Standardized Patient Method Research Articles

The impact of provider-patient communication skills on primary healthcare quality and patient satisfaction in rural China: insights from a standardized patient study

ObjectivesIn middle-income countries, poor physician-patient communication remains a recognized barrier to enhancing healthcare quality and patient satisfaction. This study investigates the influence of provider-patient communication skills on healthcare quality and patient satisfaction in the rural primary healthcare setting in China.MethodsData were collected from 504 interactions across 348 rural primary healthcare facilities spanning 21 counties in three provinces. Using the Standardized Patient method, this study measured physician-patient communication behaviors, healthcare quality, and patient satisfaction. Communication skills were assessed using the SEGUE questionnaire framework. Multivariate linear regression models and multivariate logistic regression models, accounting for fixed effects, were employed to evaluate the impact of physicians’ communication skills on healthcare quality and patient satisfaction.ResultsThe findings indicated generally low provider-patient communication skills, with an average total score of 12.2 ± 2.8 (out of 24). Multivariate regression models, which accounted for physicians’ knowledge and other factors, demonstrated positive associations between physicians’ communication skills and healthcare quality, as well as patient satisfaction (P < 0.05). Heterogeneity analysis revealed stronger correlations among primary physicians with lower levels of clinical knowledge or more frequent training.ConclusionThis study emphasizes the importance of prioritizing provider-patient communication skills to enhance healthcare quality and patient satisfaction in rural Chinese primary care settings. It recommends that the Chinese government prioritize the enhancement of provider-patient communication skills to improve healthcare quality and patient satisfaction.

Patient satisfaction and its health provider-related determinants in primary health facilities in rural China

BackgroundPatient satisfaction is an important outcome measure of health service and is one of the main reasons for the gradual deterioration of doctor–patient relationships in China. This study used the standardized patient (SP) method to explore patient satisfaction and its health provider-related determinants among primary health facilities in rural China.MethodsThe dataset comprised 1138 clinic cases in 728 rural primary health facilities in 31 counties, spread across four provinces. Information regarding the consultation interaction between the unannounced SPs and primary physicians was recorded. Patient satisfaction was gathered from the feedback of SPs after the visit.ResultsThe overall average score of SP satisfaction with rural primary health facilities was only 13.65 (SD = 3.22) out of 20. The SP scores were found to be consistent with those of real patients. After controlling variances in patient population via the SP method, the regression analysis demonstrated that health provider-related factors, such as physician-level characteristics, consultation process, affordability, and convenience, have a significant correlation with patient satisfaction among primary physicians. Among factors relating to physician-level characteristics, affordability, convenience and the consultation process of the visit, the quality of the consultation process (e.g., consultation time, proactively providing necessary instructions and other crucial information) were found to be the prominent determinants.ConclusionsThis study revealed the need to improve patient satisfaction in primary health facilities in rural China. To solve this issue, we recommend that policies to increase medical service quality be implemented in rural primary healthcare systems.

Comparing the Quality of Primary Care between Public and Private Providers in Urban China: A Standardized Patient Study.

Previous studies have been limited by not directly comparing the quality of public and private CHCs using a standardized patient method (SP). This study aims to evaluate and compare the quality of the primary care provided by public and private CHCs using a standardized patient method in urban China. We recruited 12 standardized patients from the local community presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi’an, China. We measured the quality of primary care on seven criteria: (1) adherence to checklists, (2) correct diagnosis, (3) correct treatment, (4) number of unnecessary exams and drugs, (5) diagnosis time, (6) expense of visit, (7) patient-centered communication. Significant quality differences were observed between public CHCs and private CHCs. Private CHC physicians performed 4.73 percentage points lower of recommended questions and exams in the checklist. Compared with private CHCs, public CHC providers were more likely to give a higher proportion of correct diagnosis and correct treatment. Private CHCs provided 1.42 fewer items of unnecessary exams and provided 0.32 more items of unnecessary drugs. Private CHC physicians received a 9.31 lower score in patient-centered communication. There is significant quality inequality in different primary care models. Public CHC physicians might provide a higher quality of service. Creating a comprehensive, flexible, and integrated health care system should be considered an effective approach towards optimizing the management of CHC models.

Comparing the use of direct observation, standardized patients and exit interviews in low- and middle-income countries: a systematic review of methods of assessing quality of primary care.

Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers’ clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 13 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others—each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.

EFFECTIVENESS OF STANDARDIZED PATIENTS AND ROLE-PLAY SIMULATION METHODS IN IMPROVING SELF-CONFIDENCE AND THERAPEUTIC COMMUNICATION SKILLS OF NURSING STUDENTS

Background: Communication skills are critical skills that must be possessed by nurses because communication is a dynamic process that is used to collect assessment data, provide education or health information to influence clients to apply it in life, show caring, provide comfort, foster self-confidence and, value respect - client value. Nurses in communicating with clients must have high confidence in the effect of these communications.Objectives: The purpose of this study was to analyze the differences in the effect of standardized patient simulation methods and role play in increasing self-confidence and therapeutic communication skills of students of the Nursing Academy of Pasuruan.Methods: The design of this study is the quasi experimental study. There are two therapeutic communication training groups. Group A uses a Standardized Patient (SP) and, Group B uses the role play (RP) method. The population in this study were students of the Nursing Academy of Pasuruan, and the sample was taken by simple random sampling with a sample size group of 16 standardized patients and a roleplay group of 16 people. The measuring instrument used was an observation sheet on therapeutic communication skills and a questionnaire on confidence in therapeutic communication. The effectiveness of the two methods was analyzed by the non-parametric test, namely the Mann Whitney test, to test 2 unpaired samples.Results: The results of this study indicate that there are differences in standardized patient methods and role play on self-confidence and therapeutic communication skills in nursing academy students who are statistically significant at 0.03 (p=0.05).Conclusion: The standardized patient method is more effective in increasing self-confidence and therapeutic communication skills in nursing academy students compared to the roleplay method. Keywords: Standardized Patient, Roleplay, Therapeutic Communication, Self-Confidence

How to do (or not to do) … using the standardized patient method to measure clinical quality of care in LMIC health facilities.

Standardized patients (SPs), i.e. mystery shoppers for healthcare providers, are increasingly used as a tool to measure quality of clinical care, particularly in low- and middle-income countries where medical record abstraction is unlikely to be feasible. The SP method allows care to be observed without the provider's knowledge, removing concerns about the Hawthorne effect, and means that providers can be directly compared against each other. However, their undercover nature means that there are methodological and ethical challenges beyond those found in normal fieldwork. We draw on a systematic review and our own experience of implementing such studies to discuss six key steps in designing and executing SP studies in healthcare facilities, which are more complex than those in retail settings. Researchers must carefully choose the symptoms or conditions the SPs will present in order to minimize potential harm to fieldworkers, reduce the risk of detection and ensure that there is a meaningful measure of clinical care. They must carefully define the types of outcomes to be documented, develop the study scripts and questionnaires, and adopt an appropriate sampling strategy. Particular attention is required to ethical considerations and to assessing detection by providers. Such studies require thorough planning, piloting and training, and a dedicated and engaged field team. With sufficient effort, SP studies can provide uniquely rich data, giving insights into how care is provided which is of great value to both researchers and policymakers.

Group randomized trial of teaching tobacco-cessation counseling to senior medical students: a peer role-play module versus a standardized patient module

BackgroundAn important barrier to smoking-cessation counseling for physicians is a lack of education at the undergraduate level. Interactive methods such as peer role-play (RP) or modules utilizing standardized patients (SPs) may be effective for medical students to enhance their performance on tobacco cessation counseling. This study compared the effectiveness of a module using SPs to that of a RP module for undergraduate medical students on tobacco cessation counseling.MethodsThis study was conducted over a single week of the family medicine clerkship. One hundred and thirteen fourth-year medical students were randomized into either the SP group or the RP group. A RP module involved a ten-minute encounter between the student doctor and the student patient followed by five minutes of feedback from the observer student using a group developed checklist. In a SP module, each student was asked to interview a SP portraying a smoker with willingness to quit. After the encounter, the SP provided five minutes of direct oral feedback to the student. In both modules, the total intervention lasted three-and-half hours and was supervised by faculty staff. Students’ objective structured clinical examination (OSCE) scores were evaluated to determine their tobacco cessation counseling skills. Four evaluation periods were conducted at baseline, postintervention, post-clerkship, and before receiving the Korean medical licensing examination (KMLE). Students’ smoking knowledge test scores and counseling self-confidence levels at pre- and post-intervention were also compared.ResultsIn both groups, post-intervention OSCE scores increased significantly compared to baseline (Cohen’s d 0.87, p < 0.001 in SP group; d 0.77, p < 0.001 in RP group). However, there were no differences between the two groups. Students achieved the highest OSCE score for smoking-cessation counseling before the KMLE. After training, student self-confidence and smoking-knowledge test scores increased significantly, regardless of the type of module. Self-confidence was higher in the SP group compared with the RP group (d 0.37, p = 0.01).ConclusionsPeer role-play may be equivalent to the SP method with regard to knowledge and skills reported during smoking-cessation counseling and SP method may be better in self-confidence. Cost and student self-confidence may be important factors when choosing among the teaching methods for smoking-cessation counseling.

Examining the effect of simulation based learning on self-efficacy and performance of first-year nursing students.

Self-efficacy is an individual's belief in oneself and in one's own judgment and ability to be successful in a task. Strong self-efficacy allows for the achievement of success, well-being, personal development and the diversification of skills. An individual's perception of his/her self-efficacy plays a key role in adopting behaviors and initiating and sustaining change. The first aim of this study is to evaluate the effects of simulation-based learning on the self-efficacy and performance of first-year nursing students. The second aim is to examine students' pre- and post-scenario proficiency in their self-assessment of competence in regard to scenario objectives to compare the students' self-assessment and their instructor's assessment in terms of performance evaluations. This semi-experimental study was conducted with sixty-five first-year nursing students. A standardized patient method was used as a simulation technique. Students' self-efficacy and their perceptions of their own competence in completing skills were measured using the General Self-Efficacy Scale and the Proficiency Assessment Form, respectively. Students' actual performance was evaluated via an Objective Structured Clinical Assessment and performance evaluation checklists. The mean self-efficacy score of students was 52.68 (±10.19) before the scenario and 49.59 (±12.90) post-scenario (p = .001). With regard to their scenario objectives, a decrease was observed in students' proficiency in their post-scenario self-assessment of competence. This decrease was only statistically significant in the "Establishing a safe patient unit" objective (t = 2.27; p = .03). We observed that self-efficacy scores declined in the post-simulation scenario. Using standardized patients in simulation training allows novice nursing students to meet a real patient and to recognize their own true self-efficacy.

Hemşirelik Eğitiminde Standardize Hasta Kullanımı

Sağlık bakım ve teknolojisindeki gelişmeler, sağlık eğitiminde geçerli ve güvenilir yöntemlerden biri olan benzetim (simülasyon) uygulamalarını ön plana çıkarmıştır. Gerçekliği en yüksek simülatörler olarak kabul edilen standardize hastalar; eğitilmiş sağlıklı birey ya da gerçek hastadan oluşan, sağlık bakım uygulamalarının kendisine yapılmasını kabul eden toplum üyesidir. Ülkemizde hemşirelik eğitiminde henüz yaygın olarak kullanılmayan standardize hasta uygulamasının, pek çok açıdan avantaj sağlamasına rağmen müfredata entegrasyonunun ne düzeyde olduğu ve klinik ortamdaki yansımalarının bilinmediği, konuyla ilgili çalışmalara gereksinim olduğu düşünülmektedir. Bu makalede amaç standardize hasta uygulamasının eğitim müfredatında, standardize hasta gibi gerçekçi ve güncel öğretim yöntemleri ile zenginleştirilmiş öğrenme ortamlarının arttırılmasına katkı sağlamaktır.

Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities.

BackgroundIndia has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities.Methods and findingsDuring 2014–2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB “case scenarios” representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications.Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case.A total of 2,652 SP–provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%–37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management.MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05–3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06–3.03), and MBBS providers’ quality of care did not vary between cities (OR 1.15; 95% CI 0.79–1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction.ConclusionsQuality of TB care is suboptimal and variable in urban India’s private health sector. Addressing this is critical for India’s plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts.

СТАНДАРТИЗОВАНІ ПАЦІЄНТИ У НАВЧАННІ ІНОЗЕМНИХ МАГІСТРАНТІВ-МЕДИЧНИХ СЕСТЕР

Мета роботи – вдосконалення організації навчального процесу для студентів-магістрантів спеціальності «Медсестринство» з числа іноземних громадян шляхом розробки нових методів об’єктивного навчання і тестування, які б забезпечили значний прогрес у бік професійно-орієнтованого клінічного оцінювання на всіх рівнях та етапах навчання і практики.Основна частина. У статті здійснено оцінку існуючих методів викладання іноземним студентам медичних навчальних закладів III – IV рівнів акредитації за спеціальністю «Медсестринство», магістерського рівня вищої освіти. Виокремлено основні педагогічні прийоми засвоєння практичних навичок магістрантами-медичними сестрами. Визначено доцільність застосування оцінки клінічної компетентності за допомогою стандартизованих пацієнтів.Існує багато варіацій в організації іспитів із клінічної компетентності за допомогою стандартизованих пацієнтів, наприклад поєднання в одному іспиті симульованих та реальних хворих (що може підвищити достовірність усього іспиту) і навіть симуляторів, іспит може складатись з різної кількості (7 - 40) станцій (станція - це місце роботи екзаменованого з конкретним стандартизованим пацієнтом), тривалість станції може коливатись від 4 до 25 хвилин, використовуються різні форми контролю (контрольні таблиці (checklists), рейтингові шкали (rating scales), відеозапис.Висновок. Метод стандартизованих пацієнтів є ефективним та якісним методом оцінювання клінічної компетентності. Він має кращі психометричні властивості, ніж традиційні засоби оцінювання студентів біля ліжка хворого.

Application of using standardized patient tutorial in the specialized training of pancreatic surgery with WeChat platform

Objective To analyze the effect of using standardized patient (SP) tutorial in the spe-cialized training of pancreatic surgery with WeChat platform. Methods 48 surgeons participating in resi-dent standardized training in Changhai Hospital (all for postgraduate education) were enrolled as teaching object. 48 surgeons were divided into two groups: SP group (n=24) receiving WeChat combined with SP tutorial which updates learning plan, learning contents, and clinical discussion by Wechat platform and performs practical teaching by SP method, control group (n=24) receiving traditional tutorial by using tradi-tional clinical teaching methods and video teaching followed by practical teaching. The theoretical examination, questionnaires and expert assessment were used to evaluate the effect of the two teaching methods. Statistical analysis was performed using the SPSS 19.0. Continuous data were expressed as median±stan-dard deviation and compared using the Student’s t-test. Categorical data were compared using the Pearson's chi-square test. Results The score of theoretical examination of the two groups showed no significant difference [(85.5±7.6) vs. (81.4±14.9), P=0.238]. The results of questionnaires and expert assessment in WeChat & SP group were significantly better than those in the control group (P 0.05). Conclusion WeChat platform combined with standardized patient tutorial in the specialized training of pancreatic surgery is feasible and more effective than traditional tutorial to improve teaching effectiveness. Key words: Standardized patient; WeChat; Pancreatic surgery; Specialized training

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

ObjectiveTo evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program.MethodsWe investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.FindingsThe programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered.ConclusionSocial franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

Use of Simulated Patient Method to Teach Communication With Deaf Patients in the Emergency Department

BackgroundHealth care professionals should have the necessary communication skills in interacting with deaf patients. MethodsThis qualitative study revealed the communication experiences of senior nursing students with deaf patients and developed a pathway for nursing students to use when communicating with these patients. The participants were 22 senior nursing students who served as interns in the emergency department of a university hospital in Turkey. A standardized patient method using a simulation technique was performed and recorded three times. The recorded discussions during the debriefing sessions were transcribed and analyzed using the systematic text condensation method developed by Malterud. ResultsSeven main themes were identified: (a) patient preferences, (b) sitting position during training, (c) speech speed and content, (d) body language, (e) preparation, (f) eye contact, and (g) preparing a pathway for communication with deaf patients. ConclusionsConclusion: Repeating the simulation 3 times produced improvement in the students' learning of communication skills to provide services to deaf patients.

Efficacy of a Communication Skill Training Fostering Health Promotion in Primary Care: A Mixed Method Analysis

Background: Health related behavior is an important determinant of chronic disease, with a high impact on public health. Thus, motivating and assisting people to change their unfavorable health behavior is a major challenge for health professionals. Patients increasingly seek more active participation in healthcare decisions. Thus, communication skills of general practitioners (GPs) are crucial for a successful health promotive counseling, and there is a need of sound competences in communication techniques among them. Methods: We developed a training program using case vignettes and standardized patients (SPs) and evaluated its effectiveness among GPs and their patients at different levels using a validated evaluation model. Levels refer to a. acceptance and satisfaction; b. adoption of knowledge and skills; c. behavior change in regard to communication competence; d. impact on daily work with results in the targeted aim. Results: Participants' ratings in all levels were positive, between 3.9 and 5.0 on a 5- point Likert scale. Self-rated communication knowledge and skills improved significantly with ratings of 3.4 to 3.7 before and 4.2 to 4.5 after the training course (p < 0.01). Only the integration of the new role into daily work was not, or not yet, changed by the training, but the perceived communication competence and working quality of participating GPs improved. Conclusion: Communication skills and competence, as well as patient-centeredness and empathy, are crucial for GPs for helping patients to change and sustain their health behavior. Within communication skill trainings for GPs fostering health promotive counseling, the SP method is a promising format of medical education at pre- and postgraduate level, with a potentially high impact on public health.

A cross-sectional study of the quality of telephone triage in a primary care out-of-hours service

We evaluated the quality of telephone triage and the appropriateness of the decisions resulting from it at a primary care out-of-hours service. Four simulated clinical cases were used in the Incognito Standardized Patient method: an adult with nosebleed, an adult with fever, a child with fever and a child with vomiting. There was a set of obligatory questions for each case, translated from those used in a previous study. Quality was assessed by the proportion of questions asked by the call-handlers during telephone triage versus those that should have been asked. A total of 22 out-of-hours doctors were involved in the study, working in two different locations in the Verona city area. Over a 4-month period each of the four simulated clinical cases was used five times in calls to the two centres involved. The proportion of obligatory questions asked compared to those expected to be asked was 27–36%. On three occasions out of the 40 simulations, all of which were considered to be manageable by telephone, the patient was advised to go to an outpatient clinic for a face-to-face evaluation. The average duration of the calls was 3 min 47 s. The quality of telephone triage in the regions studied was low and provided considerable room for improvement. This is relevant to patient safety and risk management of the service.

The Teaching Effectiveness of Standardized Patients

Teaching nursing students therapeutic communication skills begins in the classroom and extends to the clinical environment. The usual method of instruction consists of random patient encounters observed by faculty and measures of competence that rely on paper-and-pencil tests. Using standardized patients (SPs) offers an alternative approach to the traditional method of teaching. Standardized patients are individuals who have been carefully trained to present an illness or scenario in a standardized, unvarying manner. This pilot study compared use of SPs with the usual method of instruction in a class of undergraduate nursing students. Results indicated that students who participated in the SP method overwhelmingly described the experience as positive, creative, and meaningful. No significant differences were found between the two groups on measures of interpersonal skills, therapeutic communication skills, and knowledge of depression

How to introduce incognito standardized patients into outpatient clinics of specialists in rheumatology

To know what is going on in physicians' surgery hours, assessment of practice performance is important with regard to quality assessment activities. The incognito standardized patient (SP) method is a powerful method to assess this. However, until now no reports have been published about specialists' performance using this method. In this study, 27 rheumatologists in 16 hospitals were each visited by eight incognito SPs to study the feasibility of sending incognito SPs to specialists working in different hospitals, of follow-up consultations and of simulating additional investigations. SPs recorded performance on case-specific checklists. The different steps needed for these visits are described in detail. A total of 136 first and 32 follow-up visits took place. SPs remained undetected in 98% of the visits. It is concluded that this SP method is a feasible one, however, only to be used for very specific purposes. Use of incognito SPs for larger scale projects is not recommended.

The use of standardized patients in research in general practice.

Standardized patients (SPs) are simulated patients or actual patients who have been carefully coached to present their illness in a standardized way. Much is known about the use of standardized patients in medical education. This article reviews advantages and disadvantages, reliability and validity of the use of standardized patients in general practice and primary care research. Performance in general practice can be measured with direct or indirect methods. With direct methods the physician-patient contact is directly observed or heard. Indirect methods are seldom complete and seldom accurate and therefore often invalid. Direct methods (observation, video, audiotapes, etc.) have face validity, but nevertheless have shortcomings. The SP method can mainly avoid the disadvantages of the other methods. The presentation of the case by the SP is accurate. The judgement of physician's behaviour during the consultation by the SP is accurate and reliable. SPs are generally believable. Less than one in five SPs is detected by the physicians, so the method has face validity. To obtain sufficient reliability and validity, a thorough selection and training of SPs is required, as is careful organization with an eye for detail. The SP method also has some important shortcomings. The method is time and work demanding, limiting the number of physicians that can be measured. In addition, measurement is usually limited to one consultation. In reality, however, diagnostic and therapeutic interventions are often spread over several consultations. This 'first-visit-bias' hampers conclusive answering of some research questions.