An overview of and approach to selecting appropriate patient representations in teaching and summative assessment in medical education

Bauer, Daniel; Lahner, Felicitas-Maria; Huwendiek, Sören; Schmitz, Felix M.; Guttormsen, Sissel (2020). An overview of and approach to selecting appropriate patient representations in teaching and summative assessment in medical education. Swiss medical weekly, 150(w20382), w20382. EMH Media 10.4414/smw.2020.20382

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Medical education has a long tradition of using various patient representations in teaching and assessment. With this literature review we aim, first, to provide an overview of the most important patient representations used to teach and assess clinical skills, particularly considering ‘summative exams’ that have a pass or fail outcome. Second, to provide arguments for choosing certain patient representations, and third, to show the advantages and limitations of patient representations, in particular with regard to simulated patients (SPs) and real patients (RPs). Typical patient representations include case narratives, anatomical models, simulators and mannequins, in addition to SPs and RPs. Literature indicates that there are multiple ways of using various patient representations in teaching and that the intended didactical purpose informs the choice of the representation. Early in the educational programme, even low fidelity patient representations can be a good fit for assessment purposes when this corresponds with the educational level. The use of RPs in summative high-stakes assessments (exams with particularly important consequences for the test taker) is limited due to methodological and ethical reasons. Summative exams also impose specific demands for methodological implementation, such as measurement reliability and fairness towards the test-takers. Carefully prepared SPs can perform their role with a sufficient degree of authenticity, which makes summative exams more manageable, and no strain or risk is imposed on RPs. The ongoing debate concerning use of SPs and RPs in summative assessment highlights perceived limitations of SPs in relation to RPs that are often not supported by research. Evidence shows that SPs, in combination with additional simulation modalities as needed, represent the first choice for summative clinical assessment. We also consider the strengths and limitations of this review and reflect on the applicability of our findings.  We conclude that in order to select the right patient representation in clinical teaching and/or assessment, a number of perspectives need to be considered: (i) the learning goals, aligned with the stage of study, (ii) the corresponding requirements of the clinical task itself (e.g performing a phlebotomy, versus a communication task), (iii) the level of authenticity required and (iv) the resources needed, taking also patient safety and feasibility into consideration.

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