Dr. Howard Barrows, MD Introduces World's 1st Standardized Patient
LOS ANGELES, California, 1963 - At the University of Southern California in Los Angeles, neurologist and medical educator Dr. Howard S. Barrows, M.D. introduced an SP "Patty Dugger" at its third-year neurology clerkship. The debut received strong, mixed reactions, including the comment “Hollywood Invades USC Medical School”.
In an article "Standardized/Simulated Patients in Medical Education" which was published online by the American Medical Association (AMA) on June 23, 2003, a group of physicians described the incidences that had precipitated Dr. Barrows's creation of the SPs:
As a chief resident at the New York Neurological Institute, Barrows worked on the service of an attending physician who observed all medical students work up a patient from beginning to end. When asked why, the physician replied that no one else was watching students. Barrows noted that in the absence of observation and feedback, errors could persist.
The second major event occurred as Barrows selected and managed patients for the neurology board examination. When the patients were debriefed after the exam, one described a physician who was hostile and performed an uncomfortable (physical) examination. When told that the physician would be spoken to, the patient said that he had “fixed” the examinee by “changing his Babinsky from one side to the other”... (He had simulated neurological findings).
The third triggering event for Barrows came when he was developing a set of films on the neurological examination using an artist’s model. He noted that the films did not include the elements of observation and feedback, so important for learning. He began to think about teaching the model to display a neurological problem, like the patient who could change his findings at will.
This had led to a breakthrough idea, which Dr. Barrows recounted in the paper "An overview of the uses of standardized patients for teaching and evaluating clinical skills" published by the Association of American Medical Colleges (AAMC) in its peer-reviewed journal Academic Medicine in 1993:
At that time I was using a woman model from the art department as a subject for an audiovisual resource on the neurological examination. The idea occurred to me that perhaps we could teach this person, who had already learned a lot about the neurological examination, to be a neurological patient, and use her to assess the clinical clerks.
The debut of SP character Patty Dugger (Rose McWilliams) marks the origin of programmed patients, which came to be called standardized patients later. Patty Dugger was a paraplegic woman with multiple sclerosis, her experience based on that of a real patient at the Los Angeles County Hospital. The SP Ms McWilliams was coached to have a paraplegia, bilateral Babinskis, dissociated sensory loss, and a blind eye. She learned to present with the anxiety and concern of the real patient she was modeled after. Dr. Barrows also developed a checklist for the SP to record what happened with each student during every encounter. - a process still in use today.
Influential medical education author Peggy Wallace, Ph.D., however, noted the resistance that Dr. Barrows had faced in these earlier years. In her article "Following the Threads of an Innovation: The History of Standardized Patients in Medical Education" published online by the Association of Standardized Patient Educators (ASPE) on Dec 28th, 2008, Dr. Wallace wrote:
Barrows was often invited to speak about neurological subjects, but frequently was requested not to talk about simulated patients. In fact, he was seen as doing something quite detrimental to medical education, maligning its dignity with "actors."
This made it all the more difficult for Barrows to convince his medical students that the technique he was using to teach medical students was a legitimate educational tool.
Their resistance persisted even after the 1964 publication of the first article on simulated patients, "The Programmed Patient: A Technique for Appraising Student Performance in Clinical Neurology" in the Journal of Medical Education. Barrow’s co-author on this landmark article was Stephen Abrahamson, director of the USC Division of Research in Medical Education.
The USC dean received complaints from medical schools all over the country but just decided to ignore them. However Barrows, in an attempt to legitimize the work to which he was becoming so committed, replied individually to the dean or associate dean at every single one of the complaining medical schools, sharing copies of the Journal of Medical Education article.
In 1971, Dr. Barrows furthered his works at McMaster University in Canada - the first medical school to have an entirely problem-based learning curriculum - and later, the Southern Illinois University School of Medicine. In his lifetime of tremendously influential works, Dr. Barrows published over 400 journal articles as well as 19 books - laying a strong foundation for the experiential learning method that would be adopted at medical schools world over.
References:
Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC. Acad Med. 1993 Jun;68(6):443-51; discussion 451-3. doi: 10.1097/00001888-199306000-00002. PMID: 8507309.
P. K. Rangachari (2011) Howard S. Barrows: An Appreciation, Teaching and Learning in Medicine, 23:4, 313-315,DOI: 10.1080/10401334.2011.626373. Accessible online at https://www.tandfonline.com/doi/full/10.1080/10401334.2011.626373
Hmelo-Silver, C. E. (2011). In Memoriam: Remembering Howard S. Barrows. Interdisciplinary Journal of Problem-Based Learning,
5(2). Accessible online at https://doi.org/10.7771/1541-5015.1251
Peggy Wallace. (2008) "Following the Threads of an Innovation: The History of Standardized Patients in Medical Education". Published online by the Association of Standardized Patient Educators (ASPE). Accessible online at: https://web.archive.org/web/20081228115335/http://aspeducators.org/wallace.htm
Williams RG, Makoul G, Hawkins R, Hallock JA, Scoles P, Reichgott MJ. (2003) Standardized/Simulated Patients in Medical Education. Published online by the American Medical Association (AMA). Accessible online at: https://web.archive.org/web/20030623123811/http://www.ama-assn.org/ama/upload/mm/44/standardizedpatients.doc
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Last updated May 11th, 2021
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