The use of simulations in medical schools has been gaining ground in recent decades. The use of standardized patients began in the 1960s, with teachers and physicians unknown to students acting as patients (Pate and Ricardo, 2016). This strategy allows identification of the student's ability to identify problems and perform diagnostic and therapeutic maneuvers. However, patients' emotional reactions, such as anxiety, fear and frustration, are important aspects of optimal clinical management and require specific reflection and training. Unlike standardized patients, simulated patients are those to whom a specific script is not provided, but a full text including symptoms, previous medical history, information on education, financial and social conditions, family and emotional aspects (Beigzadeh et al., 2016; Pate and Ricardo, 2016). Based on this information, they can improvise in the contact with the students, giving their own emotional response, from the perspective of the patient, to the student (Pate and Ricardo, 2016). Actors are encouraged to react according to the student's situation and performance, as well as to disclose information only at the request of the students, who find themselves challenged to find unexpected and unforeseeable responses, requiring more students to develop empathy skills (Pate and Ricardo, 2016). The use of professional actors as simulated patients is still restricted, both in Brazil and in the rest of the world (Pate and Ricardo, 2016), and represents an innovation in this course that we describe. This aspect of medical training is very important and has been increasingly recognized as capable of modifying clinical outcomes (Pate and Ricardo, 2016).
Unlike other simulation modalities, these scenarios allow for a more flexible approach and wider feedback than simply using checklists where the actions are categorized as correct and incorrect. This makes students more committed to bonding with their patients, being attentive to their mental and emotional states, and developing strategies to gain confidence and improve communication with their patients (Beigzadeh et al., 2016; Bokken et al., 2008). Repeated contact with simulated situations with simulated patients decreases the students' anxiety about their performance (Beigzadeh et al., 2016; Bokken et al., 2008). With the development of this type of activity, receiving constant feedback, students from the beginning of their training are familiar with the fact that patients have feelings, impressions, experiences, beliefs and attitudes in relation to care that are very specific to each individual (Beigzadeh et al., 2016) and this experience and reflection enable the student to be able to have empathy, capacity for dialogue and negotiation in the face of different situations.
Clinical skills are typically acquired in a complex, step-by-step development process with differentiated skills at each stage. The anagrama "RIME" describes the development of clinical expertise throughout the training of the student: Reporter (obtain information); Interpreter (analyzes and prioritizes patient's problems); Management (elaborates care plan); Educator (reflects and educates others) (Tolsgaard, 2013). These steps correlate with the Bloom taxonomy, starting with the knowledge of information, analysis, synthesis and evaluation (Tolsgaard, 2013). The constant feedback in the simulations, from different sources - the colleague, the actor and the teacher - leads to self-reflection and, together with the work in a small group where situations are problematized, allows the identification of knowledge gaps, learning opportunity and the development of metacognition.
As for the possibility of evaluation by the colleague, we also find another rich opportunity, since the literature on strategies based on peers suggests that these are effective in the training of complex motor skills and have a positive impact on factors such as self-confidence and social aspects (Tolsgaard, 2013).
The teacher’s role is to strengthen the student in the appropriation of his trajectory in the acquisition of the skills. Some strategies used in process evaluation and assistance feedback, which can be used in the simulations are: (1) the didactic question, whereby they incorporate the student's reasoning in a process of reflection and learning. In this strategy, the questions asked by the teacher should be reflexive about the action performed, always based on the student's performance in the simulation. Another possibility is to answer the student's questions with other questions, so that the student himself identifies his / her knowledge gap and seeks to identify the solution based on his previous knowledge or later research in the literature. (2) Didactic empathy: through this the teacher understands the student's perspective, which allows him to value his responses and actions, in addition to establishing a relationship with respect and trust. (3) Pedagogical silence as a tool for reflection. The teacher should become the person the student allows himself to question, rather than the one who will answer his or her questions (Rodriguez-García and Medina-Moya, 2016).
With another look, the training of reflexive practice since graduation empowers and gives autonomy to the individual to have as habit to reflect on their situations of practical work, problematizing their experience and qualifying their daily professional practice (Rodriguez-García and Medina-Moya, 2016).
As conclusion, we present an innovative methodology for the insertion of clinical skills in the undergraduate curriculum from the first year, with potential to favor the students' critical and reflexive thinking. A differential of this activity is to count on professional actors who count their impressions on the service. The student also receives feedback from a fellow observer and the teacher in formative evaluation, being these materials for reflection and improvement of their practice, in different spheres, both technical and humanistic.