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The Use of Standardized Patients in the Competency Testing of First Year Physical Therapy Students

Dixie H. Bowman, PT, DPT, EdD,
Assistant Professor, Department of Physical Therapy,
School of Allied Health Professions


The purposes of this study were to: 1) expand pre-clinical formative assessments of physical therapy students at Virginia Commonwealth University (VCU); 2) improve the reliability and validity of these formative assessments; 3) build VCU’s relationship with the clinical community by having physical therapists become involved in these pre-clinical formative assessment; and 4) encourage collaboration between VCU’s School of Medicine, Department of Physical Therapy and Eastern Virginia Medical School’s Theresa A. Thomas Professional Skills Teaching and Assessment Center.


Howard Barrows, M.D., first introduced the idea of standardized patients in 1964 while working at McMaster University in Canada.  A standardized patient (SP) is either an actor trained to simulate a patient’s illness in a standardized way or an actual patient who is trained to present his or her illness in a standardized way.  An SP is trained to provide information and signs and symptoms in such a way as to present the same clinical picture as realistically and consistently as possible (Barrows, 1968; Stillman et al., 1990).

Standardized patients have been used in medical education for demonstration and instruction, practice and experience, and for evaluation and assessment.  They are also an appropriate methodology for research on clinical decision making. 

The advantages of using standardized patients include the following:

  • Availability – standardized patients are easily available
  • Reliability – standardized patients’ roles are standardized and repeatable
  • Controllability – the situation, setting and level of difficulty are flexible and controllable
  • Adaptability – scenarios can be adapted as needed for demonstration
  • Feedback – feedback is immediate and constructive
    (Barrows, 1968; Chalabian et al., 1997; Glassman et al., 2000; Basco et al., 2000)

The disadvantages of using standardized patients include:

  • A limited range of clinical problems that can be simulated and therefore, a limited number of clinical skills that can be    evaluated (Barrows, 1993). 
  • Accurate evaluation is difficult.  It is critically important in performance-based techniques to define in detail what is being tested. The items on many evaluation checklists are too general to provide an accurate representation of practitioners’ competence. Others fail to use evidence-based criteria in their formulation (Gorter et al., 2000). 
  • Validity - Some standardized patient experiences are faulty because the training of the standardized patient or the evaluator lacks specificity which undermines the validity (Stillman, 1993).
  • Costs – standardized patient experiences are expensive.  Costs include concept and case study development; standardized patient recruitment, training, and payment; laboratory rental and consumable supplies; audiovisual equipment and taping costs; faculty, case consultants, support staff, and other associated personnel expenses (King, et al,, 1994).

Standardized patient encounters have been widely used in medical education to allow educators to focus on helping students develop their appropriate clinical skills as well as to test the students’ competence in clinical skill and clinical decision making.  This pedagogic approach is also being adopted by advanced practice nursing programs and pharmacy programs.  However, there is little evidence of its use by physical therapy programs.  In physical therapy programs, the current method is to use fellow students as the “patients” for competency testing.  The primary purpose of this Small Grant Project was to employ standardized patients in order to expand on the competency testing of and feedback to physical therapy students prior to their first rotation in the clinical setting.

Methods and Materials:

A camcorder and mini-DVDS were purchased through funds provided in the Small Grant. These supplies were used to record the student/SP encounter for later review and feedback to the student. Case studies and detailed evidence-based evaluation criteria were developed by the instructor (grant recipient) with input by a trainer from Eastern Virginia Medical School (EVMS)'s Theresa A. Thomas Professional Skills Teaching and Assessment Center and six licensed physical therapists from the VCU Medical Center.  The six licensed physical therapists served as standardized patients. Monies for the trainers and stipends for the physical therapists were also provided through the Small Grant.

The VCU Institutional Review Board granted approval for this study. Students in the physical therapy class of 2010 (n=52) were given a final competency evaluation in the course PHTY 537 (Rehabilitation II) in the spring, 2008. Half of the students (n=26) were tested using these standardized patients (called the “SP Group) and half  (n=26) utilized classmates as patients  (called the “Classmate Group”) for their final competency evaluation.   All of the students completed a survey asking their impression of the competency testing.  (Survey questions can be found in Figure 1.) The survey was completed on the day of the final exam prior to their first clinical rotation.  A similar survey was completed on their first day of the fall semester, 2008 after they had completed their first clinical rotation. Because one student dropped out, 26 surveys were returned for the Classmate Group  and 25 were returned for the SP Group.


A comparison was made between the surveys for both groups pre-clinical and for both groups post-clinical. A comparison was also made between the pre and post clinical surveys of the standardized patient group and the pre and post clinical surveys of the classmate group.

Survey results from pre and post clinical rotations were essentially unchanged for both groups. When comparing the results between the "classmate" group and the "standardized patient" group, only two results were significant.  The written comments provided by the students for both groups and for both the pre and post clinical surveys were very positive regarding the use of physical therapists as standardized patients during competency testing.

A final outcome of the project was the strengthening of our relationship with the physical therapists from the VCU Medical Center who serve as clinical instructors and lab assistants. They obviously enjoyed the experience and have volunteered to serve as standardized patients again.


Students felt more competent in their clinical skills for their first clinical rotation after being tested with standardized patients. Due to the positive outcomes of this study, standardized patients will be used for both mid term and final competency testing of first year physical therapy students in PHTY 537 (Rehabilitation II) at Virginia Commonwealth University.

Figure 1 – Survey Questions

  1. Skill checks effectively measured my competence in individual skills (i.e. bed mobility, vital signs, gait training, etc. (same question for both groups)
  2. Laboratory practical examinations with classmates (or physical therapists as standardized patients) effectively measured my competence in the integration of patient skills for evaluation and treatment.
  3. Laboratory practical examinations with classmates (or physical therapists as standardized patients) were intimidating and negatively impacted my performance.
  4. Being videotaped and provided with a DVD afterwards increased the value of the learning experience.
  5. I feel confident about my ability to integrate my clinical knowledge with my clinical skills.
  6. I feel confident about my ability to evaluate and treat patients during my first clinical rotation. Six statements were asked to be rated "strongly agree," "agree," "neither agree nor disagree," "disagree," or "strongly disagree."


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Last modified: June 20, 2013
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