Origin of Standardized Patients in the United States

"Historically, a central component of health professions training has involved observing and working with practitioners in the treatment of actual, ‘real-life’ patients.  While this continues to be an indispensable experience for trainees at all levels, it can now be supplemented with realistic experiences involving Standardized Patients (SPs)."
Terry D. Stratton, Ph.D. – UK College of Medicine

The conceptual origin of the Standardized Patient dates back to 1963, although it has gone through many name changes.

Dr. Howard S. Barrows, M.D., a neurologist and medical educator, created the first standardized patient in 1963 for his third-year neurology clerkship while teaching at the University of Southern California. He worked with a physician who spent an hour with every medical student, watching them work up a patient from beginning to end. By directly observing the students, Barrows and the physician realized that a number of skills were being incorrectly performed because students were unaware of the inaccuracy. Barrows also experienced difficulties when he tried to find patients with specific findings for Psychiatry and Neurology board examinations for and realized that some findings could be simulated. Thus Barrows was inspired to create his first "simulated patient." The case was based on an actual patient Barrows had treated, so he knew all the signs and all the symptoms the patient would have to exhibit for an accurate portrayal. He chose a case that could be reproduced for every student the same way. It was also important to Barrows that the person who represented the case had the knowledge to record what happened in each encounter. To make the process easier for the standardized patient (SP), Barrows created a checklist for the SP to complete at the end of each encounter. Initially, he monitored the SP and the students but eventually the SP became primarily responsible for recording what happened during the encounter.

The birth of the simulated patient came out of a need for a more comprehensive method to evaluate the clinical skills of third-year medical students. In the 1960s, Barrows’ innovative teaching and assessment methodologies were not widely accepted amongst his peers. But he believed that his concept was working and that his method provided an objective clinical measure to evaluate students.

Barrows left USC to become a member of the founding faculty at McMaster University in Hamilton, Ontario. McMaster was the first medical school with an entirely problem-based learning curriculum. Barrows had already seen the advantages of using SPs for evaluating students but he now began to see the value of SPs in teaching and research. He began to work with other physicians to develop workshops using SPs. His underlying philosophy in these workshops was experiential learning, learning by doing and receiving immediate feedback.

Paula Stillman, M.D., a pediatrician, has also been significantly responsible for establishing SPs as both a credible teaching and evaluation methodology. In the early 1970s when she was a pediatric clerkship director at the University of Arizona in Tucson, she started using "simulated mothers" as a technique for teaching interviewing skills to medical students. These simulated mothers gave histories of common pediatric complaints to the students when they were interviewed. Stillman believed she could develop a better instrument for teaching and assessing both the content and the process of medical interviewing. She developed an instrument that was based on behaviors that could be used to give feedback to the students. The Arizona Clinical Interview Rating Scale (ACIR) or Arizona Scale which we use at the University of Kentucky was the first behaviorally-anchored Likert scale to assess medical interviewing skills. Stillman taught the simulated mothers complicated histories involving several children, how to use the checklist to grade the student, and how to give feedback to the students on their interviewing skills.

In the mid-1970s, Dr. Stillman took over the physical diagnosis course and expanded the work she started in her pediatric clerkship. She wanted to develop something for the physical exam that was similar to her interviewing scale. She developed a physical exam checklist with Internal Medicine and Family Practice faculty that contained more than 200 items. A modified version of the checklist is used at UK today. In this situation, Stillman’s patients were not simulating any illness. For her needs, they were healthy people who were taught the complete physical examination from her checklist. These patient instructors taught workshops and graded students on their physical examination skills.

When Stillman took a position at the University of Massachusetts as associate dean of medical education, she decided to combine her history checklist with her physical examination checklist. She developed 45 minute encounters for residents in which she used patients with chronic findings and had them tell residents simplified histories and required residents to do the appropriate physical exams. Residents were then graded after the encounter using the combined checklist. In 1982, she began to work with simulated patients in the combined scenario because she could not find an abundance of patients with chronic stable disease.

In the late 1970s, the term standardized patient became the generally accepted name for simulated patients. Geoffrey Norman, a Canadian psychometrician at McMaster University, felt "standardized patient" was a better term because it is the standardization of a particular patient problem that gives this technique an advantage over the use of actual patients in teaching and assessment.

In 1981, Barrows became the associate dean for education at Southern Illinois University School of Medicine. At SIU, his focus on the use of standardized patients expanded from a teaching and assessment methodology to a tool for the development of medical education programs in the curriculum. In June 1984, Barrows and SIU faculty, in conjunction with the Josiah Macy Jr. Foundation, held an invitational conference on curriculum reform. It was at this conference that standardized patients were introduced to medical schools throughout the country as not only a valuable tool for individual student assessment but as means for curricular change in medical education. Participants explored the use of standardized patients for evaluation of clinical competence in multi-station, performance-based assessments. One of the six recommendations regarding curriculum reform that came from the conference was to require medical students to pass a comprehensive performance-based clinical examination before graduating. In an effort to convince deans and associate deans of the usefulness of standardized patients, the Macy Foundation supported a number of demonstration projects, the first occurring in October 1984. Attendees were invited back to SIU for a hands-on, multiple station standardized patient demonstration that took place in the first fully equipped, dedicated simulated clinic in the country. Designed by Barrows, this "Professional Development Laboratory" became the model for other schools as standardized patient programs grew and the need for dedicated clinic space became a reality. SIU introduced its first comprehensive multi-station examination using standardized patients to assess clinical skills in 1986.

Many organizations, such as the Liaison Committee on Medical Education (LCME), the National Board of Medical Examiners (NBME), and the Educational Council for Foreign Medical Graduates (ECFMG), have been responsible for the establishment of this medical school curriculum throughout the United States. The Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) supported the establishment of standardized patient methodology into medical school curricula. The LCME formally incorporated into its accreditation standards the directive requiring that each medical school "develop a system of assessment which assures that students have acquired and can demonstrate on direct observation the core clinical skills and behaviors needed in subsequent medical training."