Using real patients in professional medical exams. Suggestions would make examinations with real patients impractical.

Editor—The paper by Sayer et al raises important issues for those responsible for developing and delivering undergraduate and postgraduate clinical examinations.1 Clearly most would want to include real patients, often alongside simulated patients, to enhance the validity of the examination, although obtaining suitable real patients has become harder recently. No one would argue about the need to obtain informed consent or to ensure confidentiality of patient data. The issue of the available level of medical care, however, needs further consideration. If the source of patients includes inpatients then the environment in which the examination is conducted should offer nursing and medical support that would be available elsewhere in the hospital, and to a level appropriate to clinical need. Obviously the permission of the responsible doctor must be sought, and this should be granted only if the care available is adequate. In many examinations, however, the patients may be outpatients, and this situation is quite different. There is no reason to believe that attending the examination is more likely to cause an adverse effect than would spending the day doing something else. In fact, should the patients be taken ill or their condition become unstable one could argue that it was their good fortune to be at the examination, where medical attention was more likely to be readily available than elsewhere. The traditional places in which clinical examinations are conducted, such as wards and outpatient clinics, are becoming less likely to be made available by hospital trusts. Increasingly, purpose built clinical skills centres and other venues are being used, which may not be located on the same site as a hospital. I cannot see any reason why properly informed outpatients are at an increased risk through attending the examination or are much different from simulated patients, who may also be examined, in their need for complex medical facilities. Common sense would dictate that first aid and resuscitation equipment should be available; that only patients whose condition was stable should be recruited; that patients should be instructed to bring their normal drugs with them; and that nursing and medical staff should be available during the examination. To go to some of the extremes suggested in the paper might make it impractical to continue clinical examinations using real patients, to the detriment of our attempts to ensure high quality assessment procedures.