History lesson

A senior faculty member observing an SP encounter.
[Man Holding a Caduceus via wikimedia]

Happy New Year! For Christmas this year I got several SP books, so expect to see quotes/reviews in the future from such thrillers as "Coaching Standardized Patients, "Training Standardized Patients To Have Physical Findings," "Objective Structured Clinical Exams," as well as the new SP classic "The Empathy Exams."

But first I wanted to direct your attention to an article by the esteemed Peggy Wallace: "Following The Threads Of An Innovation: The History Of Standardized Patients In Medical Education" published in 1997. How delightful! I appreciate having an authoritative source to refer to. Here's a brief summary:

"Today, as we enter the new millennium, the standardized patient has become one of the most pervasive and highly talented of the new methodologies in medical education. It was certainly not always so. The standardized patient was anything but welcome and readily excepted educational tool, especially in the early days." Though the use of SPs began in 1963, it was not until 1985 that the traditional OSCE begin to integrate SPs, and even then its dissemination was slow. National boards (USMLE Step2) didn't incorporate SPs until after the article was published!

There were 3 primary contributors to the standardized patient field:

* Howard S. Barrows was the first to use SPs at USC. "Almost never was there a student whose clinical skills were evaluated as unsatisfactory because the faculty almost never directly observed the student with patients. In fact until the advent of standardized patients, there was no objective clinical measure by which to evaluate students." It's fascinating to learn that Barrows went on to teach at McMaster University, which has similarly transformed medical applicant interviews through the MMI. While at McMaster he developed the small group format and the use of USPs. He developed ways of simulating difficult findings on SPs like bruits and pneumothorax. He was the first to develop encounters with difficult patients: seductive, angry, inquisitive, etc. 

* Paula Stillman created specific checklists at the University of Arizona. For instance, what does "examine the eye" mean, really? Stillman could tell you 20 things a student should do to examine an eye that nobody had bothered to standardize before. In addition to using SPs as a body and an evaluator, she also used SPs to teach those skills: "They knew nothing about medicine. They were strictly process people." And yet still effective, I imagine, with the appropriate training! She was the first to begin working with patients with actual physical findings (only one school here does that). 

* Robert Kretzschmar began using SP models as "gynecological teaching associates" in 1968. At first they were just bodies with a sheet obscuring their face and without commentary or feedback, but Kretzschmar expanded the teaching & communication roles for GTAs in 1972.

Things which did not come to pass:

* "The 'patient instructor' might become a necessity rather than a luxury --  and Standardized Patients might be even more extensively needed for clinical learning and self-assessment as the pool of teaching faculty dwindles." (Not without better training!) 

* "And what about the practicing physician, or the one who has lost his license to practice? Might not the standardized patient be able to support the physician in new learning... [making] it possible for the physicians-in-trouble to relearn?" (While I would love to see more of this, I only know of one program that works with physicians-in-trouble and it's a very small, closed group.) 

* One of the interesting skills that seems to have been lost over the years is the use of "stimulated recall" after the encounter. SP feedback can be great, but I imagine reviewing a video of the encounter with an expert guide to ask you questions at specific points would be incredibly effective. (I try to do something similar in my feedback -- e.g. "What were you thinking when X happened or when you asked X?" -- but I'd like it to be a standard tool for schools to use when appropriate.)

Thank you, Peggy Wallace, and thank you, Barrows, Stillman & Kretzschmar! As Wallace concludes, "May that golden rod, now firmly planted, continue to inspire winged ideals in the midst of the inevitable conflict of the opinons that will create the fertile soil for sustaining educational efforts as the search goes on for a better way to support the healers of today – and nurture those of tomorrow."