resident with standardized patient

SP Feedback to Medical Students


The Role of Standardized Patients

The School of Medicine uses standardized patients as a means of teaching students doctoring and clinical examination skills. Doctoring and clinical skills are forms of simulated learning that allows students to explore, discuss, and meaningfully construct concepts and relationships in contexts that involve real-world problems.

Using standardized patients for a simulated medical experience provides a safe and supportive environment where medical students can learn from their mistakes without fear of harming a real patient. Standardized patients provide a powerful means of teaching students because they are virtually indistinguishable from a real patient. Thus they make the scenario appear authentic to the student in every way.

In some instances (Doctoring years one and two and third-year OSCEs) standardized patients are also required to provide the student feedback on their history taking and communication skills at the conclusion of the interaction. What follows is a description of the kind of feedback required from the standardized patient and how to effectively deliver it to the student.

The Goal of Standardized Patient Feedback

The goal of standardized patient feedback is to help the student gain an empathetic understanding of the practice of medicine by providing the patient’s perspective of the student’s actions. Standardized patient feedback is an informed, non evaluative, and objective appraisal of student performance from the perspective of the patient. It is not the standardized patient's responsibility to instruct on medical content or professional proficiency. This is the responsibility of the facilitator.

Standardized patients are a valuable teaching resource for medical students because of their unique position of being both a patient and an observer. Standardized patient feedback provides learners with the opportunity to refine their knowledge and skills, in a safe environment where they can ask an standardized patient questions they may not feel comfortable asking a real patient.

Good feedback practice gives the student a clear picture of where they are currently, what they want to achieve, and what they need to do to get from one to the other. Adding the standardized patient perspective to the learning experience provides the student with a more complete picture of the doctor-patient relationship dynamic. This information will help the student in their personal assessment regarding how they are progressing. Additionally, the facilitator can incorporate the standardized patient's feedback into his or her overall assessment of the student’s progression and can tailor the teaching accordingly.

Feedback Comes From Observable Behaviors

In the simulated clinical scenario feedback is information the SP provides the student about what the SP experienced in response to what the student said or did during the interview and/or physical examination from the perspective of the patient. The standardized patient bases his or her feedback on observable behaviors--what the standardized patient saw and heard during the encounter. Observable behaviors are:

  • Noticed through the senses—seeing,hearing, tasting, smelling,or feeling.
  • Usually described by action words such as touching, walking, saying, or writing.
  • Do not include feelings or intentions, which are inferred from other behaviors.

However, it is perfectly valid—and necessary!—for you to share how the patient felt and responded to the student’s actions.

The standardized patient should always speak directly to the student and not the facilitator. Address the student in the third person—at least when you begin your feedback. For example begin with: “From the perspective as the patient…” Once it is clear you are referring to the patient you can switch to personal pronouns—he/she, him/her, his/hers. You can also shift to the first person—“I” statements—once it is established you are speaking from the patient’s perspective.

“I” statements should not come from your personal perspective and should only be used in the context of the patient role you played. Your tone should be pleasant and professional. No matter what the student has done you should never express annoyance, upset, or any negative judgment in your manner. At the same time, if you are being over positive it can come across as your being uncomfortable delivering less than positive feedback. This will minimize the emphasis the student will place on what you share. By using neutral language the student is able to focus on the message you are trying to convey.

Use CPR to Frame Your Observations

Standardized Patient's should use the following questions to formulate their feedback:

  1. Did you feel comfortable during the encounter?
  2. Was the purpose of your visit met?
  3. Would you return to the student or is there a referable point?

Referable points are used when a SP would not feel comfortable saying they would return. Rather than pointing out a negative or stating, "you would not return because…," the SP will give examples of things omitted in the encounter that had they been performed (empathy, rapport, nonjudgmental body language) they would be comfortable returning to the learner.

The standardized patient is required to complete a form answering these questions at the conclusion of the encounter. CPR (comfort, purpose, return/refer) provides the framework from which the standardized patient is to evaluate the student. CPR also provides the standardized patient with the context needed to provide the student feedback.

Provide Feedback Using "The Five Steps to Feedback"

The Five Steps to Feedback are purposely designed to maximize the standardized patient feedback in a limited amount of time. The feedback steps serve three purposes:

  • To foster student self-reflection by asking him/her to think about the interaction and by providing the patient’s unique perspective.
  • To provide the facilitator with additional insight into the interaction. Information the facilitator can use to customize the student’s development.
  • To better inform the standardized patient's understanding of the interaction. This will aid the standardized patient with completing the CPR evaluation questions.

Step 1. Eliciting self-reflection
Begin by asking the student what he/she thought of the encounter

Step 2. Probing for why
Follow-up by asking the student why they think that way. What happened during the encounter that made you think/feel that way?

Step 3. Reinforce proper behavior
Use positive feedback from the patient’s perspective to reinforce proper behavior.

  • What did you respond positively to as a patient?
  • Word your comments as if they were coming from the patient you just portrayed. Begin by speaking in the the third person, "As the patient…" before moving into the first person, "…I felt a connection when you met my eyes and shook my when I held it out."
  • When possible quote or paraphrase the student. "As the patient I felt a sense of relief when you said the situation was not the result of my actions."

Step 4. Offer up referable points
Shift the point of view to the patient’s perspective.

  • What did you respond negatively to as a patient?
  • Remember to address the student in the third person—at least when you begin your feedback.
  • Once it is clear you are referring to the patient you can switch to personal pronouns (he/she, him/her, his/hers). You can also shift to the first person — "I" statements — once it is established that you are speaking from the patient’s perspective.
  • "I" statements should not come from your personal perspective and should only be used in the context of the patient role you played.

Step 5. Turn things over to the facilitator
Feedback from an SP should not need to be more than a few minutes.  Keep it short and simple (KISS).