Communication of students.
Most comments (n = 118) referred to communication. They were distributed to six subcategories as follows: attentiveness, history taking, physical contact, student as contact person, language, and body language. SPs expressed their comfort if the student introduced himself or herself, was attentive and caring, and used appropriate physical contact.
SPs also appreciated if the student provided clear personal contact and talked in a calm and clear manner. In total, we identified 38 positive comments in this category. SPs noted that “[t]he way he's [student] holding my hand is calming me down,” or “[t]he body language is great … shows concentration and alertness.”
We identified 80 negative comments in this category. SPs felt uncomfortable when they were excluded from communication, or when they perceived that students ignored their specific needs. For example, one participant observed, “No one is paying any attention to me; they are just talking among themselves,” and another noted, “I was confused because the person I had been talking to the entire time suddenly left to get the blood pressure cuff.”
SPs also felt uncomfortable when the students all talked at the same time, asked too many questions at once, or communicated in an inappropriate tone or fashion. One participant noted feeling uncomfortable when “[t]hey're asking me so many questions at the same time that I actually can't answer.” Another participant observed, “She [the student] is talking very loudly; it feels like being screamed at.”
Finally, SPs expressed their discomfort with too much physical contact—noting, for example, “She [the student] keeps patting my arm, which I really don't want at that moment.” On the other hand, SPs were uncomfortable if students' body language conveyed disinterest or lack of confidence. One participant observed, “If you look at their body language … it's difficult if someone stands in front of you with one hand on his back and the other playing with the necklace all the time.”
Actions taken by the student doctor.
This category included 56 comments. SPs made positive comments when students explained the actions they were taking and when students were able to give information on the medical condition. For example, “It's very good how he [the student] always announces what the effects [of the medication] could be.” Also, SPs felt comfortable if the consultation was well structured by the students and if they felt that students reacted to their symptoms within an adequate time: “Very good … they're taking the most important measures first.”
SPs expressed discomfort if the students' actions were unstructured or if the SP felt the student forgot aspects of the treatment. One SP noted, “This doesn't seem very structured; I don't really know who the doctor is and who the nurse is.” Another observed, “This is going too slowly. I really need help and they're not doing anything!”
Furthermore, SPs were uncomfortable if students did not know how to use the medical equipment properly: “The one who is treating me does not know how the equipment works; that's very irritating.”
Thirty-three comments directly referred to the performance of the clinical teacher. SPs felt comfortable if the clinical teacher was calm and attentive and guided the students if necessary: “The teacher seems very competent. If the students don't know what to do next she helps them without humiliating them.” They appreciated if the role-play was well structured by the teacher (i.e., provided introduction, feedback). In contrast, SPs felt uncomfortable if the teacher interrupted the role-play without a proper time-out, if he or she did not respect the SP's limits, and if he or she was unaware of feedback rules. For example, one SP noted, “Even though I told the teacher that I couldn't play my part this often [three times in 50 minutes,] he just continued.”
In the 24 comments in this category, SPs expressed their comfort with a calm atmosphere and unambiguous student behavior.
Behaviors of medical students.
Nineteen comments referred directly to the medical students. SPs felt comfortable if the students were well prepared for the lesson and open for feedback. Conversely, SPs disliked when the students did not stay in the role-play: “Don't laugh, come on! If I had been a real patient that would have really annoyed me.”
We identified 16 comments in this category. SPs valued time to discuss the schedule of the course with the teacher before the class began. They disliked if they could not properly prepare themselves for the role-play, if the teacher did not give clear instructions before the role-play began, or if there was no clear ending of the role-play. Characteristic comments in this category were “It was very important to me to agree on the setting before the class begins” and “What was difficult here was that I didn't get a break after the role-play to prepare my feedback.”
Comments reflecting a potential influence of the teacher
One objective of this study was to describe quality of teaching from the SP perspective. Therefore, we identified all comments in which behaviors of the clinical teacher influenced the comfort of the SP. Apart from the 33 comments directly related to the teacher, we found another 111 indirect comments which were indirectly influenced by teachers' behavior. These indirect comments were spread over all the categories, focusing on teachers' support of the students during role-play, giving a clear structure to the role-play, and communicating with the SP about the teaching session in advance. In summary, 54% of all comments (144 of 269) were directly or indirectly related to the teacher. An overview of these is shown in Table 3.
Ratio of positive to negative comments
Overall, the SPs made more negative than positive comments (ratio, 1.6:1). This was especially the case for the categories “communication” (2.1:1) and “setting” (7.0:1). The other categories showed no significant predominance (1.3:1). With respect to teacher-related comments, SPs made significantly more negative comments than positive ones (1.6:1).
Differences between SP roles
When we compared rTA comments between the two SP roles (dyspnea and ACS), we did not find substantial differences (see Table 4). Statistical methods could not be applied because the number of specific comments was not high enough in most categories. Nevertheless, the distribution to categories and between negative and positive comments was very similar between SP roles. In only one category—comments directly related to the teacher—ACS SPs gave more positive comments than did dyspnea SPs. When we considered comments indirectly related to the teacher in addition to the directly related comments, there was no difference between the SP groups' positive and negative comments.
In this study, we found that SPs focus their attention on communication with the students and on the actions of the students. Sixty-five percent (174/269) of the comments were directly related to communication and students' actions. SPs expressed comfort with competent and well-prepared students, who were able to structure the consultation and to offer explanations to the SPs. Because SPs are trained to give this kind of feedback, this finding in itself is not surprising. However, these comments clearly state the necessity that students should be prepared before the teaching session to keep appropriate verbal and physical contact and to provide a transparent structure for the SP. This might also be important in communication with real patients.
We found SPs' comments on students' behavior and attitudes (n = 19) to be in agreement with the comments related to students' communication. SPs valued a calm atmosphere and appropriate physical contact, indicating that teachers should encourage their students to develop trust and empathy with the SP.
A remarkably high proportion of comments (54%; 144/269) were directly or indirectly related to the teacher, implying that he or she has substantial influence in the SP encounter. SPs highlighted the importance of a clear structure to the role-play (58 comments), which can only be provided by the teacher. SPs also expressed the desire to have the setting and schedule of the session clarified in advance. Again, this function to moderate the student–SP encounter lies within the responsibility of the teacher. Accordingly, cooperation between SP and teacher should be addressed during teacher training.
Agreement of negative and positive comments
When looking for contradicting positive and negative comments, we found no important disagreement. To the contrary, many positive comments were confirmed by corresponding negative comments. As an example, the positive comment “The way the student–doctor holds my hand is calming me down” may be matched with the negative comment “I was confused because the person I had been talking to … suddenly left to get the blood pressure cuff.” Similar observations can be made for some comments in Table 2.
Ratio of positive and negative comments
SPs made significantly more negative comments than positive ones in the category “communication” (2.1:1). A possible explanation might be that the third-year student participants were at the very beginning of their clinical education and still had much room for improvement. The second category with significantly more negative comments was the teaching setting. This might indicate that some of the teachers could benefit from specific training, for instance with respect to coordination and planning of the session together with the SP.
All SP participants successfully performed rTA. The analysis of the rTA protocols produced very detailed information on how SPs feel during the course of a lesson and what factors might influence these feelings. The data were less filtered than in other types of interviews, which might be due to rTA's distinct relation to real-time situations shown on the video. While performing rTA, SPs moved out of their didactic role of giving feedback, therefore providing more information about their personal feelings.
Regarding the two different SP roles, we found no relevant differences in the distribution of categories or negative versus positive rTA comments. This finding may support the robustness of our data.
We conducted the rTAs with 23 different clinical teachers and 11 different SPs to accommodate the existing course structure. Our aim was to gain as much rich qualitative information as possible, so we only excluded one rTA in which teacher and SP were matched a second time. Four teachers participated twice, but with different student groups, giving rise to various new teaching aspects during the rTAs. However, in these cases, the SPs' comments about the four teachers' sessions did not differ in general information.
Application to teaching with real patients
Clearly, transferring insights about SPs to real patients is difficult. It is very likely that SPs focus their attention on other aspects of the clinical encounter than do real patients with a manifest illness. SPs, for instance, will be much more sensitive to students' mistakes. Nonetheless, some of our results might also be applicable to teaching situations involving real patients, including providing a clear structure of the session, coming to an agreement with the patient on the course of the session, and promoting communication between students and patients.
This was a single-center study, so its generalizability to other institutions remains to be demonstrated. Also, the study was conducted in the context of emergency medicine teaching; other specialties may yield different findings. SPs' rTA feedback might be less pronounced in less complex teaching settings, or it might be more distinct in teaching encounters with more sensitive communication issues.
In this study, we identified factors that influence the comfort of SPs during teaching sessions in emergency medicine. SPs highly valued (1) a clear structure of the teaching setting, (2) an established agreement between SPs and teachers about the course of the session beforehand, and (3) students' preparedness for the teaching session. If clinical teachers wish to improve teaching from the perspective of SPs, they should prepare their students and SPs before the session and provide a clear teaching structure. These findings might serve as an aid for clinical teachers when working with SPs and might also be used in teacher training. Whether findings could be transferred to other medical specialties, or to teaching with real patients, remains to be investigated.
1. Cleland JA, Abe K, Rethans JJ. The use of simulated patients in medical education: AMEE guide no. 42. Med Teach. 2009;31:477–486.
2. Bokken L, Rethans JJ, Scherpbier AJ, van der Vleuten CP. Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: A review. Simul Healthc. 2008;3:161–169.
3. Nestel D, Kneebone R. Authentic patient perspectives in simulations for procedural and surgical skills. Acad Med. 2010;85:889–893.
4. Bokken L, Rethans JJ, Jöbsis Q, Duvivier R, Scherpbier AJ, van der Vleuten CP. Instructiveness of real patients and simulated patients in undergraduate medical education: A randomized experiment. Acad Med. 2010;85:148–154.
5. Bokken L, Linssen T, Scherpbier AJ, van der Vleuten CP, Rethans JJ. Feedback by simulated patients in undergraduate medical education: A systematic review of the literature. Med Educ. 2009;43:202–210.
6. Wind LA, van Dalen J, Muijtjens AMM, Rethans JJ. Assessing simulated patients in an educational setting: The MaSP (Maastricht Assessment of Simulated Patients). Med Educ. 2004;38:39–44.
7. Adamo G. Simulated and standardized patients in OSCEs: Achievements and challenges 1992–2003. Med Teach. 2003;25:262–270.
8. Wallace P. Coaching Standardized Patients: For Use in the Assessment of Clinical Competence. New York, NY: Springer Publishing; 2006.
9. Ericsson KA, Simon HA. Protocol Analysis: Verbal Reports as Data. Rev ed. Cambridge, Mass: Bradford Books/MIT Press; 1993.
10. Fonteyn ME, Kuipers B, Grobe SJ. A description of think aloud method and protocol analysis. Qual Health Res. 1993;3:430–441.
11. Young KA. Direct from the source: The value of ‘think-aloud’ data in understanding learning. J Educ Enquiry. 2005;6:27–32.
12. Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med. 2006;13:860–866.
13. Mayring P. Qualitative Content Analysis [in German]. Weinheim, Germany: Beltz; 2008.
This study was approved by the ethical committee of Charité–University Medicine Berlin.© 2012 Association of American Medical Colleges