Starting with the first day of class and ending at graduation, a number of variables compete for the time and attention of medical students. The time that students spend in the classroom should include more active (student-centered/learning-oriented) experiences and less passive (teacher-centered/content-oriented) lecturing.³ The transition to student-centered teaching methods requires changes on the part of both students and faculty. Students need to become more involved in the construction of knowledge as they develop clinical reasoning skills; faculty need to offer timely and appropriately delivered, formative feedback.^4,5 To enhance the learning process, faculty should use teaching methods that just don't instruct and give grades, but produce learning through whatever methods work best.⁵

Several positive effects have been reported when medical students are exposed to patient contact early in their medical school course work. Interacting with patients motivates students to study, promotes the development of a professional identity and fosters an appreciation of the effects of illness on patients.⁶ The ability to arrive at the correct diagnosis is dependent not only on understanding facts and concepts, but also the ability to recall them from memory. Medical knowledge is better organized in one’s memory when the learning environment includes clear examples or cases; learning medicine through prototypes facilitates learning, understanding and recall.⁷ The significant time that students spend in class and studying, and the geographic distance between some medical school campuses and teaching hospitals can make access to patients challenging.

MWU/CCOM is not located near an affiliated teaching hospital so access to real patients is limited. Beginning in the 1960s, an educational approach using individuals (real patients and actors, commonly referred to as standardized patients) trained to portray various illness scripts began to be used to teach and assess physicians-in-training.⁸ The use of healthy (and often more mobile) actors trained and coached to present realistic patient presentations (simulated patients; SPs) has proliferated among training programs for healthcare providers.^9-12 While SPs are used to both teach and assess students, most studies and reports have focused on their utility for assessment or for teaching in small groups, or during one-on-one (SP:student) encounters.

Simulation is a useful learning and training method. Simulation allows events or conditions to be imitated to allow individuals without experience the opportunity to observe a situation, to develop new skills and/or to practice responses in anticipation of future occurrences.¹³ Various simulation technologies have been employed in the training of medical students.

High-fidelity videotaped patient encounters and computerized-manikins have been used to teach students neuroscience concepts and cardiovascular physiology respectively.¹⁴ Simulated clinical encounters (SCE) using SPs to assess the ability of examinees to collect historical information and perform focused physical examinations have also been described.¹⁵ SPs have been used to teach the mental status examination in large group settings.¹⁶ A review of the literature failed to identify any publication citing the use of SPs to teach basic sciences in a large classroom.¹⁷

On the first day of medical school for three successive years, we introduced an SP experiencing difficulty breathing to the entire first-year class. Based on those encounters we surveyed the students to assess their reaction to: 1) the use of SPs to introduce basic science concepts, 2) whether SPs should be used in more basic science courses, and 3) the impact the SP encounter had on them approximately two, three and four years later.

Based on the lecture sequence of MWU/CCOM's biochemistry course from 2005-2007, we developed two clinical scenarios. Development of the cases took less than two hours. Prior to the initial biochemistry lecture sessions for the fall quarter, two actors, a 60-year-old female (Sarah Abraham, 2005-2006) and a 65-year-old male (Harry Finlay, 2007), were trained to represent patients experiencing shortness of breath. Mrs Abraham presented experiencing an exacerbation of asthma while Mr Finlay presented in acute heart failure. During a 30-minute training session, each SP was provided with scripted responses to questions the clinician-facilitator would ask. In anticipation that the students might ask questions that did not have prepared answers, the SPs were advised to ad lib the responses. SPs were each paid $50 per session for their participation.

A student volunteer interviewed each SP in front of the entire class under the guidance of one of the authors, a clinician (DS). The interviews were interrupted whenever necessary to clarify questions asked by the student interviewer as well as to pose questions to the entire class to assess understanding of the interview process. The student interview was followed by additional questions for the SP from the class. The sessions ended with summary comments from both authors.

A six-item survey instrument based on a seven-point (1 = strongly disagree; 4 = neither agree / disagree; 7 = strongly agree) Likert scale was created for this study (Figure 1).

Figure 1

Figure 1. Survey Regarding the Use of a Simulated Patient (SP) during the First Lecture Session of a Medical Biochemistry Course

During the spring quarter of 2009, all of the student groups that experienced the SP sessions were surveyed. This approach provided student responses approximately two, (Class of 2011), three (Class of 2010) and four (Class of 2009) years after the SP sessions. We waited to survey students until all basic science courses had been completed since several of our survey items ask students to relate their experiences with simulated patients in Biochemistry to other basic science courses. In addition to providing numerical responses to the six items, some students wrote narrative comments and suggestions directly on the survey instruments.

The responses to each item were compared statistically among classes using analysis of variance (ANOVA) in combination with the Newman-Keuls multiple comparison test. Data were also assessed using one-sample t-tests to determine whether the mean response to each item differed significantly from neutral (i.e., 4.00 on Likert scale).

Mean responses for the group that had most recently experienced the SP session (Class of 2011) were significantly higher than neutral (i.e., 4.00) for all items except Item 3 (Table 1).

Figure 2

Table 1. Student Survey Responses for the Class of 2011 (n = 171)

Although the surveys were administered to the different classes two to four years after the encounters, the numerical responses to the survey items were nearly indistinguishable (Table 2). The class of 2011 found the experience somewhat more engaging than did the other two classes (Table 2).

Figure 3

Table 2. Comparison of Student Survey Responses for the Classes of 2009 (n = 71), 2010 (n = 48) and 2011 (n = 171)

Students overwhelmingly accepted the SP format as engaging in a large lecture hall setting (Table 3, Item 1).

Figure 4

Table 3. Summary of Student Survey Responses (Classes of 2009, 2010 and 2011; n = 290) Regarding the use of Simulated Patients

Students who had not yet entered the clinical phase of their training (Class of 2011) were especially inclined to report being engaged during the SP session with more than 90% identifying it as engaging and only 2% disagreeing. More than 80% of all students agreed that it would be helpful if more basic science courses incorporated the use of SPs (see Table 3, Item 5), whereas less than 7% disagreed. Most students (73%) reported that the use of more SPs in basic sciences courses would increase their desire to study (see Table 3, Item 6).

More than 75% of students felt that use of the SP helped them realize how important understanding the basic sciences is to the practice of medicine (see Table 3, Item 2), while less than 10% disagreed. Similarly, more than 75% of students agreed that use of the SP helped them appreciate the close relationship between basic and clinical sciences (see Table 3, Item 4), while less than 10% disagreed.

The SP experience (Mr Finlay in acute heart failure) for the Class of 2011 was different than for the other classes (Mrs Abraham experiencing an exacerbation of asthma). It is possible that the actor portraying the acute heart failure case was more realistic or the nature of the condition more interesting to the students as they may have never encountered someone in acute heart failure. It might be that the faculty, with two years of experience with this teaching method, created a more robust case, trained and coached the actor better, or interacted in a more engaging manner with the student body. It is also possible (and more likely in the opinion of the authors) that since the students in the Class of 2011 had not yet started clerkship rotations, their more limited patient contact accounted for a more vivid recollection of the SP encounter.

It seems, at first, curious that students in the class of 2011 were, on average, neutral regarding survey Item 3 (Figure 1). Theoretically, an engaging exercise (Item 1 in Figure 1) should cause students to study the pertinent basic science (Item 2) with more interest (Item 3). This apparent contradiction can, in our view, be resolved if one considers the nature of the selection process for medical students. We agree with Albanese²⁰ who said that “students admitted to medical school generally have demonstrated superlative achievement in lecture-based competitively graded courses.” Such students fit well into a paradigm requiring more efficient training of medical students.² (Although they also likely make more challenging the development of clinical reasoning skills.^{5, 20})

In our view, it is virtually impossible for such medical students not to be interested in studying acid-base or ATP metabolism in order to do as well as possible on their first medical school examination. We think such study would occur regardless of whether the first class session were engaging. A more important question is whether engaging sessions help to make all pertinent information more memorable and lead to a greater interest in life-long learning. To achieve the latter goals, we felt that it would be necessary first to increase the number of SP sessions and faculty involvement in them.

On the first day of class since 2005, the Department of Biochemistry at MWU/CCOM has used an SP session. During the first two years, only the authors and the biochemistry course directors were involved in the planning and implementation of these sessions. Six years later the paradigm has shifted. A total of 20 thirty-minute SP sessions are planned for the biochemistry courses during the 2010-2011 academic year. All faculty in the Department of Biochemistry now participate in the development and delivery of SP sessions.

This study has clear limitations. It is based on self-reported survey data from one institution, and the response rate of the class of 2010 was low. Since this study involved only one SP encounter, its impact on course examination scores, national licensing examinations and clerkship performance was not assessed. Further study would be beneficial to examine the impact of SP encounters in large classrooms on student empathy levels,^{21, 22} orientation to patient-centered care^{23, 24} and potential to ameliorate academic burnout.²⁵