The effect of characterisation training on the congruence of standardised patient portrayal
1 Skills Centre, Faculty of Health Sciences, University of Limpopo (Medunsa Campus), Pretoria, South Africa
2 Department of Family Medicine, University of the Witwatersrand, Johannesburg, South Africa
of Medicine, Faculty of Health Sciences, University of Limpopo
(Medunsa Campus), Pretoria, South Africa
Background. Incongruence of standardised patient (SP) portrayals is worsened when SPs are given basic scenarios and too little background information on short notice. Consequently, SPs are confronted with questions they find difficult to answer owing to a lack of insight, internalisation and association with the role.
Objective. To determine whether training in characterisation enhances the congruence of SP portrayals.
Methods. SP encounters were recorded, after which the participating SPs and students reflected on the congruence of the SPs’ performances. The researchers analysed the videorecordings and reflections for incongruent behaviours. The findings were triangulated and themes of incongruency were established. The intervention comprised training of SPs in the creation of subtext (the story behind the story), characterisation, and linking to and making use of emotion memory, with the aim of rectifying the observed incongruent behaviours. Pre-training activities were repeated with Cohort 2 students.
Results. Two themes depicting congruence, i.e. internalisation of character and congruence of verbal and non-verbal communication, were identified. Post-training outcomes revealed an improvement in all subthemes. Applicable and real emotions, complementing verbal and non-verbal cues, gestures and appropriate use of voice and facial expression, led to believable/congruent role play and improved communication on various levels.
Conclusion. The post-training
outcomes showed clear improvement regarding the congruence of SP
portrayals. The changes can be contributed to SP training
focused on 3D character development by creating subtext,
providing basic clinical information, emotion memory, acting
skills, managing energy levels, and not focusing on the scenario
Dr Howard Barrows developed the standardised patient (SP) methodology in 1963 and questioned whether SP training is thorough, particularly with regard to history taking. Insufficient training can lead SPs to intellectualise their role playing, rather than become the characters they are playing. In such cases the portrayal of the characters comes across as too memorised, with little transmitted energy and little or no congruence regarding the character.1
Congruence of patient portrayals
Congruence is the state of agreement, harmony, conformity, or correspondence, taking all aspects of patient portrayals into consideration.2 It also involves the practice of personalising perception, critical thinking and creative management of multiple realities as behavioural congruence. It is the concept of being real – not playing a role – and being free from pretence.3 All of the above are relevant to SP portrayals.
It became clear that congruent character development with
regard to SPs was necessary to identify and rectify the
abovementioned challenges. More specifically, the development of
three-dimensional (3D) characters became essential. This was
achieved by empowering SPs with adequate information and
knowledge, which led to true standardisation of patient
Local context and background
At the Medunsa campus of the University of Limpopo, South Africa, SPs have been used for 12 years in the Family Medicine and Primary Healthcare training blocks during summative assessments. To protect the confidentiality of the content, the SPs were issued with written case scenarios immediately prior to the start of an assessment and given approximately 1 hour to prepare. This strategy gave rise to the following problems:
• Because of lack of time for proper training, the interpretation of how a patient would normally portray an illness was often stereotyped and/or unclear. This caused confusion between the student, the SP and the examiner.
• The cues and subtexts of case studies were not sufficiently exhaustive/explicit, and SPs were frequently confronted with questions they had not been prepared for.
• Lack of appropriate and timely cues provided to facilitate conversation.
• Insufficient time for SPs to internalise
the characters and scenarios, resulting in incongruence
regarding the verbal and non-verbal communication of the
character in relation to the clinical or psychosocial
condition. Observing a facial expression while hearing a
different emotion manifests as behavioural conflict
interferes with the believability of the portrayal.
The abovementioned problems contributed to incongruence of SPs’
portrayal of patients.
The aims of the study were to identify behavioural patterns
depicting incongruency during SP portrayals, to train SPs in
rectifying incongruent portrayals and then to determine the
effect of the training.
A qualitative design was used to gather data on the congruency of SP portrayals through observations and reflections by students, researchers and SPs during objective structured clinical examinations (OSCEs) before and after an SP training session. Medunsa’s Research and Ethics Committee (MREC) approved the study protocol and informed consent was obtained from students and SPs.
The convenience student sample comprised two cohorts of
6th-year medical students (N=43)
performing their end-of-block OSCEs in Family Medicine. The SP
sample included the four junior SPs who participated in both
Reflections prior to training SPs in characterisation
SP encounters with Cohort 1 students during OSCE 1 were
videorecorded. On completion of the OSCE, students and SPs
reflected separately on the incongruence/congruence of the SP
performances and videos were analysed by the four researchers.
The reflections of the participants were guided by questions and
the discussions were audiorecorded.
Data analysis before training
Qualitative content analysis was done according to the steps described by Creswell.4 The four researchers made summative notes of the videorecorded verbal and non-verbal communication that they regarded as incongruent. Interpretive validity was enhanced by summarising each individual researcher’s documented and interpreted observations and personal experiences. These notes were compared and discussed among the other researchers until consensus was reached on the characteristics of incongruent/congruent SP portrayals observed. The audiotaped focus group discussions of the students and SPs were analysed similarly.
Corresponding information on characteristics of incongruence obtained from the three sources was grouped in categories, and then organised in themes. Validity and synchronic reliability of the study were achieved by using these multiple sources of information (triangulation) (Fig. 1).5
Fig. 1. Triangulation of data (SPs = standardised patients).
Training of SPs
The intervention comprised a 1-day workshop aimed at transforming the incongruent behaviour of SPs identified during OSCE 1. The training focused on various aspects of creating a believable person behind the patient by finding the subtext relating to the specific scenarios (resulting in 3D character development and energy level management). To enhance their understanding, SPs were given information on the pathology of the disease afflicting the ‘patient’.
Training also comprised updating basic acting skills
(imagination, listening, emotional expression, use of voice,
body movements) to enhance the congruence of their verbal and
non-verbal communication. To facilitate SPs to relate to
emotions, improvisation exercises were incorporated in the
Post-training reflections and data analysis
A similar content analysis was performed on post-training
observations and reflections on SP portrayals at OSCE 2 using
the same scenarios with Cohort 2 students.
Reflections before training SPs in characterisation
Two themes of congruence and characteristics of congruent
behaviours emerged from the data obtained prior to the training
of SPs (Table 1).
Theme 1 (pre-training). The SPs experienced problems in internalising the patient’s character.
Student participants’ observations are summarised as SPs being robotic, hesitant and inconsistent, appearing bored and tired:
‘He’s not answering your question … he has a fixed answer. Give him a context of who his patient is … ’
‘ … it was very robotic but I understand why because they are given a set number of parameters that we are supposed to elicit … ’
‘ … only a small portion of patients are going to be hesitant like that … ’
SPs reflected that they feared self-expression, were inconsistent and became tired:
‘I faked emotions and that made me tired.’
The researchers observed that the SPs lacked confidence, were inconsistent and struggled to concentrate.
Theme 2 (pre-training). The SPs’ portrayals lacked congruence of verbal and non-verbal communication at times.
Student participants observed the following incongruencies:
‘ ... the confusion was the body language … he looked “cheery” ... he said he was concerned … but he didn’t show it … ’
‘ … he didn’t look like it (fears) bothered him … ’
SPs acknowledged that they forgot to show symptoms:
‘ … I forgot to show the emotion of pain.’
The researchers found the facial expressions inadequate.
Reflections following training
Observations of the SPs’ portrayals in OSCE 2 reflected
improvement regarding the characteristics of congruence (Table
Theme 1 (post-training). Problems in internalising the patient’s character.
Students reflected that SPs were believable and trustworthy:
‘ … very real … sincere … like a real patient … believable.’
‘ … she was staying in her role … giving what you were asking for … did not offer information … until a person comes and explores … that’s what people would do … ’
SPs reflected that they understood the role, felt confident and could pace their energy:
‘ … we know you said we must go there and do whatever we were taught during the workshop … then we did exactly that so the doctors (assessors) were so impressed.’
‘ ... like in the past I was trying to force those fake emotions. I was really getting tired … today from start to finish my energy levels were so high.’
The researchers observed that the SPs managed the information well and their portrayals were consistent. Their energy levels improved and were maintained.
Theme 2 (post-training). Incongruence of verbal and non-verbal communication.
Students observed that the symptoms portrayed made sense and that the emotional reactions complemented the verbal cues:
‘ … whenever she talked about a hysterectomy she’d take a deep breath … and then talk about it … she really doesn’t want the hysterectomy because [of] her ideas behind it … ’
‘ … her voice tone changed when she spoke … her body and voice were corresponding … you could see that she was really worried … ’
The SPs felt they were able to portray real emotions:
‘ … what really helped me to show my emotions was the advice that you gave us from the workshop that I have to think of something that makes me like worry so that I need not fake my emotion … ’
‘ … before the workshop I was constantly smiling, you know even if I had a problem. Today I played a very sad patient … ’
The researchers found the SPs’ gestures appropriate, reflecting the change of voice and expressing emotions were applicable.
An unexpected finding was that examiner manipulation of the context and unclear scenario outcomes pose additional threats to congruence:
‘The assessor expects me to do what he wants me to do and
that’s a bit difficult … he stopped the assessment and he wants
to implement his thoughts on you … you must be consistent … ’
The insufficient 1-hour SP preparation time prior to OSCE 1, as
well as the repeat of the simulations 6 weeks later, may have
had an influence on the improvement in SP performance and
character portrayal in OSCE 2.
The effect of training was measured by comparing post- with pre-training outcomes relating to characteristics of congruence, as reflected in the corresponding lines in Tables 1 and 2.
Incongruent behaviours changed to congruent behaviours:
• SPs who lacked confidence and acted robotically became believable and managed the role well owing to better understanding.
• Hesitant and inconsistent behaviours changed to consistent portrayals executed with confidence.
• Low energy levels and problems with
concentration changed to increased and maintained energy levels.
Having to remember details regarding the scenario will inevitably hamper the flow of communication and affect congruence. SPs should be trained to focus with concentration and energy during the consultation and not try to remember the case scenario. They will then be able to focus on the student and interact spontaneously as the communication/consultation progresses.6
As far as possible, SP encounters must be true and not different to the experience of a real patient.7 For SPs to be more congruent, they need to know and give life to the person behind the patient. Portraying a patient is therefore more than repeating a given case scenario; it is about penetrating patients’ psyches, i.e. their emotional and psychological make-up. At the very least, SPs need to understand the needs, expectations and fears of a patient, as well as the biopsychosocial implications of their condition, to portray a congruent and believable patient. This should be explicitly defined in training materials.6 , 7
Subtext includes unspoken thoughts and motives of characters (what they really think and believe) and adds a third dimension to the character in the scenario. SPs should be able to portray their symptoms with real emotions, incorporating hidden fears, hopes, beliefs and reactions to interventions. Subtext therefore enables SPs to supply additional circumstances to the character’s background and encourages them to ‘flesh out’ the role.8 , 9 What happens beneath the surface of dialogue is what makes the performance exciting.10
Incongruence of verbal and non-verbal communication changed to revealing real emotions that complement verbal cues, appropriate gestures and voice use, which led to improved communication on various levels.
Once the subtext, which focuses on gesture, intonation, and expression, has been defined and the SPs can adopt the patient’s character, their non-verbal signs should become congruent with those of the character. Consequently, the student will be able to ‘hear’ what the SP is not telling them, but what has been ‘shown’ through non-verbal communication. This will keep the energy flowing and the consultation alive and true to a real patient encounter in healthcare. Non-verbal modes of experience such as bodily responses are factors that enable an observer to become more aware of the unconscious affective component of emotional resonance and provide information enabling further cognitive processing.11 Awareness of bodily responses should therefore be facilitated as non-verbal aspects of experience. This enables the SP to portray a role as alive and real, which makes it effective.9
SPs’ spontaneity will be enhanced if they are able to identify with their own inner feelings and have the courage to allow these real feelings to manifest naturally. This will result in a more congruent character.6 For example: pain is an internal physical sensation, accompanied by an emotional response made known in an external manifestation. It could entail the inability to move normally, the experience of body tension, the protection of the location where the pain is most intense, facial expressions, vocalisations, manner of speaking, tone, etc. Only a suitably trained SP can remind the student that handling an affected limb carelessly worsens the pain.9
Although this study examined the effect of training on congruence, examiner manipulation during an assessment poses a threat to standardised, consistent role play – important for creating fair and equal circumstances for examinees.12 SPs should be trained to portray ‘the same patient in such a consistent way that each medical student will be presented with the same challenge every time’.13
A congruent portrayal of a patient requires more than receiving a written case scenario. Specific elements are needed for SPs to communicate verbally and non-verbally to the extent that a patient role can become a live experience, where communication is more ‘real’, alive and interdependent.13
Incongruent performances of SPs prior to focused training can be described as portraying:
• unbelievable characters that fear self-expression and lack confidence and energy owing to poor internalisation of the character
• non-agreeable verbal and non-verbal
The post-outcome training of characterisation showed a clear improvement in the congruence of SP portrayals. The changes can be contributed to the SP training that focused on subtext creation, 3D character development, energy level management, connection with their own emotions, their acting skills as well as the basic clinical information, and not only on the information given in the patient scenario.
Training also contributed to increased confidence levels with
regard to self-expression. It can be assumed that when SPs are
used for role playing in clinical scenarios during examinations,
authenticity is of paramount importance.1 For SPs’ portrayals to
remain congruent, continuous training is essential as scenarios
and characters change.
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