Increasingly, standardized patients—actors trained in the skill of portraying patients with various diseases and conditions—are being used to teach and evaluate medical students' clinical skills. First used in student training in the 1960s, standardized patients are trained to simulate not only patient history but also a patient's body language, personality, and emotional characteristics.¹ In recent years, standardized patient programs (SPPs) have played a considerable role in developing medical students' clinical skills, particularly physician-patient communication.^2-4 

In 2001, the National Board of Osteopathic Medical Examiners (NBOME) surveyed all 19 colleges of osteopathic medicine (COMs) regarding SPPs.⁵ The NBOME used the results of the survey to proceed with the research and development of the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE). As a result, standardized patients are now used in required examinations for osteopathic medical students.^6,7 

The implementation of the COMLEX-USA Level 2-PE in 2004 ignited interest in re-examining how osteopathic medical students are being trained. The current survey, in addition to providing an update on SPPs, also sought to investigate the use of new technologies used in students' training and assessment. These technologies included various types of simulators, from endoscopic and part-task trainers to whole body robotic simulators. 

In November 2005, all 23 fully-accredited COMs and branch campuses received a 34-question electronic survey on the use of standardized patients in teaching and clinical assessment. The survey contained 23 questions drawn directly from the 2001 NBOME paper-based survey.⁵ However, though the 2001 survey questions requested information regarding osteopathic graduate medical education (OGME), the 2005 survey restricted SPP-related questions to undergraduate osteopathic medical education. New questions pertained to the use of mechanical simulators in both undergraduate and graduate medical education. 

The survey was e-mailed directly to the dean of each school. As with NBOME's 2001 survey,⁵ the deans were asked to provide the following information: 

As described in the 2002 study,⁵ an SPP was defined as a program having a paid staff consisting of a program administrator, at least one standardized patient trainer, and a core of part-time, paid standardized patients. 

Respondents were also asked to describe the use of mechanical simulators in osteopathic medical education. Those COMs who did use mechanical simulators were asked to indicate which types of simulators were used for the training and assessment of clinical procedures and psychomotor skills by selecting from the following list: 

Respondents were asked to indicate in which years of under-graduate and graduate school these technologies were used and if they were used for outside contracts. The survey also included questions regarding the number of simulators available, the mechanical simulator facilities available, and the integration of simulators with SPPs. 

The authors received a response from all 23 COMs and branch campuses surveyed for this follow-up study, resulting in a response rate of 100%. Fourteen respondents (61%) identified themselves as deans or associate deans, 5 (22%) were SP program administrators, 2 (9%) were “PhD faculty/directors,” 1 (4%) was a “DO faculty/director,” and 1 survey respondent (4%) selected “other.” In 2005, 19 (83%) of the 23 COMs had active SPPs (Table 1), compared with 12 (63%) of the 19 COMs surveyed in 2001. The remaining 4 COMs (17%) from the 2005 survey indicated that they were either in the process of implementing an SPP or they used students as standardized patients, compared with 4 COMs (21%) in 2001 that neither had an SPP in place nor were in the process of implementing one. 

The departments responsible for administrating the SPP shifted from the dean's office to other areas (Table 2). Whereas the majority of SPPs were administered through the dean's office in 2001, only 1 program was in 2005. 

Similar to the 2001 survey results, standardized patients in 2005 were used primarily during the first 2 years at COMs (Table 3). However, unlike the 2001 data, SPPs now are being used by COMs slightly more for the assessment of clinical skills than for teaching. The only instances in which standardized patients were used more for teaching than assessment were in genital and rectal examinations in men and women. Use of standardized patients to provide assessment of student skills varied by teaching component assessed and year of medical training (Table 3). 

The number of standardized patients in the schools' SPPs ranged from 21 to 235. Seventeen (89%) of the 19 COMs with active SPPs reported having access to culturally diverse standardized patients, both male and female, between the ages of 18 and 80 years. Although it is unknown whether survey respondents reported standardized patients' self-identified race or their own general impressions, nearly half of these schools (47%) reported having access to Asian, black/African American, and Hispanic/Latino standardized patients. In addition, though US Census Bureau documents ask survey respondents about race and Hispanic ethnicity in two separate questions because a person of Hispanic ethnicity can be of any race, the current survey did not make such a distinction. 

Of the 23 schools surveyed, 21 schools—both the schools with active SPPs and the 2 schools that used students as patients—employed standardized patient trainers. Thirteen COMs (62%) employed full-time trainers, and 12 COMs (57%) employed part-time trainers. Each COM had no more than 5 full-time and 7 part-time trainers. Six COMs (29%) employed both full-time and part-time trainers. In addition, 16 respondents (76%) indicated that faculty physicians were assigned as supervisors for SPPs. 

All SPP facilities had simulated examination rooms and separate video control rooms, and all SPPs had sphygmomanometers available (Table 4). Since 2001, more COMs with SPPs reported having observation rooms (67% in 2001 vs 89% in 2005), and separate video control rooms (58% vs 100%) available. Standardized patients and students are also now more likely to have separate orientation and rest areas (33% in 2001 vs 95% in 2005). The average number of SPP examination rooms was 10 (range, 4 to 24). In addition, of the survey respondents, 11 COMs had built a new facility since 2001, and 6 COMs reported having plans for a new or updated facility within the next 3 years. 

Twelve (52%) of the 23 COMs reported using mechanical simulators or equipment (Table 5). At the time the survey was conducted, 11 of 12 COMs had three mechanical simulation rooms; 1 COM was building four rooms to open in 2006. Nine COMs integrated both standardized patients and mechanical simulators into their training and assessment programs. Of these COMs, 7 administered both programs under the same department. All of the COMs that used mechanical simulators had digital audiovisual technology, 8 COMs had a data capturing system, and 7 had ambient sounds for SPPs, medical simulators, or both. Some schools allowed mechanical simulator use for OGME programs and others in the healthcare professions (eg, emergency medical technicians) on a contract basis. 

Similar to the data gleaned from the 2003-2004 school survey Osteopathic Medical Education in the United States: Improving the Future of Medicine,⁸ which showed that 15 (79%) of 19 COMs in 2003 reported the use of standardized patients, a comparison of 2005 data with the previous survey⁵ revealed a nearly 20% increase in SPP use at COMs. Many factors have likely contributed to this increase. For example, the use of SPPs in international medical education and the emerging supporting evidence in medical education literature and at academic meetings over the past decade have grown.^2-4,9-12 As reported in the current study, most COMs have moved SPPs out of the dean's offices to other departments, which can increase program visibility and therefore increase program support and widespread usage. Meanwhile, the public has mandated for a reduction in medical errors, error management, and patient safety, as well as improved patient autonomy and enhanced physician-patient communication skills.¹³ Likewise, many curricular objectives emphasize clinical skills such as physician-patient communication, professionalism, and osteopathic manipulative medicine (OMM) and osteopathic manipulative treatment (OMT), which OGME programs and the American Osteopathic Association have adopted with the integration of core competencies.^14,15 And, of course, the COMLEX-USA Level 2-PE, a multistation performance evaluation of clinical skills using standardized patients, has been incorporated into the licensure examination pathway for osteopathic physicians.¹⁶ With the 2008 requirement that all graduates pass this examination, SPP use at COMs can only be expected to continue to rise.⁶ However, as the data provided in the current study are self-reported, caution must be exercised in interpreting the results. 

The 2001 NBOME survey was a paper document that allowed schools to reply separately whether or not they used SPPs for teaching or assessment of each clinical skill area by academic year. For example, in students' second year of osteopathic medical school, 6 COMs reported using SPPs in the teaching of OMM or OMT, while 2 COMs reported using SPPs in the assessment of OMM or OMT.⁵ Although these data allowed for an exact comparison of the use of SPPs by teaching or assessment by academic year, they also inflated the total use of SPPs for teaching and assessment (ie, they were counted more than once). By contrast, data from the 2005 survey revealed how many COMs used SPPs by clinical skill and by year (eg, OMM or OMT in year 2), and then teaching and assessment by clinical skill across all 4 years. For example, COMs reported using SPPs to teach or assess OMM or OMT at any point during undergraduate medical education. 

Nonetheless, 2001 data revealed that only 5 COMs (42%) used standardized patients in the assessment of OMM or OMT,⁵ compared with 14 COMs (67%) in 2005. Likewise, the use of SPPs in the assessment of physician-patient communication skills has more than doubled, from 5 COMs (42%) in 2001 to 19 COMs (100%) in 2005. Similar increases are seen in the use of SPPs for the teaching and assessment of patient education, behavioral medicine, and medical ethics. In addition, other than in the areas of genital and rectal examinations, standardized patients are used more for student assessment than teaching. Because of the sensitive nature of these examinations, schools often use trained clinical professionals (eg, nurses, genitourinary teaching associates) for the teaching or assessment of these portions of physical examination.¹⁷ 

Although the difference in the use of standardized patients in teaching versus assessment is not statistically significant (P=.75), the greater use of SPPs in assessment may be a result of schools' desire to further improve the reliability of standardized patient–based clinical skills examinations, including the COMLEX-USA Level 2-PE before graduation. Further study of whether schools use SPPs for formative or summative assessment and how schools remediate students who fail school-based or national high-stakes clinical skills examinations would be of interest. 

Survey results also indicated that nearly half of the COMs (47%) employed white, Asian, black/African American, and Hispanic/Latino standardized patients. However, because the survey did not request specific racial data, it is unknown whether the percentage of these patients matches the racial distribution within the United States or the school's geographic location. This distribution should be further studied. 

The current study revealed that 12 COMs (52%) use mechanical simulators at their schools. Until recently, simulation-based medical education for most medical schools—both osteopathic and allopathic—had predominantly used “low-tech” simulations (eg, standardized patients).^8,9 Now, various simulators are being incorporated into teaching, learning, and assessment programs at almost half of the COMs. As the fidelity, durability, reliability, and affordability of mechanical simulators continue to improve, COMs and OGME programs are expected to expand the use of these simulators in teaching and assessment. It is also expected that mechanical simulators, alone or in combination with standardized patients, will eventually be incorporated into high-stakes assessments of hands-on skills used for licensure and certification. 

The use of standardized patients and medical simulators for teaching and assessment of clinical skills at COMs has increased considerably since 2001. While the SPPs' and medical simulators' contribution to improving clinical skills and patient outcomes awaits further empirical study, the public can be assured that COMs are committing significant resources and educational efforts to enhance facilities and training programs that teach and assess the clinical skills of their graduates.