Medical education has a long tradition of using various patient representations in teaching and assessment. With this literature review we aim, first, to provide an overview of the most important patient representations used to teach and assess clinical skills, considering in particular "summative exams" that have a pass or fail outcome; second, to provide arguments for choosing certain patient representations; and third, to show the advantages and limitations of different patient representations, especially simulated patients (SPs) and real patients (RPs).We conclude that in order to select the right patient representations in clinical teaching and/or assessment, a number of perspectives must be considered: (i) the learning goals, aligned with the stage of study, (ii) the correspond-ing requirements of the clinical task itself (e.g., performing a phlebotomy or a communication task), (iii) the level of authenticity required and (iv) the resources needed, taking patient safety and feasibility into consideration.