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Standardized patients take control of our students The simulation game:  An analysis of interactions between students and simulated patients. De la Croix A et al.  Medical Education 2013; 47: 49-58.


Reviewed by Patricia McBurney

What was the study question?
How realistic are simulated encounters?  How do the interactions between the student doctor and standardized patients (SPs) differ from interactions between physicians and patients? 

How was the study done?
At Birmingham Medical School, the authors reviewed 100 video-recorded conversations between third-year medical students and SPs.  These conversations were selected through a process of stratified sampling (based on scenario, gender, grade).   The transcriptions were qualitatively analyzed.  The conversations were analyzed for 1) controlling the flow (eg asking more questions) 2) managing the fringes of conversation (opening and closing) and taking the floor (eg talking more).

What were the results?
SPs are conversationally dominant over the students.   SPs asked more direct questions and are more likely to initiate topics than the students.   SPs do not tend to follow topics initiated by students.  Students tend to have control in opening the conversation but not in closing it.  Students are likely to follow topics initiated by the SPs and to seek permission to close the conversation.

What are the implications of the study?
Preceptors must be aware of the theatrics in simulation.   In truth, SPs must have sufficient control over encounters or the standardization is lost.   The authors propose that these encounters can be realistic enough for educational purposes. Further, the artificial nature can be used to an advantage.  Students must demonstrate their skills in challenging situations of not having control.  These encounters offer opportunities for creativity:  starting and stopping the interviews to allow participation by others, comparing between students, and acting out the role of a doctor with poor skills.  We are only beginning to understand how to use simulated encounters for testing. Training in language microanalysis will yield better understanding of human interactions.

Editor’s note:  This article reinforced the importance of observing my students interacting with real patients and their real families in order to assess their communication skills in a variety of situations.  While I will still design OSCE stations that include SPs, these stations will never replace the real world of communicating with our patients (SLB).

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