Journal Club

The risks and benefits of being a young female adolescent standardized patient. Blake KD, Gusella J, Greaven S, and Wakerfield S. Medical Education 2006; 40(1): 26-35.

Reviewed by Lindia Willies-Jacobo, University of California San Diego

Background: The adult standardized patient (SP) was first described 40 years ago for use as a teaching tool in undergraduate medical education, and has since become common practice. While significant importance is placed on the adolescent interview, there is little research looking at the use of adolescents as standardized patients.

Methodology: In this prospective study, the authors sought to determine whether adolescents could be trained to portray risk-taking individuals during SP encounters with medical students without themselves developing adverse effects from role-playing. Additionally, they sought to capture the viewpoint of the adolescent SPs over time, and to describe the process of using adolescents to portray risk-taking SPs. Eight female adolescents from two local middle-class private schools (in the Halifax, Nova Scotia area) were selected for the study, with 8 matching controls. The medical students were in their final 16 months of training. Each adolescent SP was interviewed by a different medical student for 1-3 times a month over 14 months. A validated written feedback form (SCAG-Structured Commu-nication Adolescent Guide) was completed by the adolescent and the SP mother. Focus groups of 8 adolescents were conducted at 3 points in the study. The parents of the adolescent SPs were interviewed and asked to complete an end-of-study question-naire where they were asked if their adolescents had shown any decline in home behavior, schoolwork or an interest in risk-taking. Main outcome measures were pre-and post-interviews using the Achenbach's Youth Self Report (YSR), the Piers Harris Children's Self Concept Scale (SCS), and focus groups. The YSR assessed the degree to which adolescents displayed behaviors or characteristics such as depressed mood, obsessive compulsive, and aggressive behaviors. The SCS assessed how adolescents felt about themselves in the areas of behavior, intellectual and school status, physical appearance and attributes, anxiety, popularity and happiness.

Results: The researchers found that neither of the standard questionnaires were in clinical range of concern either prior to or at the end of the study. The adolescent SPs rated their anxiety before the first simulation and towards the end of the study, with mean ratings of 3.5 and 1.2 respectively, on a 0-10 scale (‘0'-very relaxed; ‘10'-very anxious). Several significant themes emerged from the focus groups. The adolescents were somewhat concerned about the amount of risk taking of their characters. Once told that these were real-life scripts, all but one adolescent felt relief. The adolescents also expressed concern about giving feedback to the medical students while in character, as they were worried about being viewed as the actual risk-taking individuals. The protocol was subsequently changed, and the adolescents were allowed to give feedback out of their character role. The parents who were interviewed rated the experience as highly positive. There was no increased interest among the SPs in risk-taking behaviors as reported by the parents. All parents interviewed stated that they would allow their daughter to volunteer for this experience again.

Limitations: The sample size was small, and the researchers recruited high-performing, middle-class, female adolescents to participate in the study. Expanding the sample size, as well as recruiting male participants and adolescents from different socioeconomic and cultural backgrounds would have greatly enriched the study, and may have yielded entirely different results.

Implications: This research suggests that female adolescent standardized patients can be used in undergraduate medical training without any risk to the adolescent, and may be well worth the cost to institutions.

(Comment: This reminds me of the debates regarding condom use or even the HPV vaccine in adolescents. The study, like so many others, shows that teens can do the task without increasing risk taking behaviors. - Bill Raszka)