Difficult simulated patients in the FSP: staying in control

What examiners test with difficult patients

The patient is usually played by a member of the examination board who — as Saxony describes it — receives preset information about the patient's health; in Nordrhein an actor takes the role. What is graded is how you handle this counterpart. Berlin's grading sheet for part 1 asks, among other things, whether you establish “eine professionell-persönliche Kommunikation” (professional, personal communication), lead the conversation “zielgerichtet und situationsbezogen” (goal-directed and suited to the situation) and understand the other person “problemlos” (without difficulty) — details under Grading. Saxony puts it like this: “Es ist wichtig, dass der Patient richtig verstanden wird und dass er Sie versteht” (it is important that the patient is understood correctly and that he understands you).

What the chambers say officially:

• Names and unknown words. The Nordrhein examiner Dr. Jaswant Singh reports that some candidates are unsettled “bereits durch komplizierte Namen der Patienten” (even by complicated patient names). With unknown words — his example is “Leberfleck” (a mole) — candidates should “nachzuhaken und sich den Sachverhalt umschreiben zu lassen” (follow up and have the patient describe what they mean).
• Numbers. Saxony: “Achten Sie auf richtiges Zahlenverständnis” (make sure you understand numbers correctly). Rhineland-Palatinate: “Achten Sie darauf, dass Sie Zahlen und Namen korrekt erfassen, lassen Sie sich Worte, die Sie nicht kennen, buchstabieren” (record numbers and names correctly; have unknown words spelled).
• Flexibility. Nordrhein: “Es wird ein flexibler und gegebenenfalls umschreibender Sprachgebrauch gefordert” (flexible language, paraphrasing where needed, is required). Rhineland-Palatinate wants you to answer patient questions immediately rather than carrying on with your list of questions.

No chamber publishes how the role is played, and there is no official statistic on how often each type appears. The types below come from candidates' exam protocols — first-hand accounts, not chamber information. A protocol from Munich describes the principle: the examiner-patient works from a filled-in template, ticks off what has been asked and mixes up the information to confuse. Complicated facts and unusual names are deliberate: they test whether you really understand.

Asking back when you have not understood

Not understanding something is not a mistake. Pretending you have understood is: examiners quickly notice when something has passed you by, and asking back is not a sign of weakness but part of good conversation management — Berlin explicitly scores whether you understand the other person „problemlos“ (without difficulty). The reason is the exam chain: whatever you misunderstand in part 1 ends up wrong on the documentation form, and in the doctor–doctor conversation, according to the same protocol, the examiners ask about almost every detail from the patient conversation.

Phrases for asking back:

• Acoustic: „Entschuldigung, das habe ich akustisch nicht verstanden. Könnten Sie das bitte wiederholen?“ (Sorry, I didn't catch that. Could you repeat it, please?)
• Checking content: „Habe ich Sie richtig verstanden, dass die Schmerzen erst seit gestern Abend bestehen?“ (Have I understood correctly that the pain only started last night?)
• Asking for a description: „Was meinen Sie genau mit ‚Herzstolpern‘? Können Sie mir das beschreiben?“ (What exactly do you mean by “Herzstolpern”? Can you describe it?)
• Spelling: „Könnten Sie mir den Namen bitte buchstabieren?“ (Could you spell the name for me, please?)
• Confirming a number: „Sie sagten fünfzehn — eins, fünf?“ (You said fifteen — one, five?)
• Showing: „Zeigen Sie mir bitte genau, wo es wehtut.“ (Please show me exactly where it hurts.)

Nine patient types at a glance

1. The talker

He talks without a break, jumps between topics and elaborates on side issues. A Munich candidate writes that if the patient has “Logorrhö”, you must give him an “Antilogorrhoikum” straight away, “ansonsten fallt ihr durch” (otherwise you fail) — the institute adds that this has “schon sprachlich guten Teilnehmern passiert” (happened even to linguistically strong candidates). In a Düsseldorf account a candidate says he had to interrupt the actor patient “tausend mal” (a thousand times). What is tested: whether you lead the conversation purposefully and keep the 20 minutes under control.

• „Entschuldigen Sie, dass ich Sie unterbreche, Herr Becker — das ist wichtig, und ich komme gleich darauf zurück.“ (Sorry to interrupt — that's important and I'll come back to it.)
• „Damit ich nichts übersehe, gehe ich jetzt Schritt für Schritt vor.“ (So that I don't miss anything, I'll go step by step now.)
• „Lassen Sie uns kurz bei den Schmerzen bleiben: Seit wann genau haben Sie sie?“ (Let's stay with the pain for a moment: since when exactly?)
• „Das notiere ich mir. Eine kurze Frage noch zu Ihren Medikamenten: …“ (I'll note that. One quick question about your medication: …)

Acknowledge first, then steer — and follow the interruption with a short, closed question.

2. The anxious patient

She asks “Ist es schlimm?” (Is it bad?), “Habe ich Krebs?” (Do I have cancer?) or fears having the same illness as a relative who died — as in a Düsseldorf protocol in which the patient was afraid of suffering from the same disease as his late mother. What is tested: whether you reassure with empathy without promising a diagnosis or naming a frightening one. The Munich protocol explicitly advises never to tell the patient “ins Gesicht” (to their face): “Sie haben einen Tumor” (you have a tumour).

• „Ich verstehe, dass Sie sich Sorgen machen — gerade nach dem, was Ihre Mutter erlebt hat.“ (I understand you are worried — especially after what your mother went through.)
• „Woran ist Ihre Mutter erkrankt, und wie alt war sie damals?“ (What illness did your mother have, and how old was she then?)
• „Ihre Beschwerden können verschiedene Ursachen haben, harmlose und ernstere. Genau deshalb untersuchen wir Sie gründlich.“ (Your symptoms can have various causes, harmless and more serious ones. That is exactly why we are examining you thoroughly.)
• „Sie sind hier gut aufgehoben. Ich erkläre Ihnen jeden Schritt.“ (You are in good hands here. I'll explain every step.)

The second question turns the fear into a family history. Avoid “Keine Sorge, das ist sicher nichts” (don't worry, it's surely nothing) — in part 1 you cannot know that.

3. The minimiser

He plays down alcohol, smoking or symptoms. In a Münster protocol the patient first drinks “nur beim Feiern ein Glas Sekt” (just a glass of sparkling wine at celebrations) and only later admits to drinking at work. What is tested: whether you ask concretely and without judgement until you can note an amount — the form has its own field for it, “Genussmittel/Drogen” (substance use).

• „Was trinken Sie an einem ganz normalen Tag — zum Beispiel bei der Arbeit oder abends?“ (What do you drink on an ordinary day — at work or in the evening, for example?)
• „Wie viele Flaschen Bier sind das in der Woche ungefähr?“ (Roughly how many bottles of beer is that per week?)
• „Ich frage alle Patientinnen und Patienten danach, weil Alkohol und Medikamente sich gegenseitig beeinflussen können.“ (I ask all patients this, because alcohol and medicines can affect each other.)
• „Wie viele Zigaretten rauchen Sie am Tag, und seit wann?“ (How many cigarettes a day, and since when?)

4. The demanding or irritated patient

He wants a painkiller immediately, becomes impatient or corrects you sharply. A candidate from Münster reports that the patient insisted he had no pain but a feeling of pressure, and became “richtig aggressiv” (really aggressive) when asked about painkillers. His advice: “Nehmt das nicht persönlich” (don't take it personally). What is tested: whether you stay calm, adopt the patient's own words and still keep asking.

• „Gut, dann sprechen wir von einem Druckgefühl. Wie stark ist dieser Druck von 0 bis 10?“ (All right, let's call it a feeling of pressure. How strong is it from 0 to 10?)
• „Ich sehe, dass es Ihnen gerade sehr schlecht geht. Ich kümmere mich darum, dass Sie so schnell wie möglich Hilfe bekommen.“ (I can see you are feeling very unwell. I'll make sure you get help as quickly as possible.)
• „Damit ich Ihnen das Richtige geben kann, brauche ich noch zwei kurze Antworten.“ (So that I can give you the right thing, I need two more short answers.)
• „Ich verstehe Ihren Ärger. Lassen Sie uns gemeinsam schauen, wie es weitergeht.“ (I understand you are annoyed. Let's look together at what happens next.)

5. Fast or unclear speech

In protocols from Düsseldorf the patient speaks quite fast and not always clearly, or says numbers deliberately quickly; in Münster a patient sounded “als hätte er etwas im Mund” (as if he had something in his mouth). What is tested: your listening comprehension — above all for numbers that must later appear on the form. In the Düsseldorf case the patient spoke more clearly after a polite request to repeat.

• „Entschuldigung, könnten Sie bitte etwas langsamer sprechen? Ich möchte nichts falsch aufschreiben.“ (Sorry, could you speak a little more slowly? I don't want to write anything down wrongly.)
• „Ich wiederhole zur Sicherheit: geboren am 14. Januar 1962?“ (To be safe, I'll repeat: born on 14 January 1962?)
• „Sagten Sie fünfzehn oder fünfzig?“ (Did you say fifteen or fifty?)
• „Den Namen des Medikaments habe ich nicht verstanden — können Sie ihn buchstabieren?“ (I didn't catch the name of the medicine — can you spell it?)

6. The patient who tells things out of order

He jumps back and forth in time, mixes old and new complaints or mentions a trigger only in passing. What is tested: whether you create order — the basis for a clear report in part 2.

• „Lassen Sie mich kurz ordnen: Zuerst kamen die Bauchschmerzen, danach die Übelkeit — ist das richtig?“ (Let me sort this out: first the abdominal pain, then the nausea — is that right?)
• „Was war zuerst da?“ (What came first?)
• „Sie haben vorhin einen Sturz erwähnt. Wie genau ist das passiert?“ (You mentioned a fall earlier. How exactly did it happen?)
• „Ich fasse zusammen, und Sie korrigieren mich bitte, wenn etwas nicht stimmt.“ (I'll summarise; please correct me if anything is wrong.)

7. Awkward names, numbers and lay words

Double-barrelled names, unusual spellings, ages at past events (“mit vier eine Hirnhautentzündung, mit 38 den Kiefer gebrochen” — meningitis at four, broken jaw at 38), lay words such as “Herzstolpern” (palpitations), “im Kreuz” (in the lower back) or “gern einen gehoben” (likes a drink). In a Hamburg protocol the patient explains her surname with “Haar wie Haar im Kopf” (Haar as in the hair on your head), and the candidate checks whether Susanne is spelled with a double n. What is tested: accurate recording. On the form the patient must be unambiguously identifiable; Saxony explicitly names “Name, Vorname, Geburtsdatum” (surname, first name, date of birth).

• „Wie schreibt man Ihren Nachnamen? Buchstabieren Sie bitte.“ (How do you spell your surname? Please spell it.)
• „Was meinen Sie mit ‚Leberfleck‘? Wo ist er, und hat er sich verändert?“ (What do you mean by “mole”? Where is it, and has it changed?)
• „Wie alt waren Sie damals ungefähr?“ (Roughly how old were you then?)
• „Wissen Sie noch, wie das Medikament heißt? Haben Sie vielleicht einen Medikamentenplan dabei?“ (Do you remember the name of the medicine? Do you have a medication list with you?)

Whatever the patient does not know — a dose, for instance — note as “nicht bekannt” (not known) rather than guessing. In the Hamburg case the candidate wrote that the GP should be contacted.

8. The patient doesn't understand you

She asks “Was ist das?” (What's that?) or “Wie bitte?” (Pardon?). In the Mainz report the patient wanted to know what a Furunkel (boil), a Gebärmuttersenkung (uterine prolapse) and a CT are. The chambers take this seriously: Nordrhein stresses that “der Patient den zu prüfenden Arzt sicher und gut verstehen kann” (the patient can understand the candidate reliably and well); Rhineland-Palatinate writes: “Nicht Verständliches […] reduziert Ihre Punktzahl” (anything unintelligible reduces your score). A candidate from Münster reports failing because the examiner could not understand him. What is tested: pronunciation and the ability to paraphrase.

• „Gern, ich sage es anders: …“ (Of course, let me put it another way: …)
• „Ein CT ist eine besondere Röntgenuntersuchung. Sie liegen dabei auf einer Liege, die durch einen großen Ring fährt.“ (A CT is a special X-ray examination. You lie on a couch that moves through a large ring.)
• „Ist das verständlich, oder soll ich es noch einmal anders erklären?“ (Is that clear, or shall I explain it differently?)
• „Entschuldigung, ich wiederhole das langsamer: …“ (Sorry, I'll repeat that more slowly: …)

Short sentences carrying one piece of information each help more than speaking faster.

9. A relative calls

In the Hamburg protocol the husband phones towards the end of the history and mentions that his wife drinks beer in the evenings — the candidate had not yet asked about alcohol and smoking. What is tested: whether you take in the new information and follow it up.

• „Danke für den Hinweis, das ist wichtig für uns.“ (Thank you, that's important for us.)
• „Frau Keller, Ihr Mann sagt, Sie trinken abends Bier. Wie viel ist das ungefähr?“ (Mrs Keller, your husband says you drink beer in the evenings. Roughly how much is that?)
• „Ist es für Sie in Ordnung, wenn ich mit Ihrem Mann über Ihre Beschwerden spreche?“ (Is it all right with you if I talk to your husband about your symptoms?)

Use the call as a reminder: what is still missing?

What to avoid

• Pretending you have understood. The gap resurfaces in part 3 at the latest.
• Taking the tone personally. Irritation is part of the role.
• Putting off the patient's questions. Answer immediately and in everyday language — the sample dialogue under History taking shows how.
• Reciting phrases like a script. Singh advises avoiding memorised sentences “tunlichst” (at all costs); Saxony: “Vermeiden Sie Floskeln” (avoid empty phrases). Learn the phrases above as patterns and vary them.

This can only be practised aloud and under time pressure. On fsppruefung.de you take part 1 as a spoken conversation with AI patients and get language corrections afterwards. More pitfalls across all three parts are under Common mistakes.

Sources

• Ärztekammer Berlin: Fachsprachprüfung – Gesamtauswertung, Prüfungsbereich Simulationsanamnese (PDF)
• Sächsische Landesärztekammer: Fachsprachenprüfung
• Rheinisches Ärzteblatt 10/2024: Gut vorbereitet in die Fachsprachprüfung
• Rheinisches Ärzteblatt 12/2017: Die Fachsprachprüfung: Praxistest für die Kommunikation im Krankenhaus (PDF)
• Ärztekammer Nordrhein: Fachsprachprüfung
• Bezirksärztekammer Rheinhessen: Ablaufhinweise zur Fachsprachenprüfung (FSP) 2024 in Mainz (PDF)
• Bezirksärztekammer Rheinhessen: Informationen zur Fachsprachenprüfung (FSP) für ausländische Ärzte in Rheinland-Pfalz (PDF)
• Published exam reports by candidates (first-hand accounts, not chamber information; marked as such in the text)