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).

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).

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.

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John M. Eagles, Consultant Psychiatrist

Royal Cornhill Hospital, Cornhill Road, Aberdeen AB25 2ZH, email: .(JavaScript must be enabled to view this email address)

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