Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Review article: Biomedical intelligence

Vol. 150 No. 4950 (2020)

An overview of and approach to selecting appropriate patient representations in teaching and summative assessment in medical education

DOI
https://doi.org/10.4414/smw.2020.20382
Cite this as:
Swiss Med Wkly. 2020;150:w20382
Published
11.12.2020

Summary

Medical education has a long tradition of using various patient representations in teaching and assessment. With this literature review we aim, first, to provide an overview of the most important patient representations used to teach and assess clinical skills, considering in particular “summative exams” that have a pass or fail outcome; second, to provide arguments for choosing certain patient representations; and third, to show the advantages and limitations of different patient representations, especially simulated patients (SPs) and real patients (RPs).

Typical patient representations include case narratives, anatomical models, simulators and mannequins, as well as SPs and RPs. The literature indicates that there are multiple ways of using various patient representations in teaching and that the intended didactical purpose informs the choice of representation. Early in the educational programme, even low-fidelity patient representations can be a good fit for assessment purposes if chosen to match the educational level. The use of RPs in summative, high-stakes assessments (exams with particularly important consequences for the examinee) is limited for methodological and ethical reasons. The methodological implementation of summative exams also entails specific challenges, such as ensuring measurement reliability and fairness towards the examinees. Carefully prepared, SPs can perform their roles with a sufficient degree of authenticity, making summative exams more manageable, and imposing no strain or risk on RPs. The ongoing debate concerning the use of SPs and RPs in summative assessment highlights perceived limitations of SPs in relation to RPs that are often not supported by research. Evidence shows that SPs, in combination with additional simulation modalities as needed, represent the first choice for summative clinical assessment. We also consider the strengths and limitations of this review and reflect on the applicability of our findings.

We conclude that in order to select the right patient representations in clinical teaching and/or assessment, a number of perspectives must be considered: (i) the learning goals, aligned with the stage of study, (ii) the corresponding requirements of the clinical task itself (e.g., performing a phlebotomy or a communication task), (iii) the level of authenticity required and (iv) the resources needed, taking patient safety and feasibility into consideration.

References

  1. Bizzocchi J, Schell R. Rich-narrative case study for online PBL in medical education. Acad Med. 2009;84(10):1412–8. doi:.https://doi.org/10.1097/ACM.0b013e3181b6ead0
  2. Huwendiek S, De leng BA, Zary N, Fischer MR, Ruiz JG, Ellaway R. Towards a typology of virtual patients. Med Teach. 2009;31(8):743–8. doi:.https://doi.org/10.1080/01421590903124708
  3. Lim KHA, Loo ZY, Goldie SJ, Adams JW, McMenamin PG. Use of 3D printed models in medical education: A randomized control trial comparing 3D prints versus cadaveric materials for learning external cardiac anatomy. Anat Sci Educ. 2016;9(3):213–21. doi:.https://doi.org/10.1002/ase.1573
  4. Nicholson DT, Chalk C, Funnell WRJ, Daniel SJ. Can virtual reality improve anatomy education? A randomised controlled study of a computer-generated three-dimensional anatomical ear model. Med Educ. 2006;40(11):1081–7. doi:.https://doi.org/10.1111/j.1365-2929.2006.02611.x
  5. Groscurth P, Eggli P, Kapfhammer J, Rager G, Hornung JP, Fasel JD. Gross anatomy in the surgical curriculum in Switzerland: improved cadaver preservation, anatomical models, and course development. Anat Rec. 2001;265(6):254–6. doi:.https://doi.org/10.1002/ar.10030
  6. Epps C, White ML, Tofil N. Mannequin Based Simulators. In: Levine AI, DeMaria S, Schwartz AD, Sim AJ, editors. The Comprehensive Textbook of Healthcare Simulation. 7th ed. New York, NY: Springer New York; 2013. pp 209–32.
  7. Lindsay Miller J, Avery MD, Larson K, Woll A, VonAchen A, Mortenson A. Emergency birth hybrid simulation with standardized patients in midwifery education: implementation and evaluation. J Midwifery Womens Health. 2015;60(3):298–303. doi:.https://doi.org/10.1111/jmwh.12276
  8. hopkinsmedicine.org. Maryland: The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; 2020. Available from: https://www.hopkinsmedicine.org.
  9. Friederichs H, Weissenstein A, Ligges S, Möller D, Becker JC, Marschall B. Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. Adv Physiol Educ. 2014;38(4):343–7. doi:.https://doi.org/10.1152/advan.00039.2013
  10. Goulart JM, Dusza S, Pillsbury A, Soriano RP, Halpern AC, Marghoob AA. Recognition of melanoma: a dermatologic clinical competency in medical student education. J Am Acad Dermatol. 2012;67(4):606–11. doi:.https://doi.org/10.1016/j.jaad.2011.12.007
  11. Daeppen J-B, Fortini C, Bertholet N, Bonvin R, Berney A, Michaud P-A, et al. Training medical students to conduct motivational interviewing: a randomized controlled trial. Patient Educ Couns. 2012;87(3):313–8. doi:.https://doi.org/10.1016/j.pec.2011.12.005
  12. Vu N, Baroffio A, Huber P, Layat C, Gerbase M, Nendaz M. Assessing clinical competence: a pilot project to evaluate the feasibility of a standardized patient -- based practical examination as a component of the Swiss certification process. Swiss Med Wkly. 2006;136(25-26):392–9. doi:.https://doi.org/10.4414/smw.2006.11353
  13. Bokken L, Rethans J-J, Scherpbier AJJA, van der Vleuten CPM. Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review. Simul Healthc. 2008;3(3):161–9. doi:.https://doi.org/10.1097/SIH.0b013e318182fc56
  14. Gierk B, Harendza S. Patient selection for bedside teaching: inclusion and exclusion criteria used by teachers. Med Educ. 2012;46(2):228–33. doi:.https://doi.org/10.1111/j.1365-2923.2011.04054.x
  15. Biggs JB, Tang CS-K. Teaching for quality learning at university. 4th ed. Maidenhead, England: McGraw-Hill/Society for Research into Higher Education & Open University Press; 2011.
  16. Holt EA, Young C, Keetch J, Larsen S, Mollner B. The greatest learning return on your pedagogical investment: alignment, assessment or in-class instruction? PLoS One. 2015;10(9):e0137446. doi:.https://doi.org/10.1371/journal.pone.0137446
  17. Jha V, Quinton ND, Bekker HL, Roberts TE. Strategies and interventions for the involvement of real patients in medical education: a systematic review. Med Educ. 2009;43(1):10–20. doi:.https://doi.org/10.1111/j.1365-2923.2008.03244.x
  18. Beigzadeh A, Bahmanbijari B, Sharifpoor E, Rahimi M. Standardized patients versus simulated patients in medical education: are they the same or different. J Emerg Pract Trauma. 2016;2(1):25–8. doi:.https://doi.org/10.15171/jept.2015.05
  19. Bokken L, Rethans J-J, van Heurn L, Duvivier R, Scherpbier A, van der Vleuten C. Students’ views on the use of real patients and simulated patients in undergraduate medical education. Acad Med. 2009;84(7):958–63. doi:.https://doi.org/10.1097/ACM.0b013e3181a814a3
  20. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91–108. doi:.https://doi.org/10.1111/j.1471-1842.2009.00848.x
  21. Spencer J, Blackmore D, Heard S, McCrorie P, McHaffie D, Scherpbier A, et al. Patient-oriented learning: a review of the role of the patient in the education of medical students. Med Educ. 2000;34(10):851–7. doi:.https://doi.org/10.1046/j.1365-2923.2000.00779.x
  22. Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: systematic review. BMJ. 2005;331(7513):387–91. doi:.https://doi.org/10.1136/bmj.331.7513.387
  23. Dornan T, Littlewood S, Margolis SA, Scherpbier A, Spencer J, Ypinazar V. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Med Teach. 2006;28(1):3–18. doi:.https://doi.org/10.1080/01421590500410971
  24. Howe A, Dagley V, Hopayian K, Lillicrap M. Patient contact in the first year of basic medical training--feasible, educational, acceptable? Med Teach. 2007;29(2-3):237–45. doi:.https://doi.org/10.1080/01421590701294356
  25. Dammers J, Spencer J, Thomas M. Using real patients in problem-based learning: students’ comments on the value of using real, as opposed to paper cases, in a problem-based learning module in general practice. Med Educ. 2001;35(1):27–34. doi:.https://doi.org/10.1046/j.1365-2923.2001.00841.x
  26. Waterbury JT. Refuting patients’ obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students. Med Educ. 2001;35(3):286–94. doi:.https://doi.org/10.1046/j.1365-2923.2001.00865.x
  27. O’Flynn N, Spencer J, Jones R. Consent and confidentiality in teaching in general practice: survey of patients’ views on presence of students. BMJ. 1997;315(7116):1142. doi:.https://doi.org/10.1136/bmj.315.7116.1142
  28. Dent JA. AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients. Med Teach. 2005;27(4):302–15. doi:.https://doi.org/10.1080/01421590500150999
  29. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003;78(8):783–8. doi:.https://doi.org/10.1097/00001888-200308000-00006
  30. Peyton JWR. Teaching and learning in medical practice. Heronsgate Rickmansworth, Herts: Manticore Europe Ltd.; 1998.
  31. Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive Load Theory: implications for medical education: AMEE Guide No. 86. Med Teach. 2014;36(5):371–84. doi:.https://doi.org/10.3109/0142159X.2014.889290
  32. Fraser K, Ma I, Teteris E, Baxter H, Wright B, McLaughlin K. Emotion, cognitive load and learning outcomes during simulation training. Med Educ. 2012;46(11):1055–62. doi:.https://doi.org/10.1111/j.1365-2923.2012.04355.x
  33. Mancinetti M, Guttormsen S, Berendonk C. Cognitive load in internal medicine: What every clinical teacher should know about cognitive load theory. Eur J Intern Med. 2019;60:4–8. doi:.https://doi.org/10.1016/j.ejim.2018.08.013
  34. Huwendiek S, Reichert F, Bosse HM, de Leng BA, van der Vleuten CPM, Haag M, et al. Design principles for virtual patients: a focus group study among students. Med Educ. 2009;43(6):580–8. doi:.https://doi.org/10.1111/j.1365-2923.2009.03369.x
  35. Huwendiek S, Duncker C, Reichert F, De Leng BA, Dolmans D, van der Vleuten CPM, et al. Learner preferences regarding integrating, sequencing and aligning virtual patients with other activities in the undergraduate medical curriculum: A focus group study. Med Teach. 2013;35(11):920–9. doi:.https://doi.org/10.3109/0142159X.2013.826790
  36. Kotsis SV, Chung KC. Application of the “see one, do one, teach one” concept in surgical training. Plast Reconstr Surg. 2013;131(5):1194–201. doi:.https://doi.org/10.1097/PRS.0b013e318287a0b3
  37. Speirs C, Brazil V. See one, do one, teach one: Is it enough? No. Emerg Med Australas. 2018;30(1):109–10. doi:.https://doi.org/10.1111/1742-6723.12927
  38. Bundesgesetz über die universitären Medizinalberufe: MedBG. 2007. https://www.admin.ch/opc/de/classified-compilation/20040265/index.html.
  39. Michaud PA, Jucker-Kupper P, and members of the Profiles working group. PROFILES; Principal Objectives and Framework for Integrated Learning and Education in Switzerland. Bern: Joint Commission of the Swiss Medical Schools; 2017. https://www.profilesmed.ch.
  40. Frank JR, Snell L, Sherbino J, eds. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.
  41. Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34(6):e421–44. doi:.https://doi.org/10.3109/0142159X.2012.680939
  42. Yammine K, Violato C. The effectiveness of physical models in teaching anatomy: a meta-analysis of comparative studies. Adv Health Sci Educ Theory Pract. 2016;21(4):883–95. doi:.https://doi.org/10.1007/s10459-015-9644-7
  43. Collins JP, Harden JM. AMEE Medical Education Guide No. 13: real patients, simulated patients and simulators in clinical examinations. Med Teach. 1998;20(6):508–21. doi:.https://doi.org/10.1080/01421599880210
  44. Cleland JA, Abe K, Rethans J-J. The use of simulated patients in medical education: AMEE Guide No 42. Med Teach. 2009;31(6):477–86. doi:.https://doi.org/10.1080/01421590903002821
  45. Jones R, Higgs R, de Angelis C, Prideaux D. Changing face of medical curricula. Lancet. 2001;357(9257):699–703. doi:.https://doi.org/10.1016/S0140-6736(00)04134-9
  46. Trachsel S, Schaufelberger M, Feller S, Küng L, Frey P, Guttormsen Schär S. Evaluation eines neuen Mentoring-Programms für Medizinstudierende in der hausärztlichen Grundversorgung: Erfahrungen von Studierenden und Lehrärzten. GMS J Med Educ. 2010;27(3):Doc42. doi:.https://doi.org/10.3205/zma000679
  47. Barrows HS. Simulated (Standardized) Patients and other Human Simulations. Chapel Hill, N.C.: Health Sciences Consortium; 1987.
  48. Johnston JL, Lundy G, McCullough M, Gormley GJ. The view from over there: reframing the OSCE through the experience of standardised patient raters. Med Educ. 2013;47(9):899–909. doi:.https://doi.org/10.1111/medu.12243
  49. Schmitz FM, Schnabel KP, Stricker D, Fischer MR, Guttormsen S. Learning communication from erroneous video-based examples: A double-blind randomised controlled trial. Patient Educ Couns. 2017;100(6):1203–12. doi:.https://doi.org/10.1016/j.pec.2017.01.016
  50. Schmitz FM, Schnabel KP, Bauer D, Bachmann C, Woermann U, Guttormsen S. The learning effects of different presentations of worked examples on medical students’ breaking-bad-news skills: A randomized and blinded field trial. Patient Educ Couns. 2018;101(8):1439–51. doi:.https://doi.org/10.1016/j.pec.2018.02.013
  51. Smee S. Skill based assessment. BMJ. 2003;326(7391):703–6. doi:.https://doi.org/10.1136/bmj.326.7391.703
  52. Standards for educational and psychological testing. Washington, DC: Amer Educ Res Assoc; 2014. 230.
  53. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356(4):387–96. doi:.https://doi.org/10.1056/NEJMra054784
  54. Ten Cate O, Hart D, Ankel F, Busari J, Englander R, Glasgow N, et al.; International Competency-Based Medical Education Collaborators. Entrustment Decision Making in Clinical Training. Acad Med. 2016;91(2):191–8. doi:.https://doi.org/10.1097/ACM.0000000000001044
  55. Ten Cate O. Entrustment as Assessment: Recognizing the Ability, the Right, and the Duty to Act. J Grad Med Educ. 2016;8(2):261–2. doi:.https://doi.org/10.4300/JGME-D-16-00097.1
  56. van der Vleuten CP, Schuwirth LW, Driessen EW, Dijkstra J, Tigelaar D, Baartman LK, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205–14. doi:.https://doi.org/10.3109/0142159X.2012.652239
  57. Mak-van der Vossen M. ‘Failure to fail’: the teacher’s dilemma revisited. Med Educ. 2019;53(2):108–10. doi:.https://doi.org/10.1111/medu.13772
  58. Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42. Med Teach. 2016;38(11):1092–9. doi:.https://doi.org/10.1080/0142159X.2016.1215414
  59. Norcini J, Anderson B, Bollela V, Burch V, Costa MJ, Duvivier R, et al. Criteria for good assessment: consensus statement and recommendations from the Ottawa 2010 Conference. Med Teach. 2011;33(3):206–14. doi:.https://doi.org/10.3109/0142159X.2011.551559
  60. Guttormsen S, Perruchoud A. Die eidgenössische Prüfung ist keine Lehrveranstaltung. Schweiz Arzteztg. 2016;97(18–19):679. doi:https://doi.org/10.4414/saez.2016.04676
  61. Downing SM. Reliability: on the reproducibility of assessment data. Med Educ. 2004;38(9):1006–12. doi:.https://doi.org/10.1111/j.1365-2929.2004.01932.x
  62. Barrows HS, Abrahamson S. The programmed patient: a technique for appraising student performance in clinical neurology. J Med Educ. 1964;39(8):802–5.
  63. Vu NV, Barrows HS. Use of standardized patients in clinical assessments: recent developments and measurement findings. Educ Res. 1994;23(3):23–30. doi:.https://doi.org/10.3102/0013189X023003023
  64. Newlin-Canzone ET, Scerbo MW, Gliva-McConvey G, Wallace AM. The cognitive demands of standardized patients: understanding limitations in attention and working memory with the decoding of nonverbal behavior during improvisations. Simul Healthc. 2013;8(4):207–14. doi:.https://doi.org/10.1097/SIH.0b013e31828b419e
  65. Guttormsen S, Beyeler C, Bonvin R, Feller S, Schirlo C, Schnabel K, et al. The new licencing examination for human medicine: from concept to implementation. Swiss Med Wkly. 2013;143:w13897. doi:.https://doi.org/10.4414/smw.2013.13897
  66. Kane M. The Argument-based approach to validation. School Psych Rev. 2013;42(4):448–57. doi:.https://doi.org/10.1080/02796015.2013.12087465
  67. apa.org. Washington: American Psychological Association; 2020. Available from: https://www.apa.org.
  68. Baig LA, Beran TN, Vallevand A, Baig ZA, Monroy-Cuadros M. Accuracy of portrayal by standardized patients: results from four OSCE stations conducted for high stakes examinations. BMC Med Educ. 2014;14(1):97. doi:.https://doi.org/10.1186/1472-6920-14-97
  69. Sanko JS, Shekhter I, Gattamorta KA, Birnbach DJ. Development and psychometric analysis of a tool to evaluate confederates. Clin Simul Nurs. 2016;12(11):475–81. doi:.https://doi.org/10.1016/j.ecns.2016.07.006
  70. Smith C, O'Byrne C. Using an exam-readiness tool to ensure quality of standardized/simulated patient role portrayal in high-stakes simulation assessments. Clear Exam Rev. 2017;27(1).
  71. Wind LA, Van Dalen J, Muijtjens AMM, Rethans J-J. Assessing simulated patients in an educational setting: the MaSP (Maastricht Assessment of Simulated Patients). Med Educ. 2004;38(1):39–44. doi:.https://doi.org/10.1111/j.1365-2923.2004.01686.x
  72. Preusche I, Schmidts M, Wagner-Menghin M. Twelve tips for designing and implementing a structured rater training in OSCEs. Med Teach. 2012;34(5):368–72. doi:.https://doi.org/10.3109/0142159X.2012.652705
  73. Tavares W, Ginsburg S, Eva KW. Selecting and simplifying: rater performance and behavior when considering multiple competencies. Teach Learn Med. 2016;28(1):41–51. doi:.https://doi.org/10.1080/10401334.2015.1107489
  74. Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. BMJ. 1975;1(5955):447–51. doi:.https://doi.org/10.1136/bmj.1.5955.447
  75. Sayer M, Bowman D, Evans D, Wessier A, Wood D. Use of patients in professional medical examinations: current UK practice and the ethicolegal implications for medical education. BMJ. 2002;324(7334):404–7. doi:.https://doi.org/10.1136/bmj.324.7334.404
  76. Newble DI. Using real patients in professional medical exams. Suggestions would make examinations with real patients impractical. BMJ. 2002;324(7347):1217a. doi:.https://doi.org/10.1136/bmj.324.7347.1217/a
  77. Harden RM, Lilley P, Patricio M. The Definitive Guide to the OSCE: The Objective Structured Clinical Examination as a performance assessment. 1st ed. Elsevier, New York: Churchill Livingstone; 2015.
  78. Hill AE, Davidson BJ, Theodoros DG. A review of standardized patients in clinical education: Implications for speech-language pathology programs. Int J Speech Lang Pathol. 2010;12(3):259–70. doi:.https://doi.org/10.3109/17549500903082445
  79. Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC. Acad Med. 1993;68(6):443–51, discussion 451–3. doi:.https://doi.org/10.1097/00001888-199306000-00002
  80. Girzadas DV, Jr, Antonis MS, Zerth H, Lambert M, Clay L, Bose S, et al. Hybrid simulation combining a high fidelity scenario with a pelvic ultrasound task trainer enhances the training and evaluation of endovaginal ultrasound skills. Acad Emerg Med. 2009;16(5):429–35. doi:.https://doi.org/10.1111/j.1553-2712.2009.00399.x
  81. Garg A, Haley H-L, Hatem D. Modern moulage: evaluating the use of 3-dimensional prosthetic mimics in a dermatology teaching program for second-year medical students. Arch Dermatol. 2010;146(2):143–6. doi:.https://doi.org/10.1001/archdermatol.2009.355
  82. Rethans J-J, Gorter S, Bokken L, Morrison L. Unannounced standardised patients in real practice: a systematic literature review. Med Educ. 2007;41(6):537–49. doi:.https://doi.org/10.1111/j.1365-2929.2006.02689.x
  83. Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA. 2007;298(9):993–1001. doi:.https://doi.org/10.1001/jama.298.9.993
  84. Gamble A, Bearman M, Nestel D. A systematic review: Children & Adolescents as simulated patients in health professional education. Adv Simul (Lond). 2016;1(1):1. doi:.https://doi.org/10.1186/s41077-015-0003-9
  85. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007;29(9-10):855–71. doi:.https://doi.org/10.1080/01421590701775453
  86. Sohrmann M, Berendonk C, Nendaz M, Bonvin R ; Swiss Working Group For Profiles Implementation. Nationwide introduction of a new competency framework for undergraduate medical curricula: a collaborative approach. Swiss Med Wkly. 2020;150:w20201. doi:.https://doi.org/10.4414/smw.2020.20201
  87. Yudkowsky R, Park YS, Hyderi A, Bordage G. Characteristics and implications of diagnostic justification scores based on the new patient note format of the USMLE Step 2 CS Exam. Acad Med. 2015;90(11, Suppl):S56–62. doi:.https://doi.org/10.1097/ACM.0000000000000900
  88. Wright MC, Taekman JM, Endsley MR. Objective measures of situation awareness in a simulated medical environment. Qual Saf Health Care. 2004;13(Suppl 1):i65–71. doi:.https://doi.org/10.1136/qshc.2004.009951
  89. Harder N, Lemoine J, Harwood R. Psychological outcomes of debriefing healthcare providers who experience expected and unexpected patient death in clinical or simulation experiences: A scoping review. J Clin Nurs. 2020;29(3-4):330–46. doi:.https://doi.org/10.1111/jocn.15085
  90. Lilot M, Evain J-N, Bauer C, Cejka J-C, Faure A, Balança B, et al. Relaxation before debriefing during high-fidelity simulation improves memory retention of residents at three months: a prospective randomized controlled study. Anesthesiology. 2018;128(3):638–49. doi:.https://doi.org/10.1097/ALN.0000000000002045
  91. Gropper MA, Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, et al. Miller's Anesthesia, 2-Volume Set E-Book. Elsevier Health Sciences; 2019.
  92. Kolbe M, Weiss M, Grote G, Knauth A, Dambach M, Spahn DR, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541–53. doi:.https://doi.org/10.1136/bmjqs-2012-000917
  93. Brown C, Cleland J, Walsh K. The costs of medical education assessment. Med Teach. 2016;38(2):111–2. doi:.https://doi.org/10.3109/0142159X.2015.1105946
  94. Nordgren LD, Johnson T, Kirschbaum M, Peterson ML. Medical errors: excess hospital costs and lengths of stay. J Healthc Qual. 2004;26(2):42–8, quiz 48–9. doi:.https://doi.org/10.1111/j.1945-1474.2004.tb00484.x
  95. Wass V, Jones R, Van der Vleuten C. Standardized or real patients to test clinical competence? The long case revisited. Med Educ. 2001;35(4):321–5. doi:.https://doi.org/10.1046/j.1365-2923.2001.00928.x
  96. Yudkowsky R. Should we use standardized patients instead of real patients for high-stakes exams in psychiatry? Acad Psychiatry. 2002;26(3):187–92. doi:.https://doi.org/10.1176/appi.ap.26.3.187
  97. Wallenstein J, Heron S, Santen S, Shayne P, Ander D. A core competency-based objective structured clinical examination (OSCE) can predict future resident performance. Acad Emerg Med. 2010;17(Suppl 2):S67–71. doi:.https://doi.org/10.1111/j.1553-2712.2010.00894.x
  98. Durning SJ, Cation LJ, Markert RJ, Pangaro LN. Assessing the reliability and validity of the mini-clinical evaluation exercise for internal medicine residency training. Acad Med. 2002;77(9):900–4. doi:.https://doi.org/10.1097/00001888-200209000-00020
  99. Al Ansari A, Ali SK, Donnon T. The construct and criterion validity of the mini-CEX: a meta-analysis of the published research. Acad Med. 2013;88(3):413–20. doi:.https://doi.org/10.1097/ACM.0b013e318280a953
  100. Schwartz VS, Rothpletz-Puglia P, Denmark R, Byham-Gray L. Comparison of standardized patients and real patients as an experiential teaching strategy in a nutrition counseling course for dietetic students. Patient Educ Couns. 2015;98(2):168–73. doi:.https://doi.org/10.1016/j.pec.2014.11.009
  101. Carvalho IP, Pais VG, Silva FR, Martins R, Figueiredo-Braga M, Pedrosa R, et al. Teaching communication skills in clinical settings: comparing two applications of a comprehensive program with standardized and real patients. BMC Med Educ. 2014;14(1):92. doi:.https://doi.org/10.1186/1472-6920-14-92

Most read articles by the same author(s)