Medical educators are increasingly exploring interactive teaching modalities as alternatives to traditional didactic lectures. In recent years, medical schools have increasingly used standardized patients for both teaching and assessing clinical skills. Dr. Howard S. Barrows in 1963 was the first to use a standardized patient to demonstrate neurologic disorders and examine third-year medical students (1). The Educational Council for Foreign Medical Graduates (ECFMG) now uses standardized patients depicting a wide range of medical disorders for assessment of international medical graduates (2). All U.S. medical schools are required to administer objective structured clinical examinations (OSCE) using standardized patients (3). The American Board of Psychiatry and Neurology is currently exploring using standardized patients for psychiatry board certification examinations (4). Standardized patients have been used in Canada for licensure examinations for several years.
Although the medical literature includes an increasing number of articles on the use of standardized patients, few of these articles address psychiatric issues and only one focuses on the role of standardized patients in teaching, rather than evaluating, skills. In 1998, Coyle and colleagues described using standardized patients to teach psychotherapy techniques (5). Second-year psychiatry residents participated in a course that included three cases, depicting a woman with dysthymia and dependency issues, an adolescent with abandonment fears and acting-out behaviors, and a man with substance abuse and depression. Experienced mental health counselors portrayed the patients. The authors report that the course was well received, facilitating both active learning and acquisition of complex skills. No specific information was reported about student and faculty capacity for engaging with the standardized patients.
Two papers report the use of standardized psychiatric patients to assess clinical skills. Hodges and colleagues employed an objective structured clinical examination using standardized patients to evaluate psychiatric clinical clerks. An experienced standardized patient trainer prepared 15 different scenarios. The standardized patients' training materials included handouts, videotaped cases, and observed performances. The authors did not provide much information about the quality of the experience other than that students found it "an acceptable and fair evaluation" and that faculty preferred it to the traditional oral exams (6). A later study reported that 80% of a group of 15 psychiatric residents described the standardized patients as realistic (7). No study has used standardized and actual patients interchangeably and compared the experiences.
In the early 1990s, the course director John Huxsahl revised the medical school psychiatry curriculum at Mayo Medical School. He modified the second-year curriculum to include a course that combined didactic sessions with psychiatric interviewing. The new course, "Introduction to Psychopathology," was designed to minimize traditional didactic teaching, use active learning, and maximize patient contact. The objectives were for students to develop psychiatric interviewing skills and concurrently learn psychopathology. The 36-hour course is conducted during nine afternoon sessions. The first afternoon includes lectures on psychiatric interviewing, suicide assessment, and psychiatric diagnostic classification. The remaining eight afternoons begin with a 90-minute lecture, which is followed by 120 minutes of patient interviews conducted in small groups precepted by a faculty psychiatrist. The groups rotate between three inpatient units and three outpatient areas, with each group participating in two 30-minute interviews daily. Students receive faculty feedback from a standardized form and comments on an essay-style final examination.
The original course design used actual psychiatric inpatients and outpatients. Identifying and recruiting appropriate patients, who were paid, was always a major problem. Interested outpatients often had chronic, complex, and atypical clinical features and emphasized treatment issues rather than presenting psychopathology. Most of patients had depression, personality disorders, or both. Occasionally, outpatients would fail to show up or would cancel abruptly, leaving faculty scrambling to find a substitute patient or an untrained staff member to simulate a patient. Standardized patients were incorporated to minimize the recruitment difficulties and maximize the exposure of students to a wide variety of psychiatric disorders. This pilot project was undertaken to assess student and faculty perceptions of standardized versus actual patients.
Standardized outpatients were randomly mixed with actual psychiatric outpatients, and student and faculty response to all patients was evaluated. t1 describes the standardized and actual outpatients. The goal was to develop standardized patients who portrayed a variety of important psychiatric disorders in a relatively straightforward manner. The DSM-IV symptoms were always unambiguous, but in most cases there were coexisting issues or life events to enhance the richness of the case. With the exception of the course director (Dr. Krahn), students and faculty were blind to the diagnoses, life stories, or any other information about all patients. Actual inpatients, exclusively, were used for the teaching sessions held on inpatient units, providing exposure to manic, psychotic, and cognitive disorders not emphasized in the outpatient scenarios.
The standardized patients were recruited from the community. Mayo Medical School employs a standardized-patient coordinator who recruits individuals with good acting abilities. None had any medical training, and only one had previously participated as a standardized patient. The standardized patients received a case written by a psychiatrist and based on a real patient. The case was 1 to 2 pages long, in an outline format. The standardized patients were not given scripts that delineated their responses word for word. They were provided with several quotations that were to be used, particularly at the beginning of the depiction to set the right tone. Overall they were encouraged to adopt the role of the assigned patient and improvise their answers in a manner consistent with the case. Each standardized patient was also provided with descriptions of the pertinent mental status examination, a copy of the relevant DSM-IV criteria, and a training session one week prior to the course. Although they did not meet with an actual patient with the disorder in question, they were asked about any people they knew with the disorder as well as any depictions in the media. This exercise was done to strengthen any realistic preconceptions and correct any distorted perceptions of a particular disorder. The standardized patients practiced the depiction several times with the trainer and once with the psychiatrist. Between sessions of the course, the psychiatrist met with the standardized patients individually to answer questions and address unclear issues in the case material. Standardized and actual patients depicted their cases an average of five times. Both standardized and actual patients were paid.
Held during the first month of the second year of medical school, the class included 45 students divided into 7 small groups. The students observed as their preceptor, a faculty psychiatrist, interviewed two patients on the first day. Thereafter each student conducted two interviews while being observed by other group members and the preceptor. Thirty minutes of discussion addressing psychopathology and diagnostic issues followed each 30-minute interview. The preceptor provided verbal feedback about interviewing techniques in the group discussion and written feedback on the evaluation form. The first student interviews generated ungraded feedback; the second graded interviews represented 25% of a student's final grade in the course. The remainder of the grade consisted of a case write-up (25%) and final written examination (50%). The students and faculty were told that some patients used in the course would be standardized patients using scripts based on actual patient histories. Faculty and students completed anonymous questionnaires about the standardized patients that assessed their engagement with the patients and the realism of the depiction. These were distributed before and after the course. After the course, the standardized patients were identified.
All of the medical students had previous experience with standardized and actual medical patients but no previous exposure to psychiatric patients of either type. Initially the students were unsure which patient type would be most effective, although overall they expressed a preference for "real patients." Some students felt shortchanged if the course could not recruit sufficient actual patients for their needs regardless of the quality of interview. Six of the faculty psychiatrists had previously taught in this course using actual psychiatric patients. One psychiatrist had previously worked with standardized psychiatric patients and two with standardized medical/surgical patients. They universally expressed optimism about the introduction of standardized patients. t2 shows the student and faculty expectations and opinions about standardized versus actual patients.
Overall, the students viewed the course favorably. They could accurately identify the standardized patients most of the time. The disorders were portrayed as desired, with unambiguous symptoms but imbedded in a context of maladaptive personality issues or an unsettling recent life event. The students perceived the scenarios representing obsessive-compulsive disorder, anorexia nervosa, bulimia, and borderline personality disorder as effective educational experiences that depicted the disorders well. They reported that when symptoms were too simple, without a convincing life story, they suspected the patient to be a simulation. Even though there was general agreement that the quality of acting was good, some of the responses were described as shallow. Several students stated that they became less emotionally engaged with the interview once they perceived it was a standardized patient, and 91% said they had difficulty feeling empathy for the person. The advantages of standardized patients included clear symptoms, cooperation, direct answers, and an emphasis on psychiatric symptoms, not treatment issues.
The faculty strongly preferred actual patients but were divided as to which standardized patients were the most effective. In general they were most satisfied with the anorexia nervosa, bulimia, panic disorder, and conversion disorder scenarios. They felt able always to detect standardized patients based on symptomatology and life story. However, they agreed with the students that the quality of acting was good despite an occasional rehearsed quality. Six of the seven faculty stated it was definitely more difficult to feel empathy for standardized patients, and the seventh found it somewhat more difficult. They agreed that the standardized patients offered clear symptoms, direct answers, and cooperation, but they questioned if presentations with such qualities were realistic.
Students preferred working with patients they perceived to have actual psychiatric issues. In part, this may relate to their eagerness to interact with persons with real pathology. Several students remarked that they already felt experienced enough to move beyond standardized patients and expressed a desire to interview "real" patients. During interviews with standardized patients, they reported feeling more inattentive and less engaged. Others reported feeling distracted by the mix of standardized and actual patients. Instead of listening to the patient's story or experiencing empathy with their psychiatric symptoms, they focused on detecting whether this patient was an "imposter." Regardless of whether they suspected the patient to be real or standardized, their skepticism appeared to interfere with learning that psychological symptoms exist and legitimately deserve medical attention. Consequently we do not recommend attempting a blinded comparison study of this type. Future study designs may include revealing the existence of standardized patients only after the completion of the course.
Clearly an introductory psychopathology course that uses patient interviews in small-group settings involves many variables. Despite a student preference for actual patients, the availability, variety, and quality of actual psychiatric outpatients can differ tremendously at each institution and from year to year. Standardized patients offer course directors more control in regulating content and quality, if good actors are available and appropriate training is arranged for them. Furthermore, in an examination environment standardized patients can replicate their scenario, facilitating test reliability and fairness.
Significant drawbacks related to using standardized psychiatric patients may be more obvious in the less structured teaching setting than in the clinical examination context. The clear difficulty of developing empathy reported by the majority of students and faculty is a serious concern when students are learning to understand the person behind the psychiatric diagnosis. While this issue may not be as relevant in medical or surgical situations, a standardized patient's inability to engender empathy represents a serious shortcoming in psychiatry. Empathy is viewed as a crucial component to psychiatric diagnostic evaluations as well as treatment. In its absence, a patient encounter can seem superficial, leaving an examiner unable to detect subtle symptoms or demonstrate interpersonal skills. Lacking empathy, the patient encounter may simply become shallow role-play. Empathy alone is not a sufficient tool for competent psychiatric interview, but sensing a patient's emotions is an important means of interpreting the patient's distress. Recognizing the list of neurovegetative symptoms of depression, for example, without appreciating the related emotional upheaval provides only a superficial understanding of the nature of the disorder.
Actual psychiatric patients convey their emotional experience along with the chronological events, but at a cost. However, if they agree to repeated participation in interview sessions, their answers can eventually develop a rehearsed, detached style. They may resist coaching, despite having no acting training. They may not clearly describe their pre-treatment psychiatric symptoms, but prefer to give their opinions about specific psychopharmacologic agents or psychotherapy. Patients with recent-onset symptoms or transient disorders like conversion disorder are generally not available for teaching.
Our introductory course's twofold purpose of teaching psychiatric interviewing while also introducing psychopathology is ambitious, but we believe these two objectives can be combined. If the primary goal of a course is teaching psychopathology, then the nature of the student—patient encounter is less critical. The students require exposure to a large number of cases depicting diverse symptomatology. But in psychiatry, we believe that it is unrealistic to separate out the gathering of cross-sectional mental status findings and the patient's life story. The student must simultaneously develop the required interpersonal skills needed to collect both sets of data. A convincing context and an emotionally engaging depiction make symptoms more impressive, which encourages students to develop a comprehensive multiaxial differential diagnosis. Whether standardized patients are the best method employed is debatable.
What is the optimal method to teach psychiatric interviewing? Most students need to first gain comfort with the basic elements of an organized psychiatric interview before they learn how to adapt their approach to a difficult patient. How straightforward should a case be? Classic presentations of a disorder clearly illustrate the most common symptoms, yet the presentation may seem unconvincing. More complicated cases may obscure the most common set of presenting symptoms, but if acted well, they have more emotional depth. Can standardized patients effectively depict cases appropriate for novice and experienced interviewers?
Overall, the medical students enjoyed this interactive course that combined interviewing skill development with an introduction to psychopathology. The faculty also consistently expressed enthusiasm for the small-group, case-based format. Using a simulation to teach students that psychiatric symptoms are real phenomena is inherently difficult. However, the issues involving the recruitment of actual patients and the fostering of the emotional dimension of standardized patients are challenging.
Projects should continue examining the educational considerations related to use of actual and standardized patients, although this might be best accomplished in separate projects without a direct comparison. Future studies could include the addition of a rating scale for empathy completed by the students, faculty, and patient. Standardized psychiatric patients need further study, particularly in the teaching setting, with close attention to case development, training process, student acceptance, and faculty response. Training must focus on facilitating actors' ability to convey emotion realistically and therefore evoke empathy in the interviewer. Other users of standardized psychiatric patients, whether in psychiatry or primary care fields, will need to consider whether actual psychiatric patients, when available, may offer a more realistic clinical encounter. More research is needed into how to effectively employ standardized psychiatric patients and incorporate emotional content sufficient to facilitate an empathic encounter.
The authors thank T. Enger, S. Stuve, and S. Weissler, who scheduled and coordinated the small-group interviews. Also thanks to the actual and standardized patients who participated in the course. This work was presented at the Academy of Academic Psychiatry, Vancouver, BC, October 4—8, 2000.