schools using standardized patients for evaluation is a decent idea, so they can make sure that you at least have the process down. As for the national standardized SP test, I still say its a bad idea, especially since, like I said before, and as others have said, many schools already require such a thing.

Hope that clarifies my point.

 

[ericdamiansean]

My school tries to train it's actors so that they are as standardized as ever. BUt then, they are human, and humans have emotions. At the end of the day, or if they get an exceptionally irritating student, they have no choice but to be mean to him. I've tried to be nice to all of them, be it real or faking it, some of them just piss me off.
I had a senior who was so pissed with his mock patient (during an exam where we all rush to get as much info as possible), the patient just didn't want to talk, open or closed ended questions. When he walked out of the room, he gave him 'the finger'. And this guy failed

 

[Jaded Soul]

I thought SPs were useful at the very beginning when you didn't know how to talk to patients. It's all natural now, but for most of us it wasn't like that when we came to med school.

 

[Adcadet]

we use "paid patients" extensively first and second year to learn how to do an H&P. Second year we bring in standardized patients (not just paid patients) for our final exams during second year. I love 'em (and one in particular - my wife!). Very nice people who so far don't seem to be doing it for the money - they really want us to learn how to be good at what we're doing. Definitely not a substitute for real patients, but paid patients + standardized patients + a an excellent clinical learning facility (full exam rooms with two cameras per room) and it's an awesome introduction to clinical medicine. I sure was more competent because of this setup when I saw some real patients near the end of first year.

 

[Adcadet]

And occasionally some of our SP's actually do have pathology - I had one that had about a 3/6 systolic ejection murmur, another that had a weird looking TM from an old cholesteatoma removal, and there is a story floating around (not sure how much urban legend) that there used to be one that actually had situs inversus. Never mind the SP's that actually volunteer to be paid to let you learn how to do prostate and pelvic exams. I think I'd be at least a little bit uncomfortable doing those for the very first time on a real clinic patient, not knowing what to look / feel for.

One of the paid patients I learned the MGR exam on had an unrepaired inguinal hernia. Not rare, but an awesome learning opportunity for somebody who spent hours figuring out what a hernia is during anatomy and had just learned what normal feels like on a previous paid patient. Then along cames patient #2 with a big whopping hernia that I only found out about when I felt it myself.

 

[ericdamiansean]

One of the paid patients I learned the MGR exam on had an unrepaired inguinal hernia. Not rare, but an awesome learning opportunity for somebody who spent hours figuring out what a hernia is during anatomy and had just learned what normal feels like on a previous paid patient. Then along cames patient #2 with a big whopping hernia that I only found out about when I felt it myself.

I think some schools try to recruit real patients as well, and you're screwed if during an exam, that guy has an enlarged thyroid and you say 'it's normal' 😀

But the only thing keeping them back, is that the patient has to be stable, if not, here comes the lawsuits

 

[Adcadet]

I think some schools try to recruit real patients as well, and you're screwed if during an exam, that guy has an enlarged thyroid and you say 'it's normal' 😀

Damn those sneaky medical schools for trying to get us to recognize abnormal findings! What do they think we're studying to be? Oh wait . . .

 

[MacGyver]

The problem with SPs is that they are usually actors by training. They constantly OVERACT the situation.

One SP I had got mad at me because I didnt give him a hug when he came into the room. Of course I was cordial, shook his hand and smiled at him, but that wasnt enough. This guy was gay, and this is how he described my demeanor:

"You didnt give me a hug. I'm a sick individual and I need to be held and hugged to feel better."

This idiot apparently didnt like the fact that I didnt sing "cum ba yah" with him and hold his hand the whole time.

Lets face it. Real patients are ALWAYS BETTER than SPs. SPs are used as a copout. All schools should use only real patients.

Paid patients are MUCH better than SPs too. Their reactions are much more realistic because they arent trying to "act" they are just being themselves.

SPs should be banned from medical school. Its a sign of a weak program that has to use a lot of them for training. It means that their clinical center and clinical faculty are too weak to provide the students with real patients.

 

[hakksar]

There seems to be a lot of negative comments about SPs . . . however, when you consider that SP's are gernerally used in the first 2 years of medical school which in the "old system" pretty much involved little to no patient contact and the fact that medical students still receive the same amount or more real patient contact in the scope of their medical training it really does not hurt to have SPs. At Colorado we have both real patient and standardized patient contact in the first year of medical school. This allows us to practice on standardized patients who are there to help us get better while still experiencing the challenges of working with a real patient who is there to get themselves better. I just do not see how it could hurt as long as they do not eliminate any real patient contact. I also think that Urology and Gynecological Teaching assistants are a good idea since with invasive exams like those I know that if I was the patient I would like the person to have done a few on a willing volunteer before me. As for the step 2 clinical skills exam I feel that it is a waste. By that point in our training we would have already failed out if we do not have the H and P skills which that tests.

 

[ericdamiansean]

Damn those sneaky medical schools for trying to get us to recognize abnormal findings! What do they think we're studying to be? Oh wait . . .

HAha...I think they are teaching us to be observant, and not to lie 😀