This handbook assumes that you have already been training SPs as it does not deal with the training of a complete patient problem. It assumes you will know where the ability to train SPs for physical signs is needed in your activities (for the basics of SP training see "Simulated (Standardized) Patients and Other Human Simulations", 1987, Health Sciences Consortium, Chapel Hill, NC).

With many of these signs, non-clinician trainers will need to work initially with a clinician to learn the correct manifestation of a particular physical finding and to learn how clinicians elicit the finding on the examination of the patient. The term "clinician" is used here as many of you may be clinicians in many different areas of health or work with clinicians in many different areas (physicians, nurses, therapists, chiropractors, psychologists, etc). If you are not a clinician yourself be sure the clinician helping you always shows you how to elicit these signs and how they should look, feel or sound.

It is important that you do everything necessary during training to encourage the SP to take on the patient's problem as his own to ensure the reality of his performance. For example, do not tell the SP "This patient had weakness in his left arm," instead say, "You have weakness in your left arm, can you imagine how that feels?"

During training give copious feedback to the SPs about their performances in a very positive manner. If they get it right - celebrate! (cheer, pat on the back, etc.). If they come close to being right tell them. For example, "Wow, that's almost it!" and then "Now, just try it a little more this way (or whatever)." If they get it wrong, tell them in essence, "You're trying hard, but that's not quite what we want; it's difficult I know, now let's try it this way (or words to that effect)." Coaching with clear, unambiguous, continuous and positive feedback is essential to successful training.

You should have the SP's performance of a new physical finding reviewed by a clinician at some point during training to reassure both you and the SP that the finding convinces and in no way seems fake.

After an initial training session it is often helpful to have the SP practice performing the sign at home before a review session.

Some SPs may be better suited to the simulation of particular physical findings than others. Time and experience, trial and error can best determine the best fit of an SP and signs to be simulated.

During training, the SP should have a pad and pencil for recording things that he is going to have to remember and practice. Such notes are far more valuable than any protocol you might provide as they will address the specific things he has trouble with and will describe them the way he will understand. With these notes he can later review the techniques needed to produce the sign. With some of the more complex signs you will need to practice and fine-tune the SP's performance just before a simulation session, and the SP's notes should be reviewed for this.

Also, if you or other faculty involved in the simulation session note problems in the SP's performance, the problems should be reviewed with him after the session and written down in his notes. These problems can be reviewed and practiced before the SP starts another session.

The signs described here are seen in varying degrees in different patients, they may be subtle and not at all obvious to being very marked and obvious. The instructions here show how to create the signs, but you will have to train the SP to have them to the intensity or degree consistent with the patient being simulated.

A videotape library of patients with these findings would provide an invaluable training resource; as would videotapes of SP training for the more difficult signs.

Some of these signs occur in unusual and rare conditions. However, they are valuable to know in case you want to show what incredible things can be simulated. More importantly, knowing the techniques used to create these signs may help you create other signs needed in your simulations.