by George Pate and Libby Ricardo
The Journal of American Drama and Theatre
Volume 28, Number 2 (Spring 2016)
ISNN 2376-4236
©2016 by Martin E. Segal Theatre Center
In the Summer of 2010, the worlds of theater and medicine collided in Athens, Georgia. What was then known as the Georgia Health Sciences University and is now the Georgia Regents University (GRU), based two hours down the road in Augusta, was in the process of opening a new branch campus that fall in Athens attached to the University of Georgia (UGA). Dr. Stephen Goggans, the head of first-year clinical skills training, contacted Dr. David Z. Saltz, head of UGA’s Department of Theater and Film Studies, about creating a new training program for volunteers performing in simulated doctor-patient encounters as part of the first-year curriculum. These early meetings led to a collaboration which continues to this day and looks to continue to be profitable for both sides into the future. This essay will explain the nature of the collaboration and training and its implications for performance and actor training from the theater department’s perspective, particularly based on the experience of the authors. In narrating the brief history to date of this collaborative project, we hope not only to expose some of the potential issues in bringing together professionals from such disparate fields and suggest some possible solutions, but also to explore the practical applications of actor training and what these applications teach us about our methods.
Before getting further into the specifics of the training program at UGA and GRU, we need to take a moment to look at the history and variety of simulated and standardized patients and understand the differences between those two terms. The use of standardized patients began in 1963 at the University of Southern California, under the direction of Dr. Howard Barrows. In some of the earlier tests, doctors unknown to the students being tested played the patients. The doctors were used both for the sake of accuracy in portraying symptoms of the simulated ailment and to provide immediate and interactive assessment on the students’ perceptiveness and diagnostic abilities. This type of encounter persists in the form of simulated patients who serve as “secret shoppers” in real practices to research such issues as access to care.[1] The standardized patient eventually became a fixture in many medical schools, primarily as an assessment tool. The most prevalent of these tools, the OSCE, or Objective Structured Clinical Examination, was first designed to assess medical students’ clinical skills, and continues to be used today. Medical students-in-training go to a test site and engage in encounters with actors trained as standardized patients and are evaluated on their clinical skills such as communication, relationship building, and ability to extract information. In fact, many of the encounters for which we trained actors served as preparation for the OSCEs for the medical students in Athens. The primary concern of the OSCEs is the mechanics of a hypothetical and neutral encounter, testing skills such as the medical student’s ability to read a chart or take a history. Additional obstacles, such as a patient’s anxiety or frustration, are taken into account only rarely and even then in a rehearsed, predictable way. The fact is, however, that the difficulties faced by doctors come not only in the form of complicated diagnoses and faltering treatments but also in the interaction with the patient in crisis. While little might prepare a student for the reality of a genuinely sick individual, medical schools now promote clinical skills to help the transition from theoretical to concrete.
Traditionally, actors or volunteers who participate in the OSCEs or similar encounters have been known as standardized patients. Standardized patients follow a very specific script, often containing lines of dialogue and specific instructions on when to divulge certain information about the case. For example, a standardized patient may be instructed to mention their father’s heart condition the first time they are asked about family history, but only reveal their grandfather’s cancer if asked about family history a second time. Standardized patients are still used for evaluation at the OSCEs and for training at many medical schools all over the country, including GRU’s main campus in Augusta. Recently, however, some schools, such as GRU’s Athens branch, have been experimenting in a new and innovative kind of encounter by making the transition from standardized to simulated patients for the purposes of training. Unlike traditional standardized patients, simulated patients are not given a specific script. Instead, they receive all the details of a case including symptoms, medical history, patient’s education and socioeconomic status, and any other significant factors. Based on this information, they improvise their encounters with the medical students. Unless the case calls for a specific emotional challenge for the students, the simulated patients are encouraged to go with their own emotional response to the situation. Also, the simulated patients are encouraged to respond and react to the students as they would in a real doctor-patient encounter and to divulge information only as the medical students elicit it from them. In this way, simulated patients offer a higher level of fidelity to doctor-patient interaction than standardized patients offer. [2] While the use of standardized patients in the United States goes back to at least the 1960s, simulated patients represent a relatively recent development in medical training. Their rise can at least in part be attributed to recent research suggesting that clinical skills are not ancillary to medical care but in fact affect healing and recovery in measureable ways.[3]
High fidelity simulated patient encounters provide practice in performing empathy. In a standardized encounter, empathy is a moot point.[4] The medical student more or less knows the game and knows that the ability being tested is whether or not they know the right questions to ask, how to take a history, or when to press a patient for a particular piece of crucial information. Not unlike the SATs, success in the OSCEs depends at least as much on an understanding of how the test works as it does on knowledge of the material. A simulated patient encounter, on the other hand, innovates on this process by demanding of a medical student that they pay close attention to the emotional responses of their patients, which may develop in ways they cannot anticipate. In other words, the simulated encounter demands more empathy from doctors in training. Empathy is not a new concern for the medical profession. In his lecture to Harvard Medical students in 1925, Dr. Francis Peabody states:
The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients.[5]
Empathy is desirable not only in a holistic sense but also on a very practical level. A patient who trusts and respects their doctor as a human and confidant may be more likely to share crucial information and engage earnestly in discussions of treatment options, for example. Though the medical profession has long recognized the importance of instilling empathy in new doctors, the question of how to teach this skill persists. In “Medical Professionalism Crossing the Generational Divide,” Colin Walsh and Herbert T. Abelson address the overwhelming concern for the future of the profession:
But recent medical graduates also cannot assume that earning a degree means they know what they need to know about earning a patient’s trust and providing the best care, even when therapeutic options beyond palliative care have run out. In the next 50 years, this professional schism must be negotiated. If it is not, doctors in 2050 may actually be no more than technicians, as patients become increasingly more interested in “what the test shows” instead of what the doctor has to say.[6]
The doctor-patient relationship is inherently intimate, as the physician is charged with managing the physical well-being of his or her patient. This, however, must be coupled with the capacity for empathy. While it might seem like a small amendment, the use of the simulated patient from the onset of training forces the theoretical to become real. Physicians are never just dealing with hypothetical symptoms conveniently listed on a provided paper, but are rather constantly interacting with their patients. The simulated patient is a reminder, a harbinger, of what is to come post-graduation. And the medical students of GRU will be better prepared to face a patient and negotiate between their sometimes contradictory roles as scientist and caretaker.
Both standardized and simulated patient encounters offer several unique pedagogical advantages for students preparing for the medical profession. These advantages arise from the opportunities created by applying performance and acting training to the sciences. The acted scenario lives somewhere between the textbook and the clinic. Unlike other simulation modalities such as high-tech simulation mannequins, acting scenarios are flexible, adaptive, and provide a much broader range of feedback than simply correct or incorrect.[7] They also give instructors the opportunity to see what doctors might be like in action. In our experience, many students who excelled in the classroom struggled when confronted with real (or simulated) patients. Without the encounters, their professors may not have recognized that they needed extra help in that area. To help identify the areas where students need to improve, many encounters, including ours at GRU, ask the standardized or simulated patients to fill out a form on a computer in the encounter room to provide feedback about how the students made them feel.[8]
One of the major innovations that GRU is exploring in the longstanding practice of using simulated encounters is the stage at which these encounters are introduced into the curriculum. While many schools wait to introduce simulated encounters until the second year, GRU thought it necessary to integrate clinical skills acquisition as early as possible. Thus, simulated patients are used from the first semester on, not just as a means of assessment but also as a pedagogical tool. The use of the simulated patient early in the medical school curriculum emphasizes the importance of developing communicative skills necessary for the demands of the profession. Medical school is already notoriously demanding, yet academic prowess is not enough to fulfill the demands of a physician’s practice. The encounter offers real challenges in dealing with difficult social situations. The students were faced with an average of five encounters per semester in which they were expected to complete a range of tasks from something as routine as taking a patient’s history to something as challenging as delivering news of and taking responsibility for a botched procedure. Similarly, these encounters teach skills ranging from how to take a history to how to ethically approach difficult matters such as medical error, final directives, and confidential information.[9] The simulated patients were encouraged to behave as they would if they were in these situations in their own lives, bringing elements of emotional distress or physical discomfort to the room.
Community volunteers who were recruited the summer before school began were required to attend a training session. These individuals were not professional performers but rather retired members of the University of Georgia community ranging in age from around 60 to over 80.[10] They largely came to us through their connection with the University of Georgia’s chapter of the Osher Lifelong Learning Institute. While many served as ushers at the Performing Arts Center, they were admittedly more inclined to participate as audience than performers. Thus, we were confronted with a dilemma: how might we train simulated patients who lack knowledge of performance technique? After all, high fidelity encounters require the ability to respond to the given circumstances and allow emotion to evolve naturally. An impassive simulated patient would not challenge the students to empathize.
Ricardo, who handled most of the actual actor training, found terminology to be vital in that process. Rather than try to translate theater terms into lay language, she implored the community volunteers to become comfortable using vocabulary familiar to anyone trained in Stanislavski-based acting techniques, words such as objective, obstacle, and tactic. Much of the training, then, resembled a freshman-level acting class in most American universities. We also developed some specific uses for words particular to the activity of the encounter such as scenario and background. This shared vocabulary promoted a more successful encounter in a number of ways. For one, it made the volunteers feel like actors. By encouraging the use of particular words specifically applicable to their work as simulated patients, the volunteers were more likely to take the experience of the encounter seriously. In the beginning, many of the older members of our volunteer pool wished to connect with the young doctors to the point of breaking character and trying to comfort their students. Acting terminology was the key to solving this issue. When we asked them what their objective was in the first encounter, many of them eagerly responded that their objective was to help the medical students learn. After talking about the idea of the objective as what the characters wanted to get out of their scene partners rather than what the volunteers were trying to accomplish as actors, they were able to identify objectives that increased the level of fidelity in the encounters. Instead of needing to help the students learn, they needed to understand their test results or to seek redress for a costly error. It wasn’t the retiree in a room with a nervous first year medical student, but rather an anxious 65-year old office worker with heart palpitations interacting with a doctor.
By instituting our shared terminology, we were able to support encounters that would truly test the medical students. By keeping our conversations rooted in acting rather than medical or pedagogical vocabulary, we were able to move past the initial problems caused when our volunteers began training by asking what the medical students were supposed to learn in any given encounter. We expanded beyond objectives and added other concepts such as obstacles. What happens when the doctor does something that decreases the possibility of getting what you need or want? These terms placed emphasis on the needs of the patient character rather than the aid of the student. Obviously no simulated patient wanted to see a student fail; however, by attempting to help, they were in fact hindering their potential progress.
Finally, using acting vocabulary helped to advocate more convincing emotional response, as opposed to forced or contrived reactions. As with any other actor we might coach, we never spoke of playing sad or playing frustrated. Rather, we encouraged the community volunteers to be diligent in creating a complete character. We implored each to create a backstory based on the medical history given in the encounter but also enriched with invented details distinct from their own experience and fueled by their imaginations. This fullness of character development helped to instigate or trigger particular emotional responses while also giving the volunteers a sense of ownership over the characters they created, thus heightening their stakes in the encounter. One of the cases detailed a medical error involving a missing blood test. The circumstances were that the test would indicate whether or not the patient had a cholesterol problem. Many volunteers asked for tips on how to “play mad.” We encouraged them instead to rely on the concepts of objective, obstacle, and backstory. We asked them to imagine that their character’s family history showed many heart problems. We also asked them to think of the hassle of going to the doctor, and even encouraged them to create a scenario that they were either unable to get to an appointment on their own and thus had to burden a loved one for a ride or that they had to travel a great deal of time to get to the office. By placing these seeds of thought in the mind of the volunteer, we never had to prompt visible frustration and annoyance; it sprouted organically within the encounter. Thus, the medical student was faced with a more realistic and devastating scenario, an unhappy customer.
We found that different situations called for exercises drawn from various acting theories. Exercises based on Sanford Meisner’s work were used earlier in the training to instill a sense of dependence on the partner, or in this case, the medical student.[11] It is important that the simulated patient be able to read and respond to the student, and that these reactions are organic. Ricardo also speaks frequently about Konstantin Stanislavski’s magic if, entreating the community volunteers to consider what they might do if they were in the same situation specified by a case. Being that we work with predominantly older simulated patients, we sometimes adopt affective memory for our work.[12] In the case involving medical error, many of the patients were able to relate the irritating scenario to one that they had actually suffered themselves. This helped to bolster the reality of the encounter and imbued the case with a greater sense of import.
In the Spring of 2011, Ricardo began to work not only with the community volunteers, but also a group of upper level undergraduates from the Department of Theater and Film Studies. The thirteen students admitted to the course had taken pre-requisite acting courses, and thus entered the training with a greater knowledge of acting methodology. The primary obstacle with the theater students was encouraging them to allow more introverted characters to evolve. Working in simulations is significantly different then stage work, as the audience is hardly visible. It is an improvisation with a partner whose stakes are very different than the actor’s.
Working with a younger demographic posed a variety of new obstacles for the medical students. Before the semester began, we met with Dr. Stephen Goggans, the head of first year clinical skills, to discuss what might be accomplished with the new simulated patients. While we toyed with various possibilities, it became clear that a group of theater students in their early twenties would create an entirely different encounter than the retirees did. While some cases were difficult to alter, there was a strong attempt to fit the case to the age group. Both sides of the collaboration wanted the event to benefit everyone involved, meaning that the medical students should gain an understanding of working with a younger demographic, while the acting students should be challenged and learn from the encounters.
The process of preparing our students for the role of simulated patient was slightly more comprehensive than the work with the community volunteers. For one thing, the cases assigned to the acting students were more complex, generally speaking, some anticipating extreme emotional response. For example, the first case of the semester dealt with alcohol abuse. The medical students not only had to identify the problem but also confront the simulated patient about his or her self-abusive behavior. While many of my students created characters that tended to be contentious, a number chose rather to play an individual humbled and shamed by the confrontation. In fact, one of my students was brought to tears, and in this moment, the medical student seemed uneasy and unsure of how to proceed. This creation of character served as an important example to the medical students. Patients can be combative at times, but they can also tend toward introversion and somberness. A doctor must relate to all patients, despite disease or demeanor.
Finally, we turn to the question of the benefits of this kind of training program and of simulated patients in general. Obviously, there are advantages and disadvantages to both the simulated and standardized patient approaches. Standardized patient encounters are more consistent and predictable. This makes them a good choice for assessment tools such as the OSCEs as their consistency makes creating standards for evaluation easier. However, the lack of flexibility also potentially allows medical students to behave in a rote manner without actually engaging with the patient. Simulated patients lead to a much less predictable but, ideally, higher fidelity experience. As a pedagogical tool, simulated patients force students to learn to adjust to changing situations. Though the unpredictability of these encounters creates certain risks, the benefits of being able to simulate high-stakes emotional situations with no chance of harming a patient seeking care more than compensates.
On the other hand, one drawback of the simulated patient encounter is that, because of its flexibility, assessing it is much harder than in the case of standardized patient encounters where medical students’ responses are either correct or not according to a script and a rubric. This conflict between testing and training has been one of the biggest obstacles and also the most exciting grounds for discussion in collaboratively developing the training program. This conflict has centered around trying to negotiate the meaning of “failure” and its potential uses within the clinical skills curriculum. In an assessment situation such as the OSCEs, standardized patients are useful because any deviation from their scripts becomes a sign of failure, or at least shortcoming, on the part of the doctor. Going in to the project, we on the theatrical side were excited about the potential for encounters to “go wrong,” to veer off the planned and predictable course. Our excitement was born out of no ill will towards the doctors-in-training. In fact, we believed that building in the potential for the situation to fall completely out of their control was one of the key ways in which we could help train them more effectively with simulated rather than standardized patients. After all, if you build a flight simulator programmed never to crash, you are not doing future pilots any favors or really teaching them anything at all. This is also not to say that all failures are created equally. Early on in the training program, we had a number of situations in which the medical students were uncomfortable with a patient’s emotional reactions or not perceptive of physical and verbal cues to the point that they could not elicit the information they needed. This is the kind of “failure” we like to see. In training simulated patients to react to their medical students fluidly rather than simply following a script, we put more pressure on the students to really engage with their patients, to be aware of their mental and emotional states, and to develop multiple strategies for building trust with and gaining access to patients. Initially, some doctors from the medical school had difficulty with the fluidity of these encounters. They wanted our patients to stay on script so that they could tell whether or not their students were behaving “appropriately” or according to their own scripts. A specific example from early in the development process illustrates the complexity of the failure issue. In an early round of encounters, one community volunteer was given a situation in which the doctor was telling him to limit his physical activity, advice that would have kept his character from work, a situation he could not afford. His response was, based on the training he had received, fluid, justifiable, and realistic. He became quite agitated and demanded answers from the flustered young medical student, who, in turn, could not come up with a good response. After the encounter, the student was very upset, even to the point of tears. We on the theatre side at first considered it a great success. It was honest, unpredictable, and effectively simulated the kind of situations these medical students might face with upset patients. The doctors were initially less enthusiastic because, where we saw exciting flexibility, they saw our setting up their students to fail. And, to an extent, they had a point. While that situation may have been realistic and educational, it was perhaps too much for a first-year medical student’s second encounter. Moving forward, we have become aware of the importance of balancing our desire for realism in the encounters with the more local pedagogical needs of each particular scenario.
Recently, the relationship between our departments has shown promise of developing in areas other than simulated patient training as well. The issues of empathy and communication in the medical profession are not limited to doctor-patient relationships. On July 11, 2011, The New York Times published an article entitled “New for Aspiring Doctors, the People Skills Test,” which chronicled the efforts of Virginia Tech Carillion to incorporate an assessment of the medical school candidate’s social skills. The school, however, seems less invested in improved bedside manner and more concerned with a student’s ability to interact with other medical professionals. While the ability to communicate successfully with colleagues is imperative, a doctor must also have the aptitude to relate to his or her patient one on one. Some may inherently have this skill set, but we believe that it might also be acquired through training and practice. While the article at least suggests that Virginia Tech Carillion is aware of the lack of social skills and empathy some of its students show in their medical practice, it offers no signs that they are being trained in these skills. Again, while simulation has long been used in medical and forensic as well as other fields as a means of testing or preparation for real-world scenarios, we believe that the kind of acting training we employed at GRU participates in an innovative push to actually train professionals in empathy as a skill. With this in mind, we decided to take our acting skills directly to the medical students, and engaged them in a day of workshops and improvisations designed to lay bare and begin to correct issues in their communication skills that might prevent them from fully engaging with their patients. One exercise we had them do, for example, dealt with the concept of high context versus low context. In this exercise, we had them tell the group about something they knew very well other than medicine as though they were addressing other insiders to that knowledge, and then tell the same information as though they were telling a sibling or friend who had little to no knowledge about the subject. One medical student described a round of Dungeons and Dragons. In the second telling, he occasionally found it very difficult to proceed without the use of some jargon. We discussed how these difficulties were similar to the challenge of respectfully and exhaustively informing patients without being condescending.
Of course, we are not the first to suggest using skills traditionally found in humanities classrooms to help improve medical students’ clinical skills. Delese Wear and Lois LaCivita Nixon, co-authors of “Literary Inquiry and Professional Development in Medicine Against Abstractions” argue that literature, rather than simple abstracts of illnesses, would foster a greater understanding of professional development within medical trainees because students would be forced to acknowledge emotions and responses the detailed descriptions might invoke:
Our approach is grounded in medical narratives written by physicians — memoirs, essays, and poetry — as they grapple with the daily challenges of medicine that involve altruism, duty, excellence, honor and integrity, accountability, and respect for others. Arising from the literary domains, these narratives suggest responses without dictating them, urge behaviors without ordering them, illuminate values without oversimplifying them, and in general complicate the matters rather than clarifying or confirming them.[13]
While Wear and Nixon recognize the necessity for medical students to relate to the plights of both patients and fellow practitioners, it disregards the need for the fictional to become reality. A medical student must acknowledge a patient not just as a case, but something living, then navigate the difficulties of interacting with this real person. Wear and Nixon suggest that medical students read poems such as Allen Ginsberg’s “Line Drive” and Marc Straus’s “The Pause” to relate the importance of altruism within the profession. Unfortunately, these poems romanticize the duty of the doctor, and, while they may acknowledge the difficulty of the situation, a reader remains removed, the experience second hand, unlike the immediacy of an actual encounter. This is not, of course, to dismiss Wear and Nixon’s approach, but to suggest that improvisatory acting situations may offer a greater immediacy and a wider range of possible responses than a poem or story can. When a hasty move to immediate contact with a real patient would be detrimental to both parties, the use of simulation has emerged as a means of teaching clinical skills to medical students. The simulated or standardized patient is an individual who performs “the patient” in order to give medical students an opportunity to interact with a real human being. Whereas literature and art might help medical students better understand empathy as a concept, simulated patient encounters give medical students actual practice in performing empathy, in doing the act of empathizing.
Our work with simulation has expanded beyond the medical community as well. While we were both still graduate students at the University of Georgia, some faculty in Social Work heard about our simulations and approached us to work on scenarios with their students as well. In the field of social work, the actors are known as simulated or surrogate clients (SCs).[14] Recently SCs have been used in social work to assess and improve the preparedness of future social workers for a variety of situations. One study used SCs to simulate encounters with families of veterans struggling with mental illness leading to domestic violence, finding that the encounters helped social workers learn the signs that might identify when real world clients might pose a “risk of harm to others … or to self.”[15] And another recent study found that “the best measure of students’ competence… is in their ability to effectively perform the core functions of the profession in practice situations.”[16] As in the medical field, social work educators use simulations both for training and assessment. In our case, we trained some of our actors to portray a family working through the kinds of domestic issues social workers regularly encounter. We both now teach at the University of South Carolina at Beaufort, where we are working with our nursing program to develop simulated encounters for their students—encounters ranging from simple clinical intake to mental health and alcohol withdrawal.[17] Because nurses are often the frontlines of patient interaction, simulations may have even greater potential application in nursing education than in training doctors, helping teach skills that improve the focus on “patient-centerdness in… nurse-patient interactions.” [18] In all of these encounters, we are guided by the large body of research on simulated patients and simulated clients from the fields of medicine and social work, our experiences and failures, and our deep belief that acting provides unparalleled opportunities for imparting interpersonal skills to professionals in service fields with a clinical component.
The medical students’ response to these encounters evolved over the course of that first year. Initially, many students were skeptical of the encounters, fearing that they might lose precious time to study important medical, biological, or anatomical topics. However, as the encounters increased in complexity, the students became increasingly grateful and enthusiastic as they realized the range of clinical situations for which they were not prepared. The angry patient mentioned earlier, for example, initially shook that medical student’s confidence. Later, however, she expressed her gratitude, saying that she now felt more prepared to deal with an actual patient who was hostile in a real world setting. At a reception at the end of the year, this same student was one of several who spoke to express their enthusiasm for the program and the value of the simulations, saying they felt more prepared in general to deal with a wide range of patients. Of course, these informal responses do not prove the efficacy of the simulated patient program, but they suggest promise in terms of improving medical students’ interpersonal skills.
George Pate is a playwright, actor, standup comedian, director, and teacher who currently serves as Assistant Professor in Drama and Theatre at the University of South Carolina at Beaufort. His plays have been produced and read in New York, NY, New Orleans, LA, Columbia, SC, Greenville, SC, Charelston, SC, and Athens, GA. He won the 2008 Tennessee Williams National One-Act Playwriting contest for his play Indifferent Blue, now available from Next Stage Press. He was also a regional finalist for Comedy Central’s Open Mic Fight. In addition to his creative work, he has published works of scholarship in The Journal of Dramatic Theory and Criticism, Theatre Symposium, and Theatre Journal.
Libby Ricardo is an Assistant Professor in the Department of English, Theater, and Liberal Studies at the University of South Carolina at Beaufort. Libby has worked professionally as an actor and director in Rhode Island, New York, Georgia and South Carolina. She has won multiple South Carolina Broadway World awards, including Best Director and Best Production, for her productions of Grease and Little Shop of Horrors with the Beaufort Theater Company. In addition to maintaining an active professional life as an actor and director, Libby’s research interests include practical applications of theater skills and ensemble-based pedagogy.
[1] See Karin V. Rhodes and Franklin G. Miller, “Simulated Patient Studies: An Ethical Analysis,” The Milbank Quarterly 90, no. 4 (2012): 706-724.
[2] The medical literature uses “fidelity” to refer to the extent to which a simulation reproduces the conditions of a clinical encounter with an actual patient in an active practice setting. There are examples of this usage in almost every article from nursing and medical journals cited here. All simulation-based training starts from the precept that skills are transferrable. Much of the medical literature articulates this precept in terms of simulation-based training in other fields such as aviation or the service industry. For us, however, coming from a theater and performance studies background, this precept has resonated with concepts such as performativity and the possibility of enacting felicitous speech acts in constructed contexts. In fact the latter concept proved especially useful in recognizing that even the “real world” clinical encounter is nothing more than a constructed context with its own rules for speech acts and their felicity. Learning to perform those speech acts in the simulation, then, was not a case of trying to faithfully recreate a fictional version of a scenario, but of practicing the rules of a particular “game” of speech acts. We use “fidelity,” then, not only in the sense that the medical literature uses it to mean degree of adherence to “real” situations but also to suggest that the “real” encounters and the simulations actually operate under the same rules. A high degree of fidelity, then, simply means that the felicity conditions in the simulation and in the “real” situation are largely the same. Pate has explored the nature of speech acts under different “game” conventions in “‘This is a Real Gun’: 500 Clown and Speech Act Theory,” Journal of Dramatic Theory and Criticism 27, no. 2 (2013): 31-41.
[3] One recent study offered patients suffering irritable bowel syndrome acupuncture treatments. The treatments themselves, unbeknownst to the patients, were not based on actual acupuncture practices but were harmless. The patients who received the treatments from warm and empathetic practitioners showed much higher rates of improvement than those who received treatments from practitioners they believed to be competent but cold and distant. The practitioner’s clinical skills had a measurable outcome on the patients’ recovery. John M. Kelley et al. “Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome.” Psychosomatic Medicine 71, no. 7 (2009): 789.
[4] Recent research even suggests that the iterability and consistency that encounters such as the OSCE strive for may be impossible because of the subjectivity of both the student and the standardized patient. Johnston et. al. found strong evidence for the “unfeasibility of the absolute objectivity or standardization” of the OSCEs. Jennifer L. Johnston, Gerard Lundy, Melissa McCullough, and Gerard J. Gormley, “The View from Over There: Reframing the OSCE through the Experience of Standardized Patient Raters,” Medical Education 47 (2013): 899-909.
[5] F.W. Peabody, “The Care of the Patient,” JAMA 88. (Original address delivered in 1925).
[6] Herbert T Abelson and Colin Walsh, “Medical Professionalism Crossing a Generational Divide,” Perspectives in Biology and Medicine 51, no. 4 (2008): 560.
[7] See Stephanie Sideras, Glensie McKenzie, Joanne Noone, Donna Markle, Michelle Frazier, and Maggie Sullivan, “Making Simulation Come Alive: Standardized Patients in Undergraduate Nursing Education,” Nursing Education Perspectives 34, no. 6 (2013): 421-25; and Rebecca D. Wilson, James D. Klein, and Debra Hagler, “Computer-Based or Human Patient Simulation-Based Case Analysis: Which Works Better for Teaching Diagnostic Reasoning Skills?” Nursing Education Perspectives 35, no. 1 (2014): 14-18.
[8] See Tonya Rutherford-Hemming and Judith A. Jennrich, “Using Standardized Patients to Strengthen Nurse Practitioner Competency in the Clinical Setting,” Nursing Education Perspectives 34, no. 2 (2013): 118-121.
[9] For a deeper discussion of the concept of using simulated patientsto teach medical ethics, see Carine Layat Burn, Samia A. Hurst, Marinette Ummel, Bernard Cerutti, and Anne Baroffio, “Telling the Truth: Medical Student’s Progress with an Ethical Skill,” Medical Teacher 36 (2014): 251-259.
[10] We initially made much of the volunteers’ age, thinking that working with an older segment of the population would significantly impact the way the medical students interacted in the simulations. Recent studies suggest that we may have underestimated students’ abilities to treat all patients equally. One study recently showed that medical students showed no significant differences between their interactions with female simulated patients with “normal” or “obese” Body Mass Indexes. The study found that “the body habitus of the [patient] did not significantly affect students’ performance” and that the students gave “advice about healthy diets” equally to both groups. Vanda Yazbeck-Karam, Sola Aoun Bahous, Wissam Faour, Maya Khairallah, and Nadia Asmar, “Influence of Standardized Patient Body Habitus on Undergraduate Student Performance in an Objective Structured Clinical Examination,” Medical Teacher 36 (2014): 240-244.
[11] Sanford Meisner and Dennis Longwell, Sanford Meisner on Acting (New York: Vintage Books, 1987).
[12] Konstantin Stanislavski, An Actor Prepares (New York: Routledge, 2013).
[13] Lois LaCivita Nixon and Delese Wear, “Literary Inquiry and Professional Development in Medicine Against Abstractions,” Perspectives in Biology and Medicine 45 no. 1 (2002): 106.
[14] See Mary Ann Forgey, Lee Badger, Tracey Gilbert, and Johna Hansen, “Using Standardized Clients to Train Social Workers in Intimate Partner Violence Assessment,” Journal of Social Work Education 49 (2013): 292-306.
[15] Ibid., 304.
[16] Carmen Logie, Marion Bogo, Cheryl Regehr, and Glenn Regehr, “A Critical Appraisal of the Use of Standardized Client Simulations in Social Work Education,” Journal of Social Work Education 49 (2013): 66.
[17] Using simulated patients to train nursing students to deal with patients with mental health issues is a new approach, the outcomes of which remain questionable. One recent study showed little statistical significance in performance between students who did and those who did not undergo simulations. The exception, however, was students who had been previously identified as “at-risk” or needing additional help and experience. The results of these students show promise for using mental health simulations as a kind of remediation in certain cases. Kirstyn M. Kameg, Nadine Cozzo Englert, Valerie M. Howard, and Katherine J. Perozzi, “Fusion of Psychiatric and Medical High Fidelity Patient Simulation Scenarios: Effect on Nursing Student Knowledge, Retention of Knowledge, and Perception,” Issues in Mental Health Nursing 34 (2013): 892-900. See also Theresa M. Fay-Hillier, Roseann V. Regan, Mary Gallagher Gordon, “Communication and Patient Safety in Simulation for Mental Health Nursing Education,” Issues in Mental Health Nursing 33 (2012): 718-26; and Louise Alexander and Amy Dearsley, “Using Standardized Patients in an Undergraduate Mental Health Simulation: A Pilot Study,” International Journal of Mental Health 42 (2013): 149-64.
[18] Sally O’Hagan, Elizabeth Manias, Catherine Elder, John Pill, Robyn Woodward-Kron, Tim McNamara, Gillain Webb, and Geoff McColl, “What Counts as Effective Communication in Nursing? Evidence from Nurse Educators’ and Clinicians’ Feedback on Nurse Interactions with Simulated Patients,” Journal of Advanced Nursing 70 (2014): 1344-56.
“Playing Sick: Training Actors for High Fidelity Simulated Patient Encounters” by George Pate and Libby Ricardo
ISNN 2376-4236
The Journal of American Drama and Theatre
Volume 28, Number 2 (Spring 2016)
©2016 by Martin E. Segal Theatre Center
Editorial Board:
Co-Editors: Naomi J. Stubbs and James F. Wilson
Advisory Editor: David Savran
Founding Editors: Vera Mowry Roberts and Walter Meserve
Editorial Staff:
Managing Editor: James Armstrong
Editorial Assistant: Kyueun Kim
Advisory Board:
Michael Y. Bennett
Kevin Byrne
Bill Demastes
Jorge Huerta
Amy E. Hughes
Esther Kim Lee
Kim Marra
Beth Osborne
Jordan Schildcrout
Robert Vorlicky
Maurya Wickstrom
Stacy Wolf
Table of Contents:
- “This In-Between Life: Disability, Trans-Corporeality, and Radioactive Half-Life in D. W. Gregory’s Radium Girls” by Bradley Stephenson
- “Moonwalking with Laurie Anderson: The Implicit Feminism of The End of the Moon” by Vivian Appler
- “iDream: Addressing the Gender Imbalance in STEM through Research-Informed Theatre for Social Change” by Eileen Trauth, Karen Keifer-Boyd and Suzanne Trauth
- “Setting the Stage for Science Communication: Improvisation in an Undergraduate Life Science Curriculum” by Cindy L. Duckert and Elizabeth A. De Stasio
- “Playing Sick: Training Actors for High Fidelity Simulated Patient Encounters” by George Pate and Libby Ricardo
www.jadtjournal.org
jadt@gc.cuny.edu
Martin E. Segal Theatre Center:
Frank Hentschker, Executive Director
Marvin Carlson, Director of Publications
Rebecca Sheahan, Managing Director
©2016 by Martin E. Segal Theatre Center
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