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Empirical Investigations

How Do Standardized Patients Form Their Complex Identities? The Impact of Interactions With Medical Students

Starr, Samantha A. BS; Plack, Margaret M. PT, DPT, EdD; Lewis, Karen L. PhD, CHSE; Blatt, Benjamin MD, CHSE

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2021 - Volume 16 - Issue 1 - p 3-12
doi: 10.1097/SIH.0000000000000456
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Abstract

The idea of a layperson portraying a patient for medical student education was first introduced by Barrows and Abrahamson in 1963 for students in neurology. Barrows and Abrahamson called their patients “programmed patients” and used these patients to measure student performance in history taking and physical examination of a patient with a neurologic presentation.1 Barrows later termed these patients “simulated patients” and their use was expanded to all fields of medicine.2 In the 1970s, the terminology changed again, with standardized patient (SP) becoming the accepted term for these individuals in the United States.3

Since their inception 55 years ago, SP participation in medical education has increased and the role of SPs has expanded. Initially used only to portray patients in a standardized way, SPs now participate in providing feedback to students after their encounter. In addition, SPs participate regularly in student examinations, including Objective Structured Clinical Examinations (OSCEs) and the United States Medical Licensing Examination Step II Clinical Skills, which all medical students must pass to become medically licensed in the United States.4 Standardized patients also teach medical students physical examination skills in a role initially known as practical or patient instructors, now known as SP instructors (SPIs).5,6

As educators moved away from using SPs solely as educational instruments, they became increasingly aware of the emergence of SPs' real selves in their work. With it came the impetus to better understand SPs as real people and the interaction of their authentic selves with simulation. As a result, a number of SP-centric qualitative studies explored the SP personal experience, the SP voice, and the SP perspective on their work. Some studies focused on positive and negative effects of simulation on the SP personally.7–13 Benefits to the SPs were more informed expectations of health professionals, better communications skills, and more tolerance of others.7 Harms to SPs reported in one study were residual psychophysiological effects to portraying emotional cases8; however, a second study concluded that the frequency and intensity of such effects were minimal.9 Several studies focused on SP self-expression in various aspects of the simulation education process. For example, in exploring the SPs perceptions of grading medical students during an OSCE, the authors noted that SPs geared their evaluations toward protecting future patients; drew on their own life experiences in rating students; and experienced the examination from the perspective of a real, rather than a simulated patient.10 Other authors studied “real self” SP behavior and noted that SPs took on various roles with students (including teacher and parent), which could bias their assessment and feedback.11 Still, others examined SP influence on students' professional identity formation, concluding that SPs can make valuable contributions to this process.12 Finally, in examining the SP perspectives on the work environment, the authors found that SPs wanted SP educators to create a supportive social environment that considered their perspectives.13

The previously mentioned studies suggest that SPs' real selves play a significant role in their work and what SPs bring to simulation is an identity that is a hybrid of their standardized and real selves. Little has been done to explore the formation and nature of this complex identity. Social relational theory (SRT) offers a lens through which to better understand SP identity formation. Social relational theory posits that individuals become who they are through a dynamic process of interacting with others within a social context: “Identities are constructed and co-constructed as we participate in day-to-day social activities and through the use of language and artifacts and within power relations. These ‘constructionist’ approaches highlight the importance of the social within identities.”14(p41) Because interacting with medical students provides a major social context for SPs, we looked to the SP experience with medical students to examine the construction of SP identity.

Our aim in this study was to better understand the process of SP identity formation through the SP medical student interaction. To accomplish this, we conducted a series of SP focus groups, exploring what about their medical student interactions affected them and why. We postulated that gaining a better understanding of the SP medical student interaction could generate recommendations to help medical educators recruit, support, train, and retain their SPs.

METHODS

Because we were interested in understanding the SP experience in working with medical students, we chose a qualitative approach.15,16 Qualitative methods are best used when the researcher wants to explore individuals' perceptions, values, and beliefs about their experiences. Qualitative methods enable the researcher to probe more deeply to examine the meaning individuals make of their experiences.15,16 For these reasons, we chose to use a semistructured focus group interview protocol that allowed us to probe more deeply for understanding. Two researchers (M.P., S.S.), who did not have an evaluative relationship with the SPs, conducted 4 focus group interviews lasting approximately 1 hour each with a total of 18 SPs (n = 3, n = 9, n = 3, n = 3; Table 1). We used a semistructured interview protocol (Appendix 1) for consistency across groups, allowing for additional probes for clarity or comparison as needed. Interviews were audio recorded and transcribed verbatim.

TABLE 1 - Participant SP Demographics
Sex n Age Range Years in Program No. Who Are SPIs SPs Who Are Actors
M 7 27–74 2–10 3 6
F 11 25–66 3–10 5 8

We used a grounded theory approach to analyze the data, constantly comparing units of data in search of emergent themes.16,17 Two researchers (M.P., S.S.) independently used an inductive approach to the analysis of the first focus group transcript searching for clusters of meaning and developing codes. The two came together to develop consensus and refine the initial codes. Once consensus was achieved, each moved on to the second focus group transcript; again, coming together to discuss discrepancies, refine codes, and begin to identify categories and emergent themes. This continued until all focus group data were analyzed and themes were identified. A third researcher (B.B.) functioned as a devil's advocate and peer reviewer throughout the process to ensure accurate application of codes, interpretation of quotes, and ultimately identification of themes.17 As this third researcher raised questions, all 3 researchers revisited the transcripts and came to consensus on analysis. Throughout the process, researchers searched for negative cases that did not fit the prevailing interpretation.17 Ongoing analysis led to the identification of categories and themes. Refinement of themes was an iterative process that continued until consensus among all 3 researchers was achieved.17

To ensure credibility and trustworthiness of the results, we used triangulation of researchers and data sources, code checking, peer debriefing, devil's advocate, negative cases, and prolonged engagement with the data to build consensus and ensure accuracy of findings.15,17,18 We presented thick rich descriptions (direct quotes) as evidence of each theme.15,17 Finally, we sought to ensure transparency of methods to enable readers to judge the credibility and transferability of the findings and conclusions.15–17

The George Washington University Institutional Review Board determined the study to be exempt. Standardized patients volunteered to participate and were paid at the program's standard rate for their time spent in the focus group sessions.

RESULTS

Through our qualitative analysis of the transcripts from the 4 focus group sessions, we identified 4 major themes: SPs experienced (1) identity transformation toward a new professional identity; (2) self-actualization toward their maximum potential; (3) judgmental reactions to medical student behaviors; and (4) simulation-reality interaction between their simulated and real selves. Figure 1 illustrates the process used to arrive at these 4 themes. To optimize transparency of results, direct quotes are used to illustrate each of the themes identified. Each quote is followed by an alphanumeric code that identifies the transcript from which the quote was obtained (FG = focus group, P = page, and L = line).

F1
FIGURE 1:
Qualitative Data Analysis Process.

Theme #1: Identity Transformation

Standardized patients shared their initial reasons for becoming SPs as well as their initial assumptions about both the students and their work. They also described the past experiences and perspectives they brought with them. As their SP involvement increased, their perspectives and sense of purpose evolved: they came to question many of their initial assumptions and experienced greater meaning in their roles. They changed their perspectives on medical students and came to value the rigors of medical education. Most SPs recognized the complexity of the SP role and over time, being an SP became much more than another job that provided flexibility and additional income. They experienced their role expand into teacher, coach, and parent, providing feedback, dialog, and a safe space for students to fail. They realized how they brought humanism to a rigorous medical curriculum and how important that was for medical students. As a part of this evolution, they developed a new sense of social responsibility, recognizing the direct impact they could potentially have on the development of future physicians; they felt pride about “putting good stuff out into the world.” Through their work, they experienced a transformation of perspective and purpose leading to a new professional identity. For example:

Honestly, it was pretty much out of necessity with my other career, which is as an actor. I needed something that was flexible and kept me active in being creative… but then it kind of became something different for me…. It became something where I realized what I was doing was meaningful and not just a gig, yeah.

(FG1; P1L13)

[As actors] I feel we benefit society the long way around the barn, like indirectly and this [being an SP] is a way we use our skills to very directly, impact another human being becoming a person who is going to help maladies among the population, so I love that.

(FG2; P9L9)

I got into it because it was fun, lol, like I said I was 17, I was still in high school… and then as the years progressed, I realized how powerful the work was not only for the students but also for me.

(FG3; P2L27)

Sometimes, you have encounters where you are dancing in your head, like, he did it… sometimes you feel like such a proud mom when they walk out of the room. You are, like, I just want to write a good recommendation for them. (FG1; P8L20)

Additional exemplary quotes supporting this theme can be found in Table 2.

TABLE 2 - Additional Exemplary Quotes Supporting the SPs' Transformation
Theme #1 Categories Quotes
Identity transformation toward a new professional identity Initial thoughts (about being an SP) I'm not an actor. I came at this through my children… who are studying in medical school. I kind of saw it also at the beginning as a kind of community service thing, although you are not normally paid for community service, so it's a way to give and a way to help the next generation with their education (FG2; P1L34)
I mean I'm an actor, I graduated from—a conservatory school, and I found out that other actors were doing this to basically supplement income and pay bills (FG4P1L21)
Changed assumptions (about students) Before I started this, I thought most [students] would be type A: very antisocial. This was my outside bias perspective. I just thought they were going to be clinical minded, surgeon, super serious, but they are not. They're just... people from all aspects of life just being students again and learning and being stressed… and finding time to be humorous and times to be caring toward one another and all the things that I did not imagine would be part of their personalities. They're just like us but they are doing something very high stakes and very high stress. (FG1; P11L22)
Changed assumptions (about their role) [My student]—he's like ‘you actually, you are just as important as the faculty in my process’. Before that point that was not something that ever crossed my mind… I did not understand the gravity until that moment he put me up there with some faculty. Until that point, I thought I was tool, a good one (collective laughs), but not really much more than that… and that stuck with me. (FG3; P6L34)
New identity It became something where I realized what I was doing was meaningful and not just a gig (FG1; P1,18)
It feels it's useful, like it's something that I feel like is putting out, good stuff into the world to help people become doctors (FG2; P1L7)
We're building humans that help humans... I really feel like we are doing it to help the students. It's just little things make us feel part of the big team (FG2; P13L1)
[We] provide the human input that they just cannot get from their books... I think of our job as being like really present in the room so I can give them a fair of account of what I experienced because there's no way of them knowing otherwise. (FG2; P10L6)

Theme #2: Self-actualization

Self-actualization, as defined by Abraham Maslow, is “a desire for self-fulfillment,” a tendency to “become more and more what one is, to become everything that one is capable of becoming.”19(p382) In working with medical students, SPs experienced new, sometimes unexpected, pathways opening up in their lives, which led to a sense of self-actualization. Through recognition of their ability to help medical students grow both professionally and personally, SPs achieved this sense of self-actualization, of more fully realizing their own potential. They saw themselves contributing to and enhancing the students' awareness of their own strengths and weaknesses. They saw themselves helping students identify and modify bad habits and grow in their ability to communicate and express empathy. They found themselves able to provide emotional support and enhance student confidence and resilience. Their sense of self-fulfillment in their interaction with medical students is illustrated in the following quotes:

I can see them grow… they go from… being uncomfortable with a patient or a standardized patient at the beginning of the year, to where… you can really see them developing confidence… empathy, and a practice… it's fun to see that happen.

(FG3; P3L28)

It's pretty cool and you get to comfort some of them when their parents pass and stuff. You are able to tell them I understand this case is hard for you today because your dad had lung cancer so breaking this bad news is hard, but you know that's what you are here for, get to use that experience that you got yourself as a kid to help another.

(FG1; P3L16)

I really also find it very motivational to be able impart some teaching of empathy because the medical students have so much on their minds and so much to do and to learn and so in our environment it is really rewarding to share what I think actors are really good at [which] is empathy, we're constantly putting ourselves in other peoples' shoes and so to be able to impart some sort of that wisdom is really rewarding.

(FG2; P2L2)

Additional exemplary quotes supporting this theme can be found in Table 3.

TABLE 3 - Additional Exemplary Quotes Supporting the SPs' Self-Actualization
Theme #2 Categories Quotes
Self-actualization toward their maximum potential Helping students grow professionally and personally When I see them progress from just popping into the room and saying, ‘What brings you in today?’ or ‘Why are you here?’ or ‘What's the matter?’ and seeing that I'm crying, and the first thing that they do is take a deep breath and say ‘May I get you a handkerchief?’ or ‘May I get you a Kleenex?’ And I've seen that happen, and it's a wonderful kind of thing. It gives me chilblains. (FG2; P12L20)
You can see them at first, they are totally not doing well and then all of a sudden, the light bulb goes off and they switch directions and… all of a sudden (indicating-snapped fingers) they can get it! … I got to witness the light bulb moment, like that feels really cool! (FG3; P21L6)
From other sources It's just nice to feel like you are a part of this program that's teaching them so… that to me has just been a really, really cool part of the program; to be able to see them learning in real time and making those corrections and moving forward with them. (FG3; P21L28)
A pride… kind of came over me when people would ask me what I did for a living—saying you know proud to be an actor but also saying that I worked with medical students as well. (FG4; P1L26)

Theme #3: Judgmental Reactions

In working with medical students over time, SPs experienced strong positive and negative reactions to various medical student behaviors. Standardized patients were able to identify likes and dislikes in student behaviors and often described how each impacted the students' growth into becoming professionals. They admired students who demonstrated self-reflection, commitment, active listening, organization, flexibility, caring, empathy, and those who went above and beyond the checklist. For example:

You could tell his confidence and his excitement… to get feedback, he was like “what do you have for me to improve on?”... it makes you so happy that this is what they want to do and it's not just that they want to do it, they are making a conscious effort to put in the work to be even better.

(FG1; P14L31)

The ones who really stand out... where the good and great really distinguish themselves from one another. Like if they have a way to keep their structure and questions organized, they know not to miss anything important, but that they also aren't totally rigid to that structure, that when you share something they will follow up on that, they'll ask you more questions, they'll encourage you to share more, opening you up rather than shutting you down... they created a safe space for you and maybe you didn't have one before.

(FG1; P16L13)

Conversely, SPs were very much bothered by those students who performed in a perfunctory manner or appeared to simply be checking the box or marking off a checklist. It irked them when students were overly passive or defensive. It disturbed them when students did not take the encounter seriously, indicating that it felt like a threat to their own SP identity.

Someone else was in the room doing the case, and it was a pretty intense case... I'm monitoring this other SP in the room, and I'm noticing that this medical student is just not really into it, she sounds very bored. And then all of a sudden, the student just laughs and breaks the scenario.... And at feedback, the student was just saying like ‘I'm sorry, I just know that it's fake so I can't really get into it’... it was upsetting to see her basically [treating us like] that we're unimportant when we do put so much of ourselves into it.

(FG1; P9L7)

I think sometimes its most difficult when you have really passive students… you'll get a student just kind of nods and agrees and says yes and okay, you don't really know if you're imparting the knowledge at all.

(FG2; P7L3)

[Lacking confidence]… I trust their professors to give them the tools that they need so for them to not believe that they can do it, it's almost offending to me.

(FG3; P17L8)

Additional exemplary quotes supporting this theme can be found in Table 4.

TABLE 4 - Additional Exemplary Quotes Supporting the SPs' Judgmental Reactions to Medical Student Behavior
Theme #3 Categories Quotes
Judgmental reactions to medical student behaviors Behaviors they admired For me, …it has got to be all 3.... They have to know their clinical skills... they also have to be relatable ... [and] they have to watch you, they have to be actively listening to what you are actually saying... and when they go that extra mile... a person that is engaging you as a person that you can tell honestly cares what going to happen to you tomorrow, they want you to check in with them and you know they mean it... that's great, and that's really what sets it apart for me. (FG1; P15L26)
I really like when the students take risks or when they try something... so they can try things and kind of expand their, get out of their comfort zone a little bit, so when they are willing to do [that], I always think that's exciting (FG2; P13L23)
Perseverance for me is one that I've found I really admire with them. (FG3; P15L14)
Behaviors they disliked [A] lot of them [cases] have an emotional challenge, and one thing that I've noticed is that students who are treating it more perfunctory, they'll treat that challenge... like a hurdle that they need to swerve around. (FG1; P16L3)
Every bit of parameter feedback that I gave in the appropriate way was, well that's because this, and that's because this, and if you had done this differently, and everything was not their fault at all. (FG2; P6L15)
The student who thinks they know more than they do. The arrogance, arrogance. (FG3; P16L24)
I mean when they do not prepare or when they do not take feedback–when they do not seem interested in improving. (FG4; P9L11)

Theme #4: Simulation-Reality Interaction

The interaction between SPs' real and simulated selves was bidirectional. Their real selves interacted with their simulation world and their simulation selves with the real world. Sometimes, their real selves reacted spontaneously to happenings in their simulation world. As noted in theme 3, at times, it took the form of the intrusion of the real self in making judgments about their students' actions during simulations, both positive and negative. The positive aspects included admiration, pride, validation, and respect. The negative aspects included anger or feeling disrespected. At other times, it took the form of SPs making judgments about themselves, regarding their simulation performances. Taking their simulated roles very seriously, they were self-critical when they made errors. Emergence of the real self also occurred in relationship to the strategies they chose in playing simulation roles. Some SPs welcomed openings when they could tap into their real selves to portray a patient; others felt like they needed to compartmentalize or exclude their real selves.

There's a social anxiety case… and for the men who play Steven Thompson they feel anxious around women they might be attracted to and so on some occasions I've been in a situation where there's been a very pretty young woman as the student and I've had to wrestle with how do I address that because it's a place of learning and so I think it's an acceptable place to sort of look at those things and the case parameters sort of dictate it's necessary but at the same time it just, it's a little weird.

(FG2; P4L11)

If I'm doing a very emotional case I get in it and I—it's hard for me to take a step back… in some ways you have to put aside your own story but for me like doing ‘emotional’ stuff I just connect it to my own life and usually it's okay, it works, and it does not cause any problems, like I do not accidentally say something about my own life when it should be the character… my brain is able to compartmentalize.

(FG3; P5L4)

The real simulation interaction, however, also moved in the other direction: SPs' simulation world emerged in their real world. The influence of their simulations at times resulted in a transformation of how the SPs saw themselves. They described how they grew personally from their simulated roles: some gained a sense of empowerment; others become more knowledgeable and better communicators; still others became more assertive and better self-advocates.

I left that day feeling so empowered as a woman and as somebody who had control... she [the student] said “I just want to let you know you are in control of the relationship, it's your body and you also have a voice.....” And that was the last thing she said before she left the room and I was like, I do not even know where she came from, but I feel so empowered as a woman

(FG1; P17L4)

Every time we do a case where we are going to die, I always come out of that feeling like really transformed and appreciating that I get to kind of experience that… before it's actually my time to experience it, so it's kind of cool.

(FG3; P11L1)

It eats me up at the end of the day if I know I did something that wasn't standardized. I go right over there to the training ops room and I say, “Look at the tape. I messed up. It's on me….” I hate it. I hate it just as much as those students hate getting an answer wrong or a maneuver wrong. Like that's huge for me.

(FG3; P8L37)

Additional exemplary quotes supporting this theme can be found in Table 5.

TABLE 5 - Additional Exemplary Quotes Supporting the SPs' Simulation-Reality Interaction
Theme #4 Categories Quotes
Simulation-reality interaction between their simulated and real selves Real selves' reaction to simulation happenings: judgments about students Breaks your heart because you know deep down inside there's something else [besides medicine] that they want to be doing, but they have not found the voice or the courage to take that step. (FG1; P12L36)
I did an addiction case where I came in wanting more, wanting a prescription refilled, but I was addicted big time and this extremely compassionate student did not judge me… and in the final visit I think we were both close to tears. I was grateful to him for the care and compassion that he had shown me. I wanted to give him a hug. (FG1; P16L25)
When you end on a bad note, whether it's emotional, or regardless what type of case it is, if you end with an invalidating or an inconsiderate [student] or a student that is not listening to you or something like that, at least for me it just wrecks the rest of my day, and I need all the hot chocolate to get through that, lolol. (FG3; P11L41)
Real selves' reaction to simulation happenings: judgments about themselves My first year being a SPI is this year. It's personal in that I find myself being really hard on myself in terms of being a perfectionist in learning the maneuvers and not feeling like I'm doing a disservice to them by not learning it correctly myself and feeling like that maybe I'm teaching them incorrectly…. That's a personal thing for me to… walk out feeling like, oh my gosh, maybe I should have told them to do this, so, yes, it is personal for me in that way. (FG2; P5L23)
I have to tell you I goofed on that last couple weeks ago…. I had given my own history…. I was embarrassed and so upset that I had given all of these dreadful things, so I went in and confessed. (FG2; P14L24)
Real selves' reaction to simulation happenings: inclusion vs. exclusion of the real self in playing a role I think that that's one of our duties, you know, is separating Nick the SP from John Stockdale [the role] and trying to really be Stockdale for them and then serve them Stockdale's reactions at the end. (FG2; P9L27)
Realize I can draw on the emotion without having to have the personal connection, and it can just be living in the moment of that character and what their moment and day is, you know, losing a parent or something like that. It comes more naturally now, but yes, I do not really feel like I have to become a different person most of the time. (FG2; P6L45)
Simulation's influence on SP reality: personal transformation I feel like I have become a better patient when I actually go to see my doctor (collective laughs). I communicate better, I feel like I'm more assertive about sharing things because when I actually go see the doctor I get maybe 5 minutes in a room… and I really notice the things that my doctor does or does not do (mhm), and I'm more willing to speak up…. It's sort of demystified the whole scene for me. (FG2; P11L14)
I learned a lot about MI [motivational interviewing], and I realized how the communication skills they teach are actually really effective with not only teaching other students, but also just in my life; the whole validation, the whole allowing for silences, stuff like that I use in daily life. (FG3; P9L45)
[re: LEARNING] Yes. I realized my alcoholic grandfather was having problems neurologically…. So that was cool to realize and to be like, oh I actually have a little bit of knowledge about this that other people who do not do what I do. (FG3; P10L17)
I have learned how to be diplomatic—unbelievably diplomatic—in this job that you have to find a way to get your point across that is noncombative, but at the same time, makes them take responsibility for their actions. (FG2; P1L34)

DISCUSSION

Through focus group interviews, we explored the effects that working with medical students had on SPs and their identity formation. Four themes emerged: SPs experienced (1) identity transformation toward a new professional identity; (2) self-actualization toward their maximum potential; (3) judgmental reactions to medical student behaviors; and (4) simulation-reality interaction between their simulated and real selves. The first 2 themes highlight a journey toward new identity formation and personal growth; the second two, the challenges of functioning within that new identity. We further discuss each theme hereinafter, exploring its implications for SP educators and making specific suggestions for how it can help them in the recruitment, training, and retention of SPs (summarized in Table 6). We also indicate how the suggestions relate to the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (ASPE SOBP).20

TABLE 6 - Recommendations for SP Educators Based on the Study Themes
Theme—SPs Experienced: Actions for SP Educators
Identity transformation toward a new professional identity • Reinforce the social good of the SP role to recruit, motivate and prevent burn-out
• Provide new SPs with experienced SP narratives (face-to-face, video) that role model their developmental journey and expected future identity formation
• Provide SPs with instruction on performance and boundaries in their roles as coach, supporter, and “parent”
Self-actualization toward their maximum potential • Provide experienced SPs opportunities to engage in peer teaching
• Provide certificates of appreciation and awards for SPs
• Provide SPs with opportunities to share their positive experiences (success stories) with peers; consider doing so using appreciative inquiry
Judgmental reactions to medical student behaviors • Provide anti-bias workshops
• Provide training sessions on dealing with negative emotions (using simulations with standardized students)
• Provide opportunities for SPs to debrief on their experiences before leaving for the day (with emotional support)
• Provide safe mechanisms for SPs to report negative student behavior
Simulation-reality interaction between their simulated and real selves • Screen SPs for role appropriateness to prevent case-SP mismatch: may strain SPs' ability to sustain their simulations, resulting in case portrayal contamination from the SP's real self
• Provide enough case details for SPs to make informed decisions about accepting a case
• Provide opportunities to discuss and debrief challenging cases where SPs find it difficult to separate their personal and simulated selves
• Provide SP training to successfully implement programmatically useful channels for expression of the SP personal voice—eg, in giving feedback
• Provide psycho/social/emotional support for SPs portraying challenging roles to help them manage their emotional distress, preventing it from intruding into the simulation
• Provide program policies to prevent negative consequences from SP-student boundary crossings—eg, a “no learner-SP dating policy”

With regard to theme 1, the identity transformation ignited by the medical student-SP interaction is consistent with the social and relational theories that identity formation is not simply an internal creation of the individual but rather “a dynamic social process in which individuals construct their identity interactively with others in relation to social context.”21(p5) Theorists would also view this “new SP professional identity” as not static, but constantly transforming.14(p41) Not unexpectedly, this dynamic identity formation is mutual. Medical students play an important role in the professional identity formation of SPs and vice versa.12

The new professional identity that emerged in our SPs encompassed a sense of social commitment and was further enriched by the assumption of multiple and varied roles. Along with their designated programmatic roles as patient simulator and student evaluator, SPs related to students as coach, parent, and teacher. In sum, SPs seemed to go through a transformational process of realizing a complex identity characterized by a commitment to the public good on the societal level and to their students through varied supportive roles on the interpersonal level. This process is consistent with Mezirow's thinking about transformational learning—an expansion of consciousness through the transformation of a person's world view and self-capabilties.22 We can see elements of this sort of transformation in the self-actualization theme as well as in this one.

Understanding SP identity transformation—how SPs construe, validate, and reformulate the meaning of their experience into new identities23—has implications for SP educators in their recruitment, training, and retention of SPs (Table 6). To recruit caring, socially conscious candidates, SP educators can highlight how the work affords opportunities to advocate for the public good. To encourage novice SPs in their identity development, educators can introduce them to the stories of experienced SPs (face-to-face or video) that role model their journey, illustrating the emergence of their pride in contributing to medical student education, humanism in the curriculum, and society in general. Educators can also guide SPs in anticipating and navigating the performance and boundaries of their expanded roles of teacher, coach, and parent. More generally, understanding SP identity formation can give SP educators insight into how to best prepare SPs for their roles and responsibilities in accord with the ASPE Standards of Best Practice (SBP Domain 3, Training SPs).20

The second theme, self-actualization, illuminates how SPs' interaction with medical students moved SPs in the direction of realizing their own potential. As per Table 3, “so exciting,” “cool,” and “like a proud mom” are some of the expressions of self-fulfillment that SPs offered when seeing their work with students come to fruition. Implicit in these and other comments are SPs' motivation and movement toward becoming the persons they hope to be in keeping with Maslow's self-actualization theory.19

Like the identity transformation, self-actualization has implications for SP educators, suggesting a number of ways they can support their SPs' realization of their potential. For example, they can arrange for experienced SPs to engage in peer teaching, reinforcing their self-actualization as well as freeing educator time for other activities. Standardized patient educators can also provide certificates of appreciation or awards to SPs for their contributions. In addition, SP educators can invite SPs to share their success stories. If success story sessions are done within the framework of appreciative inquiry, a quality improvement method built around individual accomplishment,24 they can benefit both individual SPs and the SP program (in keeping with ASPE SOBP Domain 4, Principle 6, Program Management: Quality Improvement).20(p7)

Themes 3 and 4, judgmental reactions, and simulation-reality interaction, capture the triumphs, challenges and tensions that SPs experienced in their new identities, with their sometimes complementary, sometimes conflicting roles. Standardized patient judgmental reactions to medical student behaviors at times filled them with joy and admiration and at other times, with offense and hurt. In their commentary, SPs did not always process these emotions further. They did not always seem to be mindful of how their emotions might convey personal judgments or biases, which could undermine their roles as coach and supporter and harm the education of students.

Standardized patient judgmental reactions create a training challenge for SP educators: to identify methods to help SPs recognize, process, and positively integrate their emotions and judgments into their varied roles. Possibilities include anti-bias workshops25 and training sessions on managing emotional responses to negative student behavior. To enhance realism, such sessions can incorporate simulations with standardized students. Another possibly is an SP debrief before leaving for the day to mitigate negative responses. Debriefing SP judgments can have the added value of providing insights on the curricular level. For example, SPs' negative reactions to students for not suspending their disbelief can indicate cases which lack authenticity and need revision. Finally, on a programmatic level, SP educators can create a method for SPs to report negative student behaviors without fear of adverse consequences (in accord with ASPE SOBP Domain 1, Safe Work Environment).20(p4)

The fourth theme, simulation-reality Interaction, reveals added layers in the construction of SP identity. If identity is conceived of as a continual process of asking “Who am I?26 SPs' continuously becoming and unbecoming multiple patients adds complexity to their sense of who they are. Also adding complexity are SPs' experiences of the emergence of their real selves into their simulation world and vice versa. It is not surprising that SPs' real selves emerged when portraying cases. Unlike in traditional theater, SPs and their student partners are not scripted typically, and SPs must often improvise and draw upon their real lives in their responses. An example of “real self” emergence is the previously quoted narrative of the SP during a patient portrayal, wrestling with how to address his own feelings toward a “very pretty young woman” medical student. As well as in character portrayal, SPs' real self can manifest in the evaluation of students. In one study,10 SPs reported that they routinely let their individual life experiences influence their completion of OSCE checklists.10 Instead of seeing it as a validity threat, however, the authors emphasized the often-untapped advantages of making the SP's real voice an essential part of evaluation. They commented that rating by checklist alone is reductionist and diminishes validity, going on to cite evidence that SPs' holistic manner of rating, influenced by their personal experiences, may actually improve psychometrics.10,27 Calling up true emotion and authentic verbal and nonverbal responses is what enables the SP to elicit humanistic and empathic responses from the students. It is this authenticity that most closely mimics real-world encounters. Standardized patient educators are thus always challenged with how to strike the best balance between standardization and providing students with the authenticity of the SP's real voice.

Standardized patients also experienced the simulation-reality interaction move in the opposite direction—the intrusion of the simulated world into their real lives. Sometimes, their simulation performance evoked critical self-judgments. At other times, as in a previously cited study,7 simulation experiences stimulated personal growth and transformation. In reacting to these simulation-reality interactions, SPs in some instances handled them well, in other instances struggled with them, and in still other instances they simply expressed awareness of them without further processing.

Aside from reports of debriefing SPs after playing emotional simulations to protect their real selves,7 there is little in the literature to guide SP educators in addressing the simulated-real self-interaction. Because this interaction can have both positive and troubling effects on both the SP-student interface and student evaluation, finding ways to help SPs navigate this challenge is an important training issue. Standardized patient educators can start with effective case recruitment. Case-SP mismatch may strain SPs' ability to sustain their simulations, resulting in case portrayal contamination from the SP's real self. To minimize the threat, educators should provide SPs with enough case information to make informed decisions about whether they can portray a case professionally. Once the case is accepted by the SP, training and ongoing supervision should include opportunities to discuss where their simulated and real selves might intersect and how to navigate intersectional challenges. Since, as noted previously, standardization is possible only to a point, training by educators is essential to target if, when, and how SPs should bring in their real voices. For example, for student feedback/debriefing sessions, the SP educator can train SPs to optimally balance the feedback given in the patient's voice verus in the SP's personal voice. In addition, holding role debriefing sessions to provide psycho/social/emotional support for SPs portraying challenging roles can help them manage their emotional distress, preventing it from intruding into the simulation (while supporting their personal wellbeing in keeping with ASPE SOBP Domain 1, Safe Work Environment).20(p4) Finally, educators can create program policies to prevent negative consequences from SP-learner boundary crossings. For instance, having a “no learner-SP dating policy” can prevent SPs from acting on their “real self” attraction to a learner (ASPE SOBP Domain 4, Principle 5, Program Management: Team Management).20(p6)

This study has several limitations. First, we only looked at the SP medical student interaction; relationships of SPs with SP educators and other SPs may also contribute significantly to SP growth and development. Second, as with any qualitative study, results cannot be generalized; however, given the methods used to ensure credibility and trustworthiness, including transparency of methods and analysis, and the use of direct quotes to support the themes, the reader can judge transferability or applicability to their own context.28,29 A limited number of participants were included in our focus groups; however, we did include SPs from a range of demographics to obtain a broad perspective on their experiences. This study took place at a single institution in a large metropolitan area; however, because all of the SPs interviewed work in 4 other Baltimore-Washington area medical schools, they provide a range of perspectives beyond a single institution. This study focused on the SP-student interaction; future studies should explore the impact of the SP community and SP educators on identity development. Future studies should also be designed to determine the impact of the recommendations that emerged from this study on SP training, development, and retention and on student engagement.

CONCLUSIONS

From the 4 themes identified in this study, identity formation, self-actualization, judgmental reactions, and simulation-reality interaction, insights emerged about the SP experience and how it contributed to SP identity formation. Standardized patients experienced a transformation into an unexpectedly complex identity composed of multiple roles. Within this identity, they found purpose and fulfillment through fostering students' as well as their own personal and professional growth and through developing a higher sense of social responsibility. Within this identity, they also encountered the challenges of navigating between judging and supporting medical students, and toggling between their real and simulated selves. Guided by the SPs' perspectives presented in this study, and in conjunction with professional organizational standards (eg, ASPE), we suggest a number of actions with the potential to prove useful in the training, recruitment, and retention of SPs.

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Appendix #1

Focus Group Interview Guide

  1. What made you become an SP? (other than financial gain)
  2. What keeps you coming back?
  3. Has your reason for participating as an SP changed since you started? If so, in what ways?
  4. What do you most enjoy / least enjoy about working with medical students?
  5. Can you give us an example of a time your role as an SP really had an impact on a student?
  6. Can you give us an example of perhaps when a medical student had an impact on you?
  7. Can you give me some examples of your greatest successes with med students?
  8. Can you give me some examples of your greatest failures with med students?
  9. In what ways do you think your role as an SP contributes to the growth and well-being of medical students – or not?
  10. What role do you see yourself playing in the medical students’ future identity as a physician?
  11. What surprised you most about working with medical students?
  12. What medical student behaviors do you value the most? What behaviors do you think need to change the most? Why?
  13. What else would you like to tell us about your perceptions in working with medical students?
Keywords:

standardized patients; identity formation; simulation

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