A simulated patient program is a standing service, not a list of volunteers. It has a coordinator and a bank of trained people. It has a recruitment route, a pay scale, and a training standard for each case. It has a quality check before high-stakes use, and welfare rules. The Association of Standardized Patient Educators' standards of best practice give it five domains. Build the program to those, and every station gets the same patient forty times.
Why the program decides the exam's fairness
An OSCE station is standardized only if the patient is. A simulated patient who answers a question differently for the afternoon cohort has changed the station. No marking scheme can undo it. The AMEE guide on OSCE organization names poorly standardized patients first among the four things that lower OSCE reliability.
Standardization is expensive. The same guide cites an estimate of up to 15 hours to adequately train a simulated patient. A school that pays for that once and loses the person has to pay again. The program exists to keep the investment: a bank of people trained for several roles, paid, thanked, and asked back.
What are the five domains?
The ASPE best-practice standards were published in 2017 after three and a half years of international consensus work. They organize simulated patient work into five domains. The table maps them onto a program.
Domain | What the program provides | Who owns it |
|---|---|---|
Safe work environment | Role limits written into every case; a way to stop a station; debriefing after difficult roles; no physical examination beyond what was agreed | Coordinator |
Case development | The simulated patient part of the station template: identity, history, concerns, what to say and not say, standardized answers | Station writer with the coordinator |
Training for portrayal, feedback, and completing instruments | A training plan per case; separate training if the simulated patient gives feedback or completes a rating | Trainer, see training an SP for a case |
Program management | Recruitment, the bank, scheduling, pay, records, consent, evaluation | Coordinator with the exam office |
Professional development | Training for trainers; the coordinator's own development; the simulated patients' progression to harder roles | Coordinator |
A 2026 companion standard covers physical examination teaching associates, the people who teach and are examined in physical examination. If the program uses them, it follows that standard as well.
Who runs it?
One person: the simulated patient coordinator, named on the governance page's roles table. The AMEE guide explicitly calls for the role. A 2009 survey covered 61 programs in the United States and Canada. It found an average of 4.8 permanent staff per program, not counting the simulated patients themselves. Few new programs start there. One coordinator with administrative support is the minimum, and the coordinator's time is a line in the budget.
How are simulated patients recruited and kept?
The bank is the asset. The program recruits for it continuously, not for each exam.
- Sources. Retired people, drama students and community actors, patient groups, university staff from outside the faculty, former simulated patients' contacts. Never current students of the program being examined.
- Selection. A short interview and a read-through of a sample role. Then a check that the person can present the role's demographics and, where needed, its signs. Some roles need a particular age or sex; the bank needs a range.
- Records. Name, contact, availability, roles trained, sittings played, ratings from video QA, the consent form on file. The consent page covers what the consent form must say.
- Retention. The AMEE guide's advice is brief and right: remunerate and thank. Pay on time, give feedback, and offer new roles. Invite people to see the results of the exam they helped run.
The 2009 survey found that 54 percent of programs hired 51 to 100 simulated patients a year. That is a bank, and it needs a coordinator to run it.
What should simulated patients be paid?
Something. The same survey reported average pay of US$15 an hour for training time and US$16 an hour for portraying a case. Those are 2009 figures from one region. Current rates vary by country and by whether the role includes physical examination. The principle holds across all of them: training time is paid for, as is exam time, and the rate is set before recruitment starts.
A program that relies on unpaid volunteers can run a formative OSCE. For a high-stakes exam, it is a risk: the person who does not turn up has no reason to. Reserves cost money too, and the AMEE guide's exam-day list includes simulated patient selection with reserves.
How is quality assured?
Two checks. The first is training to a standard, one case at a time, covered on the case training page. The second is video QA before high-stakes use, as recommended by the AMEE guide. A trainer or a second clinician watches a recorded rehearsal or a formative run. They score the portrayal against the script.
The evidence says the check is needed. A study recorded four stations of a high-stakes OSCE, with four simulated patients trained for each case. Verbal portrayal was consistent across most items. Facial expression differed significantly. An emergency station that depended on physical presentation was played differently by all four. Training standardizes the words. Video QA catches the rest.
Should simulated patients rate candidates?
Sometimes, and with care. Simulated patients can rate the candidate's communication, and some exams use them as examiners at selected stations. The evidence on what that rating measures is mixed. In a 2006 Canadian study, simulated patient examiners scored students higher than physicians did. The two sets of scores correlated weakly, and the simulated patient scores did not predict performance elsewhere. A 2023 study compared simulated patient ratings with those of trained observers. Where they differed, the simulated patients rated higher on 20 of 21 items, particularly in empathy and nonverbal communication. The AMEE guide's summary is that simulated patient scores agree with physicians on checklists but not on global scoring.
The program's rule follows: a simulated patient rating is a separate instrument, trained separately, reported separately, and never merged into the examiner's global rating.
Welfare and limits
Roles that involve distress, bad news, or intimate examination need a written limit, a way to stop, and a debrief. The program caps the number of times a person plays a demanding role in a day. It records incidents. It gives the same person a lighter role next time. The exam-day briefing repeats the limits on the morning.
Frequently asked questions
What is the difference between a simulated patient and a standardized patient?
The same role: a trained person who plays a patient the same way for every candidate. Standardized patient is the older North American term. Simulated patient is more common elsewhere. ASPE's standards use simulated participant to cover both.
How many simulated patients does an OSCE program need?
Enough to cover every station that uses one, in every circuit and session, plus reserves. The bank also needs a range in age and sex for the roles. A 2009 survey found 54 percent of programs hired 51 to 100 a year.
How long does it take to train a simulated patient?
The AMEE guide cites an estimate of up to 15 hours. A short history with no signs takes less. A role with distress or physical findings takes more. Training time is paid. A recorded run checked against the script is the last step.
Should simulated patients be paid?
Yes, for training time and exam time, at a rate written down before recruitment. A 2009 survey of US and Canadian programs reported US$15 an hour for training and US$16 for playing a case. Rates now vary by country. Unpaid volunteers are a risk in a high-stakes exam.
Can simulated patients act as OSCE examiners?
On some stations, with their own training and their own instrument. Studies show they score higher than physicians. They agree with physicians on checklists but not on global judgments. Keep their rating separate from the examiner's global rating.