Since the introduction of standardized patients by Barrows in 1964, this role has mostly been played by adults.1–3 Relatively, recently, adolescents have made their debut in this role.4,5 They have contributed to the training and assessment not only of medical students5,6 but also of junior and senior doctors.7,8 Adolescents have performed patient roles in front of groups of 20 to 30 physicians7 or in encounters with individual students, either alone or in the presence of a simulated parent.5,8,9 Feedback from adolescent standardized patients has been shown to be very effective in teaching interviewing skills to medical students.6
Most research on adolescent standardized patients has focused on the impact of performing a patient role on the adolescent.4,5,10,11 None of these studies have reported adverse effects. Possibly, this is attributable to careful selection of adolescent standardized patients.5,10,11
In these previous studies, the adolescents were trained to play predefined roles based on relatively fixed patient scenarios, with emphasis on standardized and consistent role performance.5,7–9 Within the context of this article, it is important to clarify the difference between the role of a standardized patient and that of a simulated patient (Table 1). Because simulated patients are the key topic of this study, we will use the abbreviation “SP” to refer to this role while no abbreviation will be used to refer to standardized patients. Although the terms standardized patient and SP are sometimes used interchangeably, there is a distinct difference between them.1,12–14 Because standardized patients are mostly used for assessment, it is essential that their performances are uniform and consistent. However, SPs perform mostly in teaching contexts and provide formative feedback, for which authenticity and credibility of performance are most important. Thus, to enhance authenticity and credibility of performance, roles are individualized, so that they are closest to the personality of the person playing the role.15 This is consistent with method acting. Method actors are more likely to develop negative effects because of role playing in comparison with technique actors maintaining a greater personal distance to the role.16 Because SPs are trained to incorporate more of their own personal backgrounds into their roles (method acting), the impact of role performance on adolescent SPs might differ from that on adolescent standardized patients (technique acting). Recent studies reported moderate stress symptoms in adults caused by performing SP roles.17,18 We have found no studies reporting similar effects in adolescents, possibly because most studies involved adolescent standardized patients. In one study, adolescents indicated that it took them less time to get in and out of their patient role if the role was close to their own personality.11
Because of the scarcity of published literature on the quality of adolescent standardized patients and SPs and on the impact of role playing on adolescent SPs, we performed a study to evaluate (1) the quality of the role playing and the quality of feedback provided by adolescent SPs and (2) the effects of role performance on adolescents trained to perform an individualized SP role.
Every 3 weeks, students in years 1 to 3 of the 6-year medical undergraduate curriculum of Maastricht University practice communication and physical examination skills in contacts with SPs.19 These contacts consist of simulated consultations involving two students and one SP, with one student playing the role of a doctor and the other student an observer. Except for the symptoms, SPs play a role that is tailored to their personal characteristics and background. In addition to role-related training, SPs receive feedback training enabling them to give feedback to the student-doctor at the end of the consultation in accordance with four feedback rules (Table 2). The SP encounters are recorded on DVD and discussed in groups of approximately 10 students and a teacher. All group members have individually watched the recorded encounters, including the feedback given by the SP, before discussing the encounters in a subsequent group meeting. Students watched the recordings of the encounter they were involved in (in the role of a doctor or an observer) and the recorded encounters of other student-doctors in their group. Teachers watched the recorded encounters of all five student-doctors in their group. The groups meet throughout the year with the same teacher. This SP program is developed and organized by the Skillslab and is fully integrated with the Maastricht undergraduate medical curriculum.19
In year 2, students are offered a 6-week “Puberty and Adolescence” module. An important objective of this module is learning to communicate with adolescents about contraception and sexuality. In 2002, adolescent SP encounters were introduced to support students' learning about this topic. Student-SP encounters last a maximum of 30 minutes and are scheduled on three consecutive days between 4 pm and 8.30 pm after regular school hours. The study reported in this article was conducted in the academic year 2006–2007.
Recruitment and Selection of Adolescent SPs
The first adolescent SPs to be recruited were all daughters of Skillslab staff members. The SPs were encouraged to bring along their girlfriends as well. In the year of the study, the group of adolescent SPs recruited for the program consisted partly of adolescent SPs who had participated in 2005–2006 (N = 5) and partly of new SPs recruited by word of mouth. Some of the SPs' boyfriends came along and asked if they could participate too. We agreed, because we thought having real couples as SP couples would enhance authenticity. A total of 12 adolescents, 9 girls and 3 boys (6 individual female roles and 3 couples), were selected. Although young couples seeing their general practitioner (GP) for matters related to contraception may seem somewhat unusual to many, this is a regular occurrence in the Netherlands.
The objectives of the SP consultations and the feedback were explained to the SPs (both female and male) in a 90-minute meeting with one of the researchers. The scenarios of the SP roles were introduced as well. We encouraged the SPs to inform their parents of their participation in our program and also of the content of their roles. We provided a letter addressed to their parents explaining the program. However, we also told the SPs that it was their choice whether they gave the letter to their parents or not. The SPs were paid €10 per hour for participation. We planned a maximum of eight consultations per day for one SP.
The content of the role was aligned with the content of the Puberty and Adolescence module. All the girls played the role of “Miss Jacobs,” coming to see her GP to ask about oral contraception. However, the reasons for seeing her GP differed for each SP, and the student-doctor could only discover this after establishing good rapport with the patient and gaining her trust in combination with careful history taking. The individual roles were created together with the SPs and were largely based on the SP's personal history. Because these consultations were demanding in terms of the required quality of communication skills, physical examination was not included in the consultation. To illustrate the SP role, we will describe two individualized scenarios:
- For the past 2 years, Miss Jacobs (aged 17 years) has had severe abdominal pains, back pain, and headaches during her periods. It started about a year after her menarche. She has been taking ibuprofen for 3 months, but this has not helped at all. She has heard from a friend and also at school in biology class that taking an oral contraceptive might help. At the same time, she has a lot of questions about ‘the pill,” such as “What are the side effects? What if I forget to take one? What about sexually transmitted diseases?”
- Miss Jacobs (aged 16 years) says she comes to see her GP because she wants to start taking “the pill,” but she is not quite sure of this. Her boyfriend (aged 17 years, who accompanies her) is putting pressure on her and has even threatened to end the relationship if she refuses to use an oral contraceptive. When she told him she was going to see her GP, he wanted to come with her. The doctor's positive remarks, for example “there are not many side effects,” are welcomed by the boyfriend with: “I told you so!” However, Miss Jacobs is not quite ready to make an immediate decision whether she wants to start using an oral contraceptive. She just wants some information to help her think things over. To her boyfriend it is simple: “just take it.” When the doctor shows that she/he is under the impression that this may not be what Miss Jacobs really wants for herself, Miss Jacobs is clearly relieved. Subconsciously, she is seeking support from her doctor.
As with all regular SP sessions, all second-year students (N = 363) can enroll voluntarily for a session in pairs, with one student as a doctor and the other as an observer. Students are unaware of the exact content and purpose of the adolescent SP encounters. All SP consultations are held in special SP consultation rooms in the Skillslab, equipped with recording equipment. For each planned consultation, a spare SP or SP couple is available.
We used the Maastricht Assessment of Simulated Patients (MaSP) questionnaire to evaluate the quality of SP performance and feedback as perceived by the students.15 The MaSP contains 10 items about the authenticity of SP role performance and 10 items about feedback provided by SPs (based on the four feedback rules in Table 2 and general feedback rules), all to be rated on a 4-point Likert scale (1 = totally disagree, 4 = totally agree). Students are also asked to rate on a 10-point scale (1 = very poor; 10 = excellent) how they valued the overall quality of SP performance, including feedback. In addition, students are invited to give additional comments. The MaSP has been proven to be valid, reliable, and feasible for assessing SP performance in an educational setting.15 In our study, the students were asked to complete the MaSP immediately after their consultation with the adolescent SP.
After their last student-SP encounter, the SPs were asked to complete a 17-item questionnaire about their experiences and to give comments. The questionnaire evaluated how performing as an SP had affected the adolescents.
The teachers who discussed the SP encounters with the students were also asked to fill out a questionnaire containing open-ended questions about the adolescent SP consultations. These questions addressed the reactions of the students in the group and the teacher's opinion on the quality of the adolescent SPs' performance and feedback.
We analyzed the data using SPSS (version 13.0) for Windows. Frequencies were calculated for all items. Because the distribution was not normal, Mann-Whitney tests were used to analyze differences between the MaSP scores of the student-doctors and observers.
The adolescents (N = 12) were aged between 16 and 18 years (mean age, 17.1 years). All were in secondary school. Of the 363 students eligible to participate in the SP encounters, 341 (94%) participated. This is comparable with participation rates for other SP encounters. Of the 341 participating students, 138 acted as “doctors,” 137 observed, and 66 failed to state their role in the questionnaire.
Table 3 shows students' evaluations of SP performance as measured by the MaSP. The general performance rating was 7.5 (on a 10-point scale). There were significant differences between some of the scores of the student-doctors and those of observers. Compared with the observers, student-doctors could better judge from the reactions of the SPs whether or not they were listening (item 13) and whether the SPs spoke about their role in the first person (item 17). In addition, the student-doctors gave higher ratings compared with the observers when asked whether they thought the SP acted in a friendly manner (item 20). There were no significant differences between the general performance ratings from student-doctors and observers.
The teachers were positive about the quality of SP role performance and feedback. For example: “Authentic,” “good roles and good feedback,” and “more straightforward feedback (compared with that of other, adult, SPs).” The teachers commented that the adolescent SP encounters addressed interesting aspects of communication, such as “learning to deal with 2 people in a consultation (dividing attention),” “dealing with peers professionally (less formally, yet remaining serious),” “setting personal boundaries in a consultation (with a quarrelling couple),” and “asking questions/talking about sexuality.” Moreover, teachers reported that in some groups, students had admitted to feeling attracted to the “patient” during the consultation, a feeling they found difficult to deal with. This led to a discussion about professionalism in the group.
Table 4 shows the SPs' evaluations of the encounters. All of them had informed their parents of their participation in the program (item 7). The adolescents experienced nothing that made them regret the experience (item 10) and indicated that they would be willing to act as an SP again (item 8). The evaluation showed no differences between male and female SPs.
Judgments of students and teachers about the quality of role performance and feedback by adolescent SPs are positive, with high ratings from students for overall quality of role performance and feedback. Nevertheless, the results show that improvements are needed on some points. When giving feedback, the SPs could give more encouragement to students to ask questions and more examples from the encounter to illustrate their feedback. Adolescent SPs indicated that giving feedback was quite difficult. These findings suggest feedback should be addressed more extensively during training of adolescent SPs. In feedback training, attention should be paid not only to the four feedback rules (Table 2) but also to general feedback rules such as giving concrete and specific feedback with examples.
Although there are some significant differences between the evaluations of student-doctors and those of observers, these differences are small. However, we think they may be because of the inherently different perspectives of these student roles, with student-doctors being more focused on the patient than observers.
A reassuring finding is that the adolescent SPs reported no negative effects because of their performance in an individualized role, unlike the moderate stress reported by some adult SPs whose training involved identification with the patient they portrayed.17,18 In fact, the adolescents said they would like to continue their SP work. The impact on adolescents of performing as a SP seemed not to be different from the impact of performing as a standardized patient.4,5,10,11 Role playing even seems to be easier if the role is close to the adolescent's personality.11 This is encouraging because we believe that, for teaching purposes, authenticity of SP roles is more important than uniformity.
There are some limitations to this study. First, for practical purposes, possible negative effects because of role playing were assessed with one item in the questionnaire. We could obtain more detailed data with a more detailed questionnaire. It is possible that the questionnaire we used missed some subtle negative effects of role performance. This is an important area for future research. Another limitation is that the study was performed in the setting of one particular undergraduate curriculum. Although we believe that most of the results are transferable to other educational settings using adolescent SPs, some might not be. Furthermore, in educational practice, the difference between SPs and standardized patients is often not as absolute as presented here. Rather, there is a continuum between standardized patients in which the emphasis is on consistency of role playing and SPs in which the emphasis is on authenticity of role playing. Other limitations are the small number of SPs and the risk of bias because of the fee they were paid. Hence, although the results are encouraging and suggest that adolescent SPs have a valuable role to play in undergraduate medical education, they will need further support from studies among more SPs and in different settings.
The results seem to support our view that, provided more attention is given to feedback, encounters with adolescent SPs can offer authentic and high quality learning experiences for undergraduate medical students. SP roles, largely inspired by real life, do not seem to have a negative impact on adolescent SPs, a finding that is supported by similar findings about standardized patient roles. We think that, for teaching situations, the absence of negative effects combined with greater authenticity and easier role playing might make the use of adolescent SPs preferable to adolescent standardized patients.
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