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In this paper, we define the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) for those working with human role players who interact with learners in a wide range of experiential learning and assessment contexts. These human role players are variously described by such terms as standardized/simulated patients or simulated participants (SP or SPs). ASPE is a global organization whose mission is to share advances in SP-based pedagogy, assessment, research, and scholarship as well as support the professional development of its members. The SOBP are intended to be used in conjunction with the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation SM , which address broader simulation practices. We begin by providing a rationale for the creation of the ASPE SOBP, noting that with the increasing use of simulation in healthcare training, it is incumbent on ASPE to establish SOBP that ensure the growth, integrity, and safe application of SP-based educational endeavors. We then describe the three and a half year process through which these standards were developed by a consensus of international experts in the field. Key terms used throughout the document are defined. Five underlying values inform the SOBP: safety, quality, professionalism, accountability, and collaboration. Finally, we describe five domains of best practice: safe work environment; case development; SP training for role portrayal, feedback, and completion of assessment instruments; program management; and professional development. Each domain is divided into principles with accompanying key practices that provide clear and practical guidelines for achieving desired outcomes and creating simulations that are safe for all stakeholders. Failure to follow the ASPE SOBP could compromise the safety of participants and the effectiveness of a simulation session. Care has been taken to make these guidelines precise yet flexible enough to address the diversity of varying contexts of SP practice. As a living document, these SOBP will be reviewed and modified periodically under the direction of the ASPE Standards of Practice Committee as SP methodology grows and adapts to evolving simulation practices.

Background The simulated patient (SP) methodology is a valuable tool in health services research, allowing for the assessment of healthcare providers’ (HCPs) real-world behavior and performance through covert interactions. Although several evidence syntheses have examined its application in pharmaceutical settings, there is a gap in synthesizing recent research findings in other healthcare disciplines. Therefore, we aimed to map the application of the SP method in non-pharmaceutical healthcare settings. Methods We conducted a scoping review, following the updated JBI (formerly Joanna Briggs Institute) guidance for scoping reviews. In October 2023, we searched MEDLINE (PubMed) and Embase (Elsevier) databases. We focused on peer-reviewed journal reports of primary studies of any design, published from May 2004 onwards, in English or German, that covertly utilized SPs in non-pharmaceutical healthcare settings. Two reviewers independently screened records and reports. Data extraction was conducted by one reviewer and validated by another one. We presented findings in table and diagram formats, accompanied by a narrative summary. Results Our search identified 1,796 records, with 163 reports meeting the eligibility criteria. Between 2004 and 2023, the use of SP methodology in non-pharmaceutical healthcare settings increased, with nearly twice as many reports published between 2014 and 2023 compared to the previous decade. The median number of SP-HCP contacts was 202.5, with a median of eight SPs per study. Most reports originated from North America (63.8%), followed by Africa and Asia (each 12.9%). Interactions primarily occurred in clinics (39.9%) and practices (36.8%), with face-to-face (58.9%) and telephone (42.9%) being the most common modes of interaction. 48.5% of reports indicated that HCPs were informed of covert assessments by SPs before the study began. Many reports lacked details on HCP specialties (41.1%) and professions (46.0%). Post-study feedback to HCPs was rarely reported (7.4%), and ethics approval processes varied, with 12.3% of reports not addressing them at all. Conclusions Over the past two decades, the SP methodology has been widely adopted across various regions and settings. However, inconsistent reporting and varying ethical considerations highlight the need for clearer guidelines to enhance the reliability and educational value of SP studies, ultimately leading to improved HCP practices and patient care quality. Scoping review registration: https://osf.io/8z9tn .

Background Verbal and non-verbal communication, as well as empathy are central to patient-doctor interactions and have been associated with patients’ satisfaction. Non-verbal communication tends to override verbal messages. The aim of this study was to analyze how medical students use verbal and non-verbal communication using two different educational approaches, student role play (SRP) and actor simulated patient (ASP), and whether the non-verbal behaviour is different in the two different poses. Methods Three raters evaluated 20 students playing the doctor role, 10 in the SRP group and 10 in the ASP group. The videos were analyzed with the Calgary-Cambridge Referenced Observation Guide (CCG) and, for a more accurate evaluation of non-verbal communication, we also evaluated signs of nervousness, and posture. Empathy was rated with the CARE questionnaire. Independent Mann Whitney U tests and Qhi square tests were performed for statistical analysis. Results From the 6 main tasks of the CCG score, we obtained higher scores in the ASP group for the task ‘Gathering information’ ( p  = 0.0008). Concerning the 17 descriptors of the CCG, the ASP group obtained significantly better scores for ‘Exploration of the patients’ problems to discover the biomedical perspective’ ( p  = 0.007), ‘Exploration of the patients’ problems to discover background information and context’ ( p  = 0.0004) and for ‘Closing the session – Forward planning’ ( p  = 0.02). With respect to non-verbal behaviour items, nervousness was significantly higher in the ASP group compared to the SRP group ( p  < 0.0001). Concerning empathy, no differences were found between the SRP and ASP groups. Conclusions Medical students displayed differentiated verbal and non-verbal communication behaviour during the two communication skills training methodologies. These results show that both methodologies have certain advantages and that more explicit non-verbal communication training might be necessary in order to raise students’ awareness for this type of communication and increase doctor-patient interaction effectiveness.

Background Appropriate communication with dental patients enhances treatment outcomes and patient satisfaction. Implementing simulated patient interviews courses can improve patient-centered care and reduce conflict during clerkship training. Therefore, this study explored the relationship among student participation in a situational simulation course (SSC), academic performance, clerkship performance, and objective structured clinical examination (OSCE) performance. Methods This study was conducted with a sample of fifth-year dental students undergoing clerkship training. After implementing a situational simulation course to investigate the relationship among participation in SSC, academic performance, clerkship performance, and OSCE performance, a path analysis model was developed and tested. Results Eighty-seven fifth-year dental students were eligible for the SSC, and most ( n  = 70, 80.46%) volunteered to participate. The path analysis model revealed that academic performance had a direct effect on OSCE performance (β = 0.281, P  = 0.003) and clerkship performance (β = 0.441, P  < 0.001). In addition, SSC teaching had a direct effect on OSCE performance (β = 0.356, P  < 0.001). Conclusions SSCs can enhance dental students’ non-operational clinical competency and OSCE performance effectively. Simulated patient encounters with feedback, incorporated into the dental curricula, have led to improved communication. Based on our findings, we suggest implementing SSC teaching before the OSCE to improve communication and cognitive skills.

Background This paper responds to previously published debate in this journal around the use of sociolinguistic methods in communication skills training (CST), which has raised the significant question of how far consultations with simulated patients reflect real clinical encounters. This debate concluded with a suggestion that sociolinguistic methods offer an alternative analytic lens for evaluating CST. We demonstrate here that the utility of sociolinguistic methods in CST is not limited to critique, but also presents an important tool for development and delivery. Methods Following a scoping review of the use of role play and simulated interaction in CST for healthcare professionals, we consider the use of the specific sociolinguistic approach of conversation analysis (CA), which has been applied to the study of health communication in a wide range of settings, as well as to the development of training. Discussion Role play and simulated interaction have been criticised by both clinicians and sociolinguists for a lack of authenticity as compared to real life interactions. However they contain a number of aspects which healthcare professionals report finding particularly useful: the need to think on one’s feet in real time, as in actual interaction with patients; the ability to receive feedback on the simulation; and the ability to watch and reflect on how others approach the same simulation task in real time. Since sociolinguistic approaches can help to identify inauthenticity in role play and simulation, they can also be used to improve authenticity. Analysis of real-life interactions using sociolinguistic methods, and CA in particular, can identify actual interactional practices that are used by particular patient groups. These practices can then be used to inform the training of actors simulating patients. In addition, the emphasis of CA on talk as joint activity means that proper account can be taken of the way in which simulated interaction is co-constructed between simulator and trainee. Summary We suggest that as well as identifying potential weaknesses in current role play and simulation practice, conversation analysis offers the potential to enhance and develop the authenticity of these training methods.

Background Empathy is a key competency and is essential for doctor-patient relationships. Studies have proven a continuous reduction of empathy in medical students during their study period. The use of SPs is positively evaluated for competency acquisition and real patient communication training has positive effects on empathy empowerment. Therefore, the present study focusses on the impact of simulated patient (SP) vs real patient (RP) communication training on empathetic behaviour in undergraduate medical students. Methods The prospective evaluation took place during a 210-minute skills lab unit on medical communication for 3rd year medical students. Study participants were allocated in advance to one of three groups: one group trained with an SP (SP-group) and was informed about the fact that it was an SP; another group trained with an SP but assumed to encounter an RP (incognito patient group (IP-group)); the last group trained with an RP and was correctly informed about it (real patient group (RP-group). Self-assessed empathy was measured by using Jefferson Scale of Physician Empathy (JSPE) and Interpersonal Reactivity Index (IRI), as these are the most commonly used instruments for assessing empathy. Study participants were evaluated on empathetic behaviour by their group-associated patient using the Consultation and Relational Empathy (CARE) scale. Results 146 students participated. There was no significant difference in self-assessed empathy between groups for JSPE and IRI. External assessment via CARE showed a statistically significant difference between SP-group and IP-group , as well as between SP-group and RP-group. There was no significant difference between IP-group and RP-group. This means that students training with real patients (or who believed them to be real) did receive significantly lower performance ratings on their empathy. Conclusion The results demonstrate a significant lower external empathy rating for students who had trained with a real patient or if they were in the belief of having encountered a real patient; this may be due to inhibitions and a lack of routine. Therefore, we recommend implementing SPs in the early study period with the gradual integration of RPs in the student’s further course of study.

Background Healthcare simulation is critical for medical education, with traditional methods using simulated patients (SPs). Recent advances in artificial intelligence (AI) offer new possibilities with AI-based simulators, introducing limitless opportunities for simulation-based training. This study compares AI-based simulators and SPs in undergraduate medical education, particularly in history-taking skills development. Methods A randomized controlled trial will be conducted to identify the effectiveness of delivering a simulation session around history-taking skills to 67 fifth-year medical students in their clinical years of study. Students will be assigned randomly to either an AI-simulator group (intervention) or a simulated patient group (control), both will undergo a history-taking simulation scenario. An Objective Structured Clinical Examination (OSCE) will measure the primary outcomes. In contrast, secondary outcomes including student satisfaction and engagement, will be evaluated following the validated Simulation Effectiveness Tool-Modified (SET-M). The statistical approach engaged in this study will include independent t-tests for group performance comparison and multiple imputations to handle missing data. Discussion This study’s findings will provide valuable insights into the comparative advantages of artificial intelligence-based simulators and simulated patients. Results will guide decisions regarding integrating AI-based simulators into healthcare education and training programs. Hybrid models might be considered by institutions in the light of this study, providing diverse and effective simulation experiences to optimize learning outcomes. Furthermore, this work can prepare the ground for future research that addresses the readiness of AI-based simulators to become a core part of healthcare education.

Background It is useful to advance simulated patient (SP) participation in teaching to improve the communication skills of medical students, so this study aims to explore the current state of Chinese mainland SP education. Methods A cross sectional survey was designed utilizing well defined quantitative research methods and descriptive statistics. The questionnaire sought information which elucidated the current status of SP-based education, the origin of SP-based learning, SP training, challenges of this learning strategy and future developments. Questionnaires were distributed to 79 medical colleges in mainland China, and 68 were returned. Of these, 64 constituted valid responses (81%). Results The number of SP-based education activities in medical colleges offering 5-year、7-year and 8-year clinical medicine programs was significantly higher than that in medical colleges which offered only a single 5-year program ( p  < 0.01). Communication skills training accounted for 73% of the content of SP-based learning activities, and was expected to rise in the future to 90%, in response to a need to improve doctor-patient relationships. Persons recruited as ‘simulated patients’ included students (21% of the total), residents (49%), medical staff (15%) and teaching staff (14%). Colleges, planning a SP-based education program, preferred teachers (80%) and students (55%) to assume ‘simulated patient’ roles. In objective structured clinical education (OSCE) scenarios, co-scoring by both SPs and teachers featured more highly in the ‘consultation’ station and ‘doctor-patient communication’ station. A number of factors were identified as hindering future development and implementation of SP-based learning including budget restraints, SP selection and training. Conclusions SP-based learning programs offer clear benefits for improving the clinical education of medical students and their communication skills. The main obstacles to achieving more widespread and higher quality SP-based education are insufficient funding and the lack of standardized training and performance evaluation processes for simulated patients. Medical colleges should consider reducing the proportion of students and teachers acting as SPs, and attract more citizens to participate in SP-based learning activities. Formalised training and evaluation of SPs performance are necessary to establish a ‘standard simulated patient’ for a particular medical discipline, thus improving SP-based activities and student learning.

Background Previous studies have focused on the role of simulated patient (SP) feedback on students’ learning outcomes after an SP-student encounter, whereas more recent studies have aimed to unravel meaningful learning during the encounter. We gain a more detailed understanding of students’ meaningful learning by examining the perspectives of students and SPs during the SP-student encounter. The research question was as follows: What are characteristics of meaningful learning moments for students during SP-student encounters and what are the perceptions of SPs during these moments? Methods Twelve second-year Technical Medicine students conducted a medical consultation with SP presenting the same patient case. Each consultation was followed by qualitative, video-stimulated recall (SR) sessions, first with the student and then with the SP. During these sessions, students were prompted to articulate the thoughts they had during the consultation to identify meaningful learning moments. Video-fragments of the meaningful learning moments identified by the student were subsequently shown to the SP to explore their perceptions. All verbatim-transcribed recall data were thematically analyzed. Results Student-identified meaningful learning moments were characterized by experiences that offered new insights, evoked emotions, and/or involved feedback-in-action from the SP. The SP’s perspectives of the same moments were compared to those of the students, revealing that these perspectives aligned approximately as often as they differed. SP experienced the moments as if they were the actual patient, fully embodying the patient’s role, while simultaneously maintaining an overview and being aware of the student’s learning position. Conclusions This stimulated recall study enhanced our understanding of students’ learning during SP-student encounters. For students, meaningful learning moments involved new insights, emotional responses, and feedback-in-action from the SP. When SP fully engage in their patient role while maintaining awareness of the student’s learning context, they can respond authentically and supportively. Preparing SP to balance authentic role portrayal with educational awareness can enhance their contribution to students’ learning.

Background Labeling a patient “non-compliant” is a form of dehumanization that can deprive the patient of positive human qualities and/or agency in the mind of a physician. The term “non-compliant” is frequently used in medical record documentation and has been shown to compromise care, particularly for marginalized communities. There is limited literature on the impact of the label on medical trainees. We aimed to explore how internal medicine residents and fellows (trainees) perceive the term “non-compliant patient” and its impact on their practice after interacting with a simulated refugee patient who has not followed a physician’s recommendations. Methods Kolb’s experiential learning cycle guided the design of the educational session which was part of a required communication skills curriculum for trainees. A scenario was created to simulate a refugee patient who had not adhered to their treatment plan and could potentially be labeled as “non-compliant.” Trainees participated in the 3-h session consisting of a remote simulated patient encounter immediately followed by a virtual structured debrief session that was recorded and transcribed. Thematic analysis of debrief transcripts was conducted starting with the use of provisional codes from the literature on the doctor-patient relationship and de/humanization. Results In group debrief sessions, trainees reflected upon the standardized patient case and chose to also discuss similar cases they had experienced in clinical practice. Trainees indicated that the term “non-compliant patient” served as a biasing function and described how this bias negatively impacted the doctor-patient relationship. Trainees described how marginalized communities might be more susceptible to the negative connotation associated with the term “non-compliant patient.” For some trainees, the term triggered further investigation of underlying barriers to care and exploration of the social determinants of health. Conclusions The use of the phrase “non-compliant patient,” though common in medical practice, may lead to patient dehumanization among trainees. A simulated refugee patient encounter followed by a facilitated group debrief allowed participants to verbalize and reflect on the meaning and possible impact of the label.