|ORIGINAL RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 1 | Page : 10-16
Simulated patient and role play methodologies for communication skills training in an undergraduate medical program: Randomized, crossover trial
Silas Taylor1, Samantha Bobba2, Sophie Roome3, Marrwah Ahmadzai4, Daniel Tran5, Dominic Vickers6, Mominah Bhatti6, Dinuksha De Silva7, Lauren Dunstan8, Ryan Falconer6, Harleen Kaur9, Jed Kitson10, Jamie Patel11, Boaz Shulruf1
1 UNSW Medicine, UNSW Australia, Sydney, Australia
2 Department of Ophthalmology, Westmead Hospital, Westmead, Australia
3 Intensive Care Medicine, Lismore Base Hospital, Lismore, Australia
4 Department of Orthopaedics, The Canberra Hospital, Canberra, Australia
5 Department of Medical, Wagga Wagga Rural Referral Hospital, Wagga Wagga, Australia
6 Department of Emergency, Prince of Wales Hospital, Randwick, Australia
7 Department of Plastic and Reconstructive Surgery, Royal North Shore Hospital, St Leonards, Australia
8 Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, Australia
9 Department of Palliative Care, Coffs Harbour Hospital, Coffs Harbour, Australia
10 Department of Rehabilitation and Aged Care, Hornsby Ku-Ring-Gai Hospital, Hornsby, Australia
11 Department of General Medicine, Port Macquarie Base Hospital, Port Macquarie, Australia
|Date of Web Publication||14-Aug-2018|
UNSW Medicine, UNSW Australia, Sydney, NSW 2052
Source of Support: None, Conflict of Interest: None
Background: Educators utilize real patients, simulated patients (SP), and student role play (RP) in communication skills training (CST) in medical curricula. The chosen modality may depend more on resource availability than educational stage and student needs. In this study, we set out to determine whether an inexpensive volunteer SP program offered an educational advantage compared to RP for CST in preclinical medical students. Methods: Students and volunteer SPs participated in interactions across two courses. Students allocated to SP interactions in one course participated in RP in the other course and vice versa. Audio recordings of interactions were made, and these were rated against criterion descriptors in a modified Calgary–Cambridge Referenced Observation Guide. Results: Independent t-test scores comparing ratings of RP and SP groups revealed no significant differences between methodologies. Discussion: This study demonstrates that volunteer SPs are not superior to RP, when used in CST targeted at preclinical students. This finding is consistent with existing literature, yet we suggest that it is imperative to consider the broader purpose of CST and the needs of stakeholders. Consequently, it may be beneficial to use mixed methods of CST in medical programs.
Keywords: Clinical competence, clinical skills, communication, curriculum, patient simulation, role playing, undergraduate medical education
|How to cite this article:|
Taylor S, Bobba S, Roome S, Ahmadzai M, Tran D, Vickers D, Bhatti M, De Silva D, Dunstan L, Falconer R, Kaur H, Kitson J, Patel J, Shulruf B. Simulated patient and role play methodologies for communication skills training in an undergraduate medical program: Randomized, crossover trial. Educ Health 2018;31:10-6
|How to cite this URL:|
Taylor S, Bobba S, Roome S, Ahmadzai M, Tran D, Vickers D, Bhatti M, De Silva D, Dunstan L, Falconer R, Kaur H, Kitson J, Patel J, Shulruf B. Simulated patient and role play methodologies for communication skills training in an undergraduate medical program: Randomized, crossover trial. Educ Health [serial online] 2018 [cited 2019 Feb 21];31:10-6. Available from: http://www.educationforhealth.net/text.asp?2018/31/1/10/239040
| Background|| |
Effective communication is central to patient–doctor interactions, and ultimately in the therapeutic process and outcomes. Consequently, programs of communication skills training (CST) are well established as a critical component of medical curricula globally,,,, based on the premise that communication skills are not innate but rather can be learned and improved., Traditional didactic methods of CST are outdated, and interactive approaches to CST are now favored.,,, Medical programs typically rely on various combinations of real patients, patient actors (in the broadest sense), and student role play (RP) in the teaching of communication skills., The mix is dependent on factors such as the educational stage and needs of the student, balanced against faculty's human and financial resources.
While seemingly attractive as a readily available and cost-free resource in teaching hospitals, the use of real patients for CST is limited, particularly in the early stages of undergraduate training. This is due to factors such as the severity and consequent impact of illness on willingness to participate, high patient turnover, and overburdened hospital systems. It is also difficult for teachers to focus reliably on particular communication skills in the hospital environment. RP, in which training partners switch “doctor” and “patient” roles, is readily implemented and widely practiced. When properly conducted, it can be successfully used by peer dyads for CST and educationally useful., However, it can be disliked by students  and may not be preferred by the majority of learners. For faculty, it has the attraction of being an inexpensive approach to CST, since the “trainer” and the learner are one and the same, simply swapping roles.
Simulated patient programs (SPPs) offer an alternative approach to CST.,,, Barrows  defines a SP as “a well person playing the role of a patient with the purpose of students learning clinical skills in controlled circumstances.” Specific methodologies vary, sometimes in important ways, but generally SPs are briefed on their patient role and play that role in an interaction with a student. SPs can also often provide feedback on student performance., Both students and faculty tend to favor such an approach since it exposes students to unfamiliar people, who provide realistic, unbiased interactions, and emotional elements are authentically intense. However, such programs can be costly., For example, trained, professional medical actor SPs are paid per hour upward of AUD80 (approximately EUR55, USD60). Consequently, running a full SP program with actor SPs is a significant enterprise and will increase the financial burden on faculty.,,, Ker et al. propose recruitment of volunteer SPs from the local community as a more financially modest approach to maintain a SPP.
Research on student attitudes to and perceptions of various CST methodologies ,,, shows few definitive outcomes. To-date, studies have directly compared SPs (studies quoted vary in use of actors and extent of training) with student RP and have shown that SP and RP are comparable as a teaching tool for specific communication skills, but neither was superior to the other.,,,, Lane and Rollnick  noted a need for more well-designed studies to objectively compare SP and RP for CST. Bosse et al. found medical students on a pediatric term valued both RP and SP approaches to CST, but that RP was superior to SP in terms of fostering empathy in students for patient perspectives because RP forces students to adopt the patient role. Bosse et al. subsequently report that RP is also significantly more cost-effective. Given the resource implications for CST programs, further data regarding the optimal approach may have a significant impact on directing the choice of methodology used for CST in medical curricula. Decision-makers need to weigh the expense of educational interventions against the expectations of stakeholders, including students, educators, and the public. This includes expectations of what knowledge, skills and behaviors a graduating student will have reliably acquired at the end of their education, and thus at the entry into the workforce, such that they are able to deliver high-quality patient care.,,
While SPP often involve paid actors, we set out to create an inexpensive program with good CST educational outcomes for preclinical medical students. Our SPP involves local people volunteering as SP, attending our clinical skills center to play patient roles as realistically as they are able without special training, as supported by Ker et al. As such, our volunteer SPP is an example of “community-engaged scholarship” in which we are involved in a mutually beneficial partnership with the community, in line with universities globally working to develop greater and more productive relationships with their communities., To support our SPs we provide patient case scenarios and other documentation well ahead of sessions and help our volunteers understand how to play the role described. Tutors discuss the scenario with the SP before each session as well as provide feedback regarding the quality of the patient role played by the volunteer SP after each session. However, we do not have the resources available for full-scale training of SPs. Consequently, in this study, we set out to determine whether our SP methodology, as part of a new volunteer SPP, offered an educational advantage compared to the existing RP methodology for CST in preclinical medical students. To the best of our knowledge, it is the first study of its kind in an Australian undergraduate medical program.
| Methods|| |
[Figure 1] illustrates that integrated enrollments of the first and second year undergraduate medical students (n = 558) were assigned into two study groups. We describe a crossover study between two courses relating to organ systems. CST sessions were in addition to other course content, which was kept identical for both groups and included lectures, scenario group learning, and bedside teaching in public hospitals.
|Figure 1: Flowchart of student participation and data collection in cross-over study across two organ system-related courses|
Click here to view
In the first (gastrorenal) course, a proportion of the group initially participated in CST sessions through RP while a second group participated in CST sessions with our volunteer SP (assume volunteer SP used throughout this study). In the subsequent course (musculoskeletal), exposure to RP or SP was reversed, such that overall, the RP and SP groups both consisted of a potential sample size of n = 420. RP and SP sessions occurred separately from one another, but during both, each trainee interacted with at least one training partner for 15 minutes, under the supervision of a tutor. All students participated in sessions as observers (n = 558), but not all were able to participate in interactions due to disparity between group size and SP availability. Up to 840 recordings were expected in total. Students' interviews with training partners were audio recorded using the Evernote ® app on iPads ® and these recordings were only identifiable as SP or RP – no other identifying features were retained (other than voice).
Recordings were subsequently downloaded with nonidentifying codes being applied at this stage, and then, reuploaded to a secure Moodle ® site, and randomly divided (using Microsoft Excel ®) into batches for rating online. By following the protocol described, raters were blind to the interaction being assessed, as well as to any other identifying information about participants, except voice. Ethics approval for the study was granted by the relevant ethics committee (Ref: HC15018). All participants gave informed consent before taking part.
Scenarios used in the interactions related to course themes and were based on typical or usual presentations and common conditions. Scenarios included biomedical information and foregrounded patient issues related to these, as delineated by Kurtz and Silverman., Patient issues were kept to a stage-of-training appropriate level, as were the learning objectives, which were focused on generic communication skills, not clinical acumen or accuracy. RP was performed by student dyads. All students were randomly paired and given preparation time to familiarize themselves with their own scenario, before working together, and swapping doctor (D) and patient (P) roles. In both SP and RP methods, feedback is provided to students in the doctor role by tutors, who directly observe the interaction.
For objective evaluation of communication skills, raters were selected from senior students trained in CST. As illustrated in [Figure 2], 12 raters accessed their allocated recordings online and each rated up to 60 recordings against 24 descriptors of a specially modified version of the Calgary-Cambridge Referenced Observation Guide [Figure 3],, created as an online survey instrument. Modification of the guide was required in order that students were only rated against stage-of-training appropriate criteria and descriptors (Initiating the Session, Gathering Information, Providing Structure, Building Relationship), as well as compared to only those descriptors that could be rated from an audio recording of the interaction. For each descriptor, each criterion was judged to be “Noted” (Yes or No), and if “Yes” then Frequency was also recorded as follows: “Above” the expected level (score = 3); “At” the expected level (score = 2); “Below” the expected level (score = 1), and “not noted” (score = 0). The sum of scores per domain and the total sum of scores were calculated per each student group, SP, or RP.
|Figure 3: Modified Calgary-Cambridge guide to the medical interview - communication process|
Click here to view
| Results|| |
Over the two courses, twenty-two volunteer SPs participated in the study. SP were aged 23 to 79 years old (average age = 63.3, median = 65.5) and were mainly female (16/22 = 73%). Student role players (RP) were aged 17 to 34 (average age = 19.7, median = 20.0), and the gender split was male (46%) and female (54%).
During the study, some students did not participate as intended or declined to participate in research, and there were some technical failures, for example, blank audio files. Of the 840 possible recordings expected in total, 692 successful recordings of student-student interactions (RP, n = 341) or student-SP interactions (SP, n = 351) were made and went forward for rating. From these, 610 complete ratings of interactions were received (RP = 303; SP = 307) and were included in analysis.
Independent t-test was performed to identify whether the two groups (RP and SP) yielded different scores. As shown in [Table 1], comparisons were made between student scores on the individual tasks from the modified version of the Calgary-Cambridge Referenced Observation Guide,, as well as overall. For each of the four tasks, namely, initiating the session, gathering information, providing structure, and building relationship, none of the differences between the two groups reached statistical significance. The results of all comparisons made between the groups, including overall, demonstrate that there were no statistically significant differences between the SP and RP methodologies. In terms of CST measured by ratings of verbal communication skills alone, the results show that the CST method used (SP or RP) has no impact on ratings of student performance.
| Discussion|| |
This study demonstrates that volunteer SPs are not superior to student RP, when used in CST targeted at preclinical students. Such a finding supports research by Murphy et al., who found similar results in CST for physiotherapy students, as well as smaller studies conducted over the last two decades for specific CST, such as that for improving motivational interviewing skills.,, It provides further evidence sought by Lane and Rollnick  in their literature review of these practices, to explore advantages and drawbacks of different methodologies of CST in various contexts and with different learners.
“Full-scale” SPP frequently involve professional actors, paid to play complex patient roles, with extensive training provided. These are resource-intensive and time-consuming programs. In comparison, our inexpensive volunteer SPP  is effectively not significantly different to the cost of implementing RP. The previous research has shown that there is particular educational benefit to RP, regarding students' understanding of the patient perspective, which can never be achieved with SP methodology, since students do not have the opportunity to play the patient role.
Despite this, and the results presented here, we see other advantages to the SPP. Our SPP aspires to improve communication skills of our students, but also to achieve other outcomes prized by students, such as the greater perceived benefit from SP interactions and deeper engagement through realistic SP role portrayal in interactions, including emotional intensity. It also provides contact with SPs before practice with real patients, consistent with student's reported preference. Anecdotally, students state that SP feedback on their performance is instructive and gives them specific indicators on which they can work to improve their communication skills, a finding supported in the literature. Therefore, volunteer SP relish contributing to the education of future doctors, and as recipients of health-care services bring an important perspective to interactions in a CST program.
Results of this study may be interpreted in two distinctive ways. If considered from the perspective of which approach to CST is best for pre-clinical medical students, one conclusion may be that an SPP provides no additional benefit in terms of communications skills educational outcomes, and thus does not warrant any outlay of resources. However, if considered from the perspective of what modalities of approach can be usefully employed to provide different but complementary benefits to students in CST programs, then we concur with Aper et al., who found that mixed instructional formats contribute to CST in different ways. Consequently, we suggest it is reasonable to conclude from this study that use of both RP and SP may be productive in CST, such that students derive, for example, emphasis on the patient perspective when role playing, and awareness of the emotional aspects of interacting with different people in SP sessions. In addition, further benefits of SPP that actively recruit and involve volunteers may accrue to faculty from the resulting interaction with the local community.
The limitations of this study include that our data are restricted to verbal communication. Nonverbal communication aspects of the consultation may show differences but were not detectable here. Further research using video recording is required to address these limitations. Data were not analyzed by year of study of the students, as they work in fully integrated groups. We accept that some masking of results may have occurred, but believe these students fall into a category of “junior students” that would more usefully be compared with other categories of trainee, rather than conduct detailed intragroup comparison.
SPP can vary widely in how they are implemented, and at whom they are targeted. Our program involves volunteer SP participants, and so expert (trained and paid) actors may give different results. Our program is also focused on early CST with preclinical undergraduate students; focus on more challenging CST, for example, delivering bad news or disclosure of medical errors, involving more senior learners and heightened emotional content, may also produce different results (for example, see Bell et al.). Finally, we adopted a quantitative approach to rating verbal behaviors using the Calgary-Cambridge Guide; qualitative research will produce more nuanced data which may help when making decisions between SP or RP instructional methodologies.
| Conclusion|| |
In this large, carefully conducted study, the data presented for CST targeted at preclinical students shows that volunteer SP and peer RP teaching methods are equally efficacious. Curriculum developers are encouraged to consider the broader context and purpose of CST, and the needs of stakeholders. For maximal educational advantage, it may be beneficial to use mixed methods of CST in medical programs, with further research helping to guide CST curriculum development.
The authors wish to acknowledge the invaluable contributions of the following people: Dr. Renee Lim for the design of the SP Program and associated learning activities; Ms. Kiran Thwaites for the administration of all learning activities referred to in the text; Ms. Suzanne Mobbs for creation of the online custom Calgary-Cambridge Guide to facilitate rating of interactions and initial handling of the data generated.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare that they have no competing interests.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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