Standardized patients (SPs) are individuals who have been trained to consistently portray the role of a patient in various clinical scenarios for educational purposes.1 Standardized patients work, for instance, with medical students to help them practice their clinical and interpersonal skills in preparation for their medical licensing examinations. Because of their role in high-stake assessments of medical student competencies, SPs are required to ensure the “standard” of a consistent patient portrayal, thus providing each student an equal learning and evaluation opportunity. At the same time, SPs must convincingly simulate realistic patient behavior rather than merely learning the patient's role as an intellectual script,2 and they must be capable of reacting spontaneously to what the student says or does or does not say or do. Therefore, SPs' work inherently involves a tension between standardization and improvisation. The balance between standardization and improvisation is particularly delicate in the learning context of “breaking bad news” (BBN) in which the students learn to deliver unfavorable medical information to a patient. Ideally, such an encounter is deeply human, authentic, and empathic, yet the interaction is also a highly structured simulation governed by clinical protocols and checklists. Studies on teaching BBN with SPs, however, typically focus on learner assessment,3–5 rather than on specific scripts and performative techniques the SPs use.
Although the BBN scenario studied here has a script that guides the SP performance in many ways, their performance includes multiple improvisatory dimensions, which have not been requested by the faculty, documented, or studied in detail. Some of these improvisational methods have, over time, established themselves as unscripted educational techniques developed by the SPs. This article focuses on one such technique embedded in the SPs' language use, advancing a view in which SPs are seen as educators controlling their own technology and methodology.6 Our work aims to fill gaps in research on tacit techniques SPs have established through years of practice and “peer reviewing” each other's performance. Many of these techniques are currently lost when the SP retires.
Although aspects of the SP work have previously been discussed in terms of dramatic arts,7 their performance has typically been studied in terms of its accuracy and consistency8 and, simultaneously, has been criticized for being inauthentic because they “stick to the script.”9 Thus, their improvisational capacities are either disciplined as flaws or considered of a lesser “standard” than theater actors' improvisational skills. Furthermore, SPs are often objectified; they are called “tools” that are being “used.”10 Correspondingly, their training may involve mechanizing components such as learning an “angry algorithm,” an if-then-else type of flowchart for angry SP responses,11 and ANGER acronym, which introduces 5 continuous steps to rapidly trigger anger in an SP.12 Although SPs' educational capacities are increasingly acknowledged, this often concerns their ability to give feedback after coming out of their role,13 instead of during their role portrayal. Although there exist educational methods that generate feedback before the simulation encounter is over, for instance, calling a “time-in” and “time-out” in the midst of a simulation, these often involve instructors deciding whether the student should “redo” certain parts of the dialog,2 instead of exploring the ways SPs elicit “redoing” in-character during the dialog. In contrast, this article focuses on an improvisational technique through which SPs give feedback to the student on the fly, in-character, performing reflection-in-action.14 This study relates to views in which improvisation is not exempt from objective measurement15 nor considered as simply random. However, instead of initiating this study to assess a particular aspect or style of improvisation, we proceeded by identifying a distinct performative technique that was previously overlooked as “mere” improvisation.
This article focuses on situations in which the SPs use representation of the student's “original” speech, by repeating what could be called “trigger words,” which sound alarming, unclear or inappropriate to them, or that the students use too casually. Linguistically seen, the SPs thus perform echo utterances, meaning that their wording repeats all or part of what the previous speaker has said.16 The technique of echo utterance can be used for a range of purposes, with typical functions of confirming, questioning, or clarifying what the previous speaker has just said.17 Although techniques such as Rogerian rhetoric, for instance, may also involve repetition of what the other speaker has uttered, the difference lies in its aim to avoid confrontation or blocking the dialog.18 In this study, the SPs use echo utterances to interrupt the flow of the dialog, typically questioning what the student has just said. Echo utterances thus often manifest in echo questions, which can be used not only when the echoer did not hear or understand properly what was said but also when they want to express disbelief at what they heard.19 Although echo utterances or echo questions can be used as a conscious educational technique, in this study, they emerged as part of the unscripted, improvisational dimension of the SP work and had not been included as part of their training.
The purpose of the present study was to analyze reasons for and impact of a specific technique we identified, in which the SP explicitly repeats 1 or more of the student's words. This qualitative inquiry was founded on a constructivist research stance, involving aspects of both cognitive and social processes related to construction of knowledge and meaning.20 In the constructivist view, individuals actively construct knowledge through engagement with each other and their social world.21 Our approach particularly acknowledges the SPs' engagement in real-time language processing as a response to the student behavior, as well as the meanings that emerged from the interaction and dialog involved in the BBN simulation. We choose to look at the BBN simulation as a social “construction site” of knowledge22 about what is considered culturally desirable interpersonal conduct in a BBN encounter. According to this view, the SPs' performative techniques thus co-construct how encounters between physicians and patients are considered in medical education and beyond.
We gathered our data by observing, recording, and transcribing 3 90-minute sessions of a BBN class given in the medical school to third-year medical students. The BBN sessions are part of an Ethics and Professionalism Longitudinal Theme “roadmap” that includes the internal medicine clerkship in which these sessions took place. The students are prepared for practicing BBN through various thematic courses on ethics and professionalism, but not by studying specific aspects of BBN or being informed about the SP performance beforehand.
During the course of the clerkship, 2 different SPs visited the class to perform BBN scenarios with students from the class. Both of these female SPs were, at the time of the study, in their mid-60s, each having about a decade of experience of SP work in variety of different case scenarios, and a minimum of 8 years of experience in performing the BBN case. The 2 SPs who performed in the BBN scenarios observed for this study remain, to date (2020), the only SPs among a pool of more than 100 trained performers involved in BBN sessions. The simulation trainers deemed these sessions to require the skills of only the most experienced SPs because of the complexity of the roles they enacted. In these sessions, 1 SP performed the role of a character who receives bad news of a concerning finding on a computed tomography scan. The SP performed that character with 3 different students, each time using a different persona (angry, sad, or distracted). The clinical faculty asked for 3 students to volunteer to enact a BBN session with an SP, to be conducted in front of the students and faculty, followed by a feedback session involving questions and comments from the students, faculty, and SPs. This debriefing was done in front of the classroom. The peers and faculty reflected on how the student performance appeared from the outside, while the student and the SP reflected on their first-person experience. The class was taught 6 times during 1 academic year by a group of faculty; our research team played no role in the development of the curriculum or the timing of the SP sessions.
Our data set includes 9 student encounters (female = 4, male = 5) with 2 female SPs, as well as the tutor and peer feedback in between each student encounter. The BBN scenario used by the medical school where we conducted this study was developed based on standards established by the 1996 Southern California Macy Consortium23 and adapted by the clinical faculty at the medical school, not by the authors of this study. The script is used in BBN trainings and in standardized examinations of the medical students and, therefore, is a confidential document. The script was not adapted in any way for this study, and our research team did not play any role in the development of the script. The SPs had been prepared extensively for this simulation scenario, using a detailed script including guidance on presentation and emotional tone, by the training team of the simulation center at the medical school where this study was conducted; our research team did not play any role in training the SPs.
On average, 240 students per year observe the BBN exercise, of which 18 students practice the simulation firsthand. In each of the 6 annual sessions, 3 students volunteer one at a time to participate in an SP encounter lasting approximately 12 minutes in front of a large classroom. The authors recorded 2 of these sessions with 2 cameras in 2016; one of the recordings was done by the medical school faculty a few years earlier and made available to the authors to complement the author-recorded data and provide a longitudinal point of reference to determine whether any changes occurred in the SPs' performance over time. In addition, the authors witnessed several BBN sessions in preparation for the study. Neither the class design nor the SPs' performance style changed in that period. In all of these sessions, the same 2 SPs exhibited 3 main personality types or moods. The analysis of these 3 distinct characters and their function will be presented in another article.
The study uses conversation analysis (CA) to discuss and examine “patterns of interaction”24 embedded in the SPs' unscripted verbal performance. Conversation analysis is an inductive qualitative method seeking to notice and explain patterns in language use and social interaction through a reliance on case-by-case analysis.25 Conversation analysis has been previously applied to address physician-patient interaction,26,27 to consider simulated interaction in communication skills training for healthcare professionals,28 and to assess interprofessional student teams' communication with SPs.29 To our knowledge, CA has not been used to study the SP performance in BBN simulations in particular.
To examine the various forms of echo utterances, we used a concept of “repair.” In CA, the so-called repair practices are initiated to undertake “trouble” in speaking, hearing, or understanding.30 Repetition of words is one of the ways to initiate repair.31 Either the speaker of the trouble source or its recipient can initiate a repair procedure and/or produce a repair solution; thus, the repair can be either self-initiated or other-initiated.32 In this study, we focused on repair practices that were other-initiated, that is, when the SP requested a reformulation of what the student had said. Our analysis includes Hoey and Kendrick's32 3 components of a repair procedure: trouble source (eg, an unfamiliar word), repair initiation (ie, a signal that begins a repair procedure), and repair solution (eg, a rephrasing of the unfamiliar word).
The data analysis process was initiated by conducting debriefing sessions after each BBN class that the research team observed in person, by sharing our notes and immediate impressions with each other. After the videos were transcribed verbatim and time coded by a professional transcriber, both researchers conducted a thorough “unmotivated” examination of the transcripts, without prespecified objective of analysis, to code previously “unremarkable” features in the BBN simulation dialog.33 The analysis subsequently proceeded by organizing “data sessions” to discuss our individual observations.24 During a data session, 1 researcher (K.K.) discovered a novel dialog technique in the transcripts that, after further review of the transcripts, we determined was a recurring unscripted technique that we named “repair request.” Based on the researchers' familiarity with the literature on SP techniques in medical education, we determined that this was a highly significant finding, which we subsequently used to guide analysis of the conversational techniques within the data set and their structural purpose. We then collaboratively arrived at the identification of specific “repair organizations”24 in the BBN simulation dialog, and through discussion, we reached consensus on the 4 most significant types.
We submitted the study protocol and received institutional review board approval at the medical school where this study was conducted (IRB Number: HSC-MS-18-0083). Informed consent was obtained from all the medical students, tutors, and SPs who were involved in this study.
Four aspects of the data will be addressed: (1) the discovery of “repair request” as a predominant but unscripted echo utterance technique used by the SPs; (2) the frequency of repair initiation by the SPs; (3) the types and functions of their repair initiation; and (4) the methods that students use to self-repair their utterances. The repair requests that we identified in the transcripts were an unscripted and unconscious technique that was initiated by the SPs but never explicitly acknowledged by the SPs, the students, or the medical school faculty who were teaching the course. Instead, this technique was only identified on the basis of our analysis of the transcripts in which we recognized this conversation pattern recurring throughout the 9 student encounters. In the context of BBN, analysis showed that the SPs responded by repair requests to the following types and aspects of the student speech: (1) speculative language (grammar, vocabulary), (2) inappropriate utterances (inauthentic, insensitive), (3) awkward timing, and (4) medical jargon. These may appear alone or in combination with each other. In the 9 student encounters, the SPs initiated 36 repair requests in the student's speech, varying between 1 and 6 repair procedures per student. Twenty of these instances were signaled by repeating one or more of the student's words. Most of the repair procedures (n = 29) were initiated in an angry character.
Standardized patients' repair requests addressed students' speculative language use through vocabulary and grammatical nuances, such as using modal verbs like “might,” speaking with vague or contradicting adverbs like “soon” or “a bit large.” The following dialog demonstrates to the student how the SP equates the word “unfortunate” with something bad, and requests the student to repair.
Doctor: Unfortunately we found some findings […] We sort of need more testing to figure out exactly what's going on.
Patient: I guess I did not like that word unfortunately. […] I guess I do not understand what you are trying to tell me.
Doctor: Okay, so the reason I say unfortunately is because unfortunately it's not just something wrong with the imaging that we suspected it to be. It does not necessarily mean that this is a bad thing we are not quite sure what it is.
Patient: Oh! So it's not bad oh! Thank God. I was thinking it's something bad.
Standardized patients' responded to several types of student comments that were perceived as inappropriate because of their tone of inauthenticity, insensitivity, or presumption of knowledge about the SP's feelings. The sequence below illustrates the student's use of inappropriate utterances and the SP's sarcastic response.
Doctor: So, what's your understanding of what's going on?
Patient: My understanding of what's going on? My understanding is that y'all are putting me through hell to, because they saw something on my x-ray.
Doctor: How do you want me to tell you about this?
Patient: Well, I want you to say it with your mouth.
Doctor: Do you want me just to tell you directly?
Patient: Well what are you going to do?
Doctor: Okay, all right some people have different preference about who they want us to tell.
Patient: No, that's not me, I'm an adult and I may not have acted like one today but I am.
Doctor: It's okay, so, your CT shows changes that are consistent with lung cancer.
Another genre of perceived inappropriate utterances concerns the student claiming to know how the SP feels after hearing the bad news or guessing out loud how the patient may feel. Four of the 9 encounters involved a situation in which the SP corrected the student who was claiming to understand what the patient's experience was like, as in the example hereinafter.
Doctor: So does that kind of make you a little more fearful?
Patient: What do you think? How would you feel if somebody was sticking a needle in your lung?
Doctor: I can understand you must have a lot of fears and a lot questions about what is going to happen.
Patient: How do you know what I feel really except that I'm angry and I'm unhappy and I wish my own doctor were here and I do not know how the hell I'm going to pay for this biopsy. I came down here to pick up a piece of paper and I'm getting this conversation. So pardon me if you cannot understand how I feel but I do not really know how I feel.
This type of repair request typically occurred when medical students delayed presenting results to the patient by instead asking many questions about what the patient understood about the situation.
Doctor: Okay, do you have any suspicions or concerns with things we are looking at your lungs?
Patient: Well I'm starting to get suspicious and concerned now about what you are telling me, why don't you tell me what it is that you saw?
Doctor: So, I'm afraid we found a mass in your right lung, it's a bit large. […] The radiologist believes that its primary lung cancer. Would you like to know more details about the report on what was found?
Patient: Oh! At some point I'm sure I will, right now I'm just concerned about the word large and the word cancer.
A variation on the awkward timing repair request occurred when the student already explained further tests required, while the SP was still waiting to hear what the imaging showed. This situation's core trouble is not necessarily the use of ambiguous words, but an absence of necessary words.
Doctor: It is recommended that we do a biopsy.
Patient: Would you just be a little honest and tell me what you think that this is?
Doctor: Look right now without the… (trails off)
Patient: I feel like you just have some kind of information that you do not want me to see. I'm getting this feeling from you and I just kind of don't understand what you are telling me.
Another type of repair request relates to the use of medical jargon, when a student reads test results directly from the medical record without translating their meaning in lay terms, as in the following example.
Doctor: Okay, all right, so, we found some evidence, potential evidence of some early metastasis to the mediastinum. We're going to… (trails off)
Patient: To the what?
The purpose of this film-based34 ethnographic inquiry was to explore the tacit techniques of the SPs' unscripted performance in portraying a BBN scenario, with a particular focus on their language use. Through our research, we discovered a performative technique that we propose to call “repair request,” in which the SPs repeat what “troubles” them in the students' words during the BBN scenario. Our study found that SPs frequently used this unscripted dialog technique in their improvised responses to a range of student behaviors during the BBN simulations. Standardized patients used specific words and phrases as well as tone of voice to convey dissatisfaction with the student's delivery of bad news. Although the SPs were trained on a script for this scenario that encouraged them to ask follow-up questions, they were not explicitly instructed to use the technique of repair request. Standardized patients used the tacit technique of repair request to increase the students' awareness of their verbal communication, and allow the students to rehearse their communication skills by reformulating their utterances in character. We found that the purpose of this technique is not to arrive at a list of forbidden words, but to generally heighten the student's language sensitivity, including the timing of presenting information. For instance, SPs used the technique both to indicate when the student appeared to be avoiding using a particular term, or using it too lightly, and when they should moderate the pace of the conversation according to the patient's needs.
Observation in this study was directed at other-initiated self-repair: the student's utterance was the trouble source for the SP, instead of the student self. The SP subsequently, often by repeating the student's words partially or wholly, required the student to reformulate, thus repair, their previous utterance. In computer science terms, the SPs conducted live and performative “speech mining”35 and a form of “undoing”36 the student's previous utterance. This allowed the student to reconsider and reframe what they just said, thus taking a step back while staying in character. The reframing may be a repetition of an entire sentence, or a selected key word that has triggered the SP either as inappropriate, alarming, vague, or including medical jargon. The repetition may concern a sentence with or without a question and may repeat the whole question or only part of it. The SP may also initiate the repair by asking another question, which includes a word used by the student, for example, “What do you mean by biopsy”? Such questions differ from questions the SPs ask unrelated to the student's vocabulary, such as: “Am I going to die?” which is presented as one of the possible responses in the (confidential) SP script. However, none of the responses in this script, developed by the simulation center trainers, suggest repetition of the student's words as an SP technique.
Physicians are typically trained to solicit patients' presenting concerns with questions such as “What can I do for you today.”37 In the context of BBN, some of these solicitations derive from the SPIKES protocol, a 6-step protocol developed for disclosing unfavorable medical information.38 The protocol, for instance, guides the student to “ask before you tell,” meaning that they should solicit information of what the patient knows of the purpose of the encounter. Although the SPIKES38 protocol is not taught in the clerkship of the medical school where this study took place, 1 student explicitly referred to it in the BBN encounter debriefing. The instances described in this study unveil challenges related to physician solicitations, and SPs typically consider these inappropriate or inauthentic, responding with irony or sarcasm. They also openly criticize the SPIKES38 protocol in their feedback. In these situations, the repair initiation is a vehicle for displaying a stance of disbelief or nonalignment with the physician31: “Say it again, what did you just say?” As relative outsiders to the medical system, SPs may have an important role in questioning some of the accepted educational protocols from the patient's point of view. In comparison, however, studies using medical trainees as simulated patients note a lack of criticism about medical jargon and acronyms.27
Medical jargon repair requests happened particularly if the students read the test results from their script without translating their meaning in lay terms. In addition, a BBN encounter is charged with words that may mean different things to the physician and the patient. A common example of such a multimeaning word is “tumor.” While by tumor a doctor typically refers to either a benign or malignant neoplasm, many patients associate the word's meaning only with malignant cancer and death.39
The SPs repair requests also point to the importance of the temporal dimension or pace of the BBN encounter, in terms of proceeding too slow or too fast regarding the patient's behavior. The SPs thus assess not only the type of vocabularies the students use but also the spaces and transitions in-between them. For example, the student excessively asked questions before telling the patient what the concern was. The SP here repeated the student's words, requesting them to get to the point more quickly. In this encounter, the student repair fails in that their repair introduces yet another trouble that the SP then attempts to repair. In the latter sequence, the first repair initiation is caused by the SP's assessment that the student goes on for too long to warn that there is bad news coming. The second repair, in turn, refers to a pause the SP needs when word combinations such as “cancer” and “large” are being introduced. Thus, both of these repair initiatives relate to the pace and timing in the dialog: first, the student is, according to the SP, taking too long to get into the point, and then, proceeding too quickly after labeling the findings. The repair initiation can thus request a step backward or forward in the encounter, although as a technique it always requires the student to undo the previous utterance.
Some research has noted that SPs can be more conversationally dominant than actual patients would be.40 However, in many ways, the SPs' technique introduces a quality of heightened perception present in actual clinical conversation: actual patients are also sensitive to the physician's communication, and patients do, for instance, “correct” their physician when experiencing solicitations inappropriate for their concerns.37 Furthermore, the technique resembles actual medical practice in that, in real life too, the physician needs to be able to solve any criticism or misunderstanding in real time, and in character. This study proposes that authenticity in an SP performance means portraying a wide spectrum of potential responses in patient encounters, and that conversationally “dominant” behavior of the SP, such as asking critical questions, may be maintained as internal dialog by real patients. This does not mean the questions are not there or may not arise later at home. Many patients may not dare to confront their physicians. Standardized patients thus have an indirect patient advocate function here: to speak for all those patients who may have similar questions and feelings without being able to voice them for one reason or another. While the tacit technique identified in this study involves a particular learning context in medical education, the technique could be used in the training of other healthcare professions too.
This study has several limitations. As it focuses on dialog between the SP and the student, it excludes paraverbal behaviors such as facial expressions, gestures, or body language that may reflect the patient's inner state. These behaviors are likely to influence how the student chooses to respond. Pairing of verbal and nonverbal student and SP performance through video-based visual analysis of aspects such as body posture and gestures in the BBN simulation would be a valuable addition to future studies.
This study explores data that involve 2 SPs' perceptions of medical students' performance. Although both of these SPs have a decade of educational experience, their responses nevertheless remain subjective. However, subjectivity is an inherent part of the BBN case scenario, as it includes faculty-generated guidelines such as “not being easy on the student.” This illustrates a difficulty of standardizing a BBN encounter, including determining the level of confrontation ahead of time. In this class, it is accepted and viewed as beneficial that there is much variance between performances and student responses. Furthermore, although the study unveils perceived mismatches in the pace of the BBN encounter, such as the SP indicating that the student is taking too long before getting to the point of the diagnosis, the sense of appropriate conversational timing is extremely subjective. In actual clinical practice, it is possible that the patient would prefer more conversation and rapport building before receiving bad news.
Although the technique of repair request may be a valuable pedagogical technique to be used by SPs in BBN scenarios at additional medical schools, it is difficult to generalize based on this small number of participants. In this regard, the sample is too small to consider these participants as representative of patients in general. However, relying on a small number of SP performers dedicated to the BBN case may be typical in many simulation centers, as the 2 SPs in this study have for many years been the only performers of this case, because of its complexity and the need for experienced SP performers. More importantly, the influence of these 2 SPs on the thousands of students who have learned from their performances highlights the impact of both scripted and tacit techniques in shaping the behaviors of future doctors.
This study has identified the performative technique of repair request that the SPs use to heighten the students' language sensitivity, including the timing of presenting information. The technique resembles realistic medical practice in that it mirrors the need for physicians to be able to solve criticism or misunderstanding in character, and it could be rehearsed and used consciously in other simulation scenarios as well. The study thus advances a viewpoint in which better understanding of SPs' tacit techniques is significant in determining which aspects of the SP work can or should be standardized in a given scenario, as well as in designing more specific SP training or simulation scenarios. In performing the repair request technique, SPs are like flesh and blood mirrors, sometimes reflecting the student's speech sharply, sometimes in a distorted (sarcastic) manner, but always with a purpose of allowing them to repeat and repair aspects of their communication in character. This study invites further research on tacit knowledge and pedagogical techniques embedded in SP work, to understand their capacity as reflective practitioners more fully. After all, by knowing more of the improvisatory dimension of their performance, we learn about what kind of image of the doctor and the patient is embedded in educational simulations.
The authors thank the faculty, staff, and students involved in the breaking bad news teaching at the medical school where this study was conducted. We also thank the director and team in the standardized patients program in the Surgical & Clinical Skills Center.
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