While teaching pediatrics at the University of Arizona in the 1970s, Paula Stillman needed a reliable way to evaluate her students' clinical competence. Her solution was to train and use "patient instructors" or "standardized patients." Stillman's system is a competency based program, Objective Structured Clinical Evaluations (OSCE), developed to assess medical students, foreign medical graduates, and U.S. doctors in danger of losing their licenses. Her system has also been adopted by medical schools in China.
Patient instructors are more than just live teaching models or actors playing a part who simulate a clinical encounter. They function as the medical students' critics and teachers, and can become excellent judges of whether medical histories and exams are done properly and completely, even assessing whether the student has shown understanding, sensitivity, and other desirable social and medical skills.
Dr. Stillman's pilot project used trained standardized patient "mothers" to describe their imaginary children's symptoms and condition to medical students. By videotaping many of these encounters, she developed checklists of tasks and competencies. These were used by the actors to rate the students' ability to develop a good physician-patient relationship with the mother-patient and to collect necessary information. For example, did the student introduce her/himself by name? Did she/he ask about the child's sleeping patterns? Did she/he mention immunizations?
The project later expanded to include assessment of history-taking skills in other medical fields, as well as physical exams. Volunteers would allow themselves to be given routine physical examinations by medical students, then critique the examiners, again using checklists. To give students a broader range of patients, Dr. Stillman also asked the school's patients to become patient instructors.
Stillman's system has been replicated in medical schools across the country, and when Stillman moved to the University of Massachusetts Medical School in Worcester in 1982, she was able to organize a standardized patient consortium among area medical schools to train volunteers.
From 1991 to 1995, Stillman was invited to work with the medical board in China to establish OSCE-based instruction and ensuing exams. Until that time, there had been no Western-style tradition of breast and pelvic exams for women in China. Most medical school clinics lacked basic tools for physical exams, such as stethoscopes, and otoscopes, and the curriculum did not cover medical students' clinical skills in detail.
