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Clinical Skills Laboratories  Joel Barish
There are two types of learning laboratories; technical skills labs and clinical skills labs. Both are being used in the United States.

For many years, medical schools in the US have commonly relied upon teaching certain technical skills with plastic or rubber models. These include learning skills such as cardio-pulmonary resuscitation, understanding heart sounds, performing endotracheal intubation, breast, prostate, and rectal exams, checking vital signs, suturing, blood drawing and injections (to name a few). These are “technical skills laboratories” and often were used voluntarily by students and residents. Generally, these were managed by the various departments and not run by the school as a whole.

Less interest was shown in clinical skills laboratories because US medical students get early and frequent contacts with real patients. And also because the Clinical Skills (CS) portion of the United States Medical Licensing Examination (USMLE) was only given to foreign medical graduates; not to US graduates. An important third reason is the cost; it is very expensive to run a CS lab.

But, with better understanding of the value, and the fact that the CS examination is now part of the USMLE step II for everyone, US medical schools have shown a greater interest in CS labs. Many schools still do not have them because of the cost, and I know of one excellent school in New York City that pays another school so their students can go to that lab. Another excellent New York school is now in the final stages of establishing such a lab. It takes space and administrative salaries, but the real cost is faculty time (salaries) and payments to the actors who play the roles of patients. These actors are called “standardized patients” (SP) because they present different medical students with the same clinical problems.

There are various regional organizations in the US to promote CS labs and to share information in their development and utilization. There is also a society of standardized patient educators. This is an organization of mainly doctors and nurses who do the teaching to the actors. This teaching is critical to the success of the CS lab.

The students learn more than just medical facts; they learn proper doctor-patient interactions and behavior. They learn how to focus on a clinical problem and ask the correct questions. They learn how to decide what portions of the physical examination must be done and how to behave in situations when patients act in different ways. They also learn how to relate information and discuss sensitive/personal issues.

The standardized patients are actors (often hired from the drama department of the university, or nearly theater companies), and they are carefully trained to simulate real patients with specific medical problems. Commonly, one actor will learn to mimic four to five clinical conditions. The interaction can be evaluated by the actor, or by a faculty member (who may be in the room or watching from outside). Sometimes the interaction is video-taped and reviewed for teaching after the encounter, by medical students and faculty members. There is a list of “key features” for each clinical situation and the student must ask each key question and look for each key finding. An example would be a patient with chest pain….a key question would be what brings the pain on…and a key finding would be listening to the heart sounds. The encounter lasts 5-10 minutes, and then 10 minutes to write a “SOAP” note (subjective/objective/assessment/plan.) Very much like a brief office visit.

These SP’s also can form a “patient bank”, so that, if a student has never seen a particular type of case, they can interact with the SP who has been trained to mimic that disease. This partially takes the place of seeing a real patient with a particular clinical problem.

Another way to use standardized patients is with actors who present themselves as “models” for specific parts of the physical examination. They are highly paid but allow the students to do breast, pelvic, genital and rectal exams. They are so experienced in this technique, that they actually teach the student during the process of the examination. SP’s do not allow such parts of the examination; they hand the student a card with the results also described, if asked.

Sometimes the actors are actually other medical students, because of the cost. This program begins in the first year of a four year medical curriculum. It standardizes and expands the students’ clinical experiences and might be very useful in social cultures where patients are not accustomed to being seen by trainees.