Series Part Two: Actor Simulations Help Train Future Doctors and More
By Dara O’Brien
How do you tell a parent that their five-year-old’s cancer is inoperable? Or a mother of five that she has early-onset Alzheimer’s Disease?
All doctors, whatever their specialty, will have to communicate traumatic news to some of their patients. In order to help prepare for that difficult task as well as gain experience with all levels of doctor-patient communications, medical schools use role play with Standardized Patients (SPs)—actors who stand in for patients or their families. These interactions have become integral to medical training.
“You can only learn so much from a simulator, or a piece of plastic, or a cadaver,” said David Deitsch, director of operations at the Mary and Michael Jaharis Simulation Center in the Vagelos College of Physicians and Surgeons at Columbia University. “Feedback you get from a live human is crucial to the development of a medical student.”
In this second part of our series on role play training simulations and the actor’s experience, we focus on the simulator’s contribution in academic/training settings, such as medical, social work, and dental schools, law schools and pharmaceutical companies.
Medical schools have built robust simulation centers that provide hands-on training through sophisticated robotic technology, video simulators, and hi-fi manikins that blink, cry, and adjust their breathing or heartbeat. But these manikins can’t express emotion or confusion, request alternatives, or pick up on verbal cues. Actors serving as Standardized Patients provide that critical human response.
A Primer on Integrating Actors Into a Simulation Program created by the Boston Children’s Hospital Simulator Program noted that “skilled actors add emotional and social context to scenarios … and, in so doing, facilitate suspension of disbelief.”
“You want the students to have as real an experience as possible,” explained Melissa Hurst, an actress based in New York City who has been serving as a Standardized Patient for more than five years. “We give them opportunities to express caring and sympathy and still be pragmatic solution-finders.”
Hurst is associated with a number of medical and dental schools in the New York Metro area, and finds that SP role play provides a rewarding supplement to her stage and film work. “I enjoy interacting with the students,” she said. “They’re so dedicated. I see them caring about their patients and wanting to understand the bigger picture: how this medical issue is impacting their patient’s work and personal lives.”
The use of SPs dates back some sixty years, and has become fundamental to healthcare training. Medical schools must offer SP simulations in order to be accredited, and doctors need to successfully complete this training in order to be licensed. Nandita Shenoy, an actress and playwright who has worked as a standardized patient on and off for more than fifteen years, explained the process: “They give us a case, and a doctor will talk us through it in rehearsal.” Actors are briefed on what the symptoms are, where their pain might be and its degree of intensity. Attention to these details and consistency is important. “The school wants each patient to deliver as similar an experience as possible, so each student has as close to the same experience as possible,” said Shenoy.
The encounters mirror real-life examinations. Actors, sometimes in hospital gowns, meet with students in examination rooms. Scenarios are based on actual cases and provide a launchpad for the kind of conversations doctors are required to navigate; they cover a wide range of communications from patient intake to motivating compliant behavior.
The work can require the actor to engage in frequent repetition of the same case, as well as shift quickly from one character to another and back again. “I had a job the other day when I went back and forth every ten minutes between being someone named Alex who had a hand injury to being Charley who had a shoulder injury, and then back to Alex and back to Charley,” said Hurst. “I had to drill myself, who am I?”
Scenarios involving delivering bad news have been especially impactful for Hurst. “It’s very much a process; you don’t go right to an emotional response,” she explained. One of the long-standing characters she plays is a mother who is eager to be at the bedside of her critically injured daughter. The doctor must deliver the news that the girl is brain dead. When the mother expresses a desire to bring her daughter home, the doctor must tell her that won’t be possible; the scenario escalates from there. “It’s almost like a play,” she said. “There’s a progression, and it takes a while for the emotional part of it to set in.”
“You have given circumstances and then you get in the room and you respond to whatever that student gives to you,” said Shenoy. She noted that the work can take a toll. One of her role plays involved a harrowing miscarriage. After enacting the scenario repeatedly for a time, Shenoy had to stop playing the role. “You keep going through that intense emotional experience over and over again. By the end, I was just a shell of a person.”
A Standardized Patient coordinator from a medical college in New York City commented on the dedication she sees in the SPs she works with: “Their commitment to portraying a case unwaveringly over days, months and years is impressive. They understand the learning objectives for the students, and why it’s important.”
“What I most enjoy,” said Hurst, “is when I lose myself to the point that I don’t even remember that I have a character to play.”
Providing Critical Feedback
A key aspect of the SP experience is providing feedback to the students. After the encounter is completed, SPs share their impressions of the simulation and initiate a dialogue, starting with the positive aspects of the interaction. “I like encouraging them based on the strengths they brought to the conversation,” said Hurst.
The discussion then moves into any areas that may require modification. SPs cite specific elements of the interaction and speak in the first person (“When you said …, I felt …”) in order to provide a constructive context to the discussion. “I start with ‘how did you feel that went? What would you do differently if you could do it again?’” said Shenoy. “Then I go into what I observed.”
Following many SP encounters, the actor is also charged with filling out a computer checklist that can include as many as thirty to one hundred items. Hurst pointed to the complications of the dual focus on role play interaction and keeping mental notes to report on afterward: “You’re investing in who you’re playing while also trying to remember what the student says and does. That split role can be kind of bizarre.”
The feedback SPs are asked to provide may include how the student entered the room and if they introduced themselves with their full names, what questions they asked or didn’t ask, what physical examinations they did or didn’t do, how they communicated and if they relied on medical jargon, if they expressed empathy, and if they washed their hands before and after the encounter.
“The best Standardized Patients are also educators at heart,” said the SP coordinator. “It’s not uncommon that a Standardized Patient will come up with something inventive when giving feedback, such as using phrases like ‘Don’t be afraid to own the room’ to a nervous student. They may also offer insights that don’t come from the faculty or patient perspectives, like advising students that older patients may appreciate more formality, and to treat them like they’d treat their grandma.”
“The feedback process has had an influence on how I communicate with people I’m close to,” said Hurst. “Sweeping judgments one way or the other really don’t help anybody. I have found that this work helps me to be specific and to bring things back to how I feel in response to another person’s identifiable actions or words.”
Staying in the Moment
“It’s a mix of both improv and acting,” said Shenoy. She also mentioned that while each scenario had clear objectives, “you have a variety of options of how you can achieve them. I think it has made me more facile as an actor, and maybe less flappable.”
“The ability to modulate emotion and adapt to last-minute changes is a strength of professional actors, whose training emphasizes flexibility and spontaneity; these characteristics are essential for SP work,” the Boston Children’s Primer observes. It notes that SP actors can make adjustments to balance the emotional intensity of the scenario, modifying the level of anger, anxiety, guilt, or grief expressed. It cites some of the many qualifications actors bring to the work, including the ability to collaborate, improvise, adapt, listen, and be emotionally vulnerable and accessible.
While the encounters are not scripted, having a firm grasp of the case history is critical, thus memorization plays a significant part in SP work. Also, as with working on a play or film, creating a character and behaving as that character would is essential. Shenoy remarked that SP work demands that she stay in the moment no matter what’s thrown at her. “Students have said some really crazy things to me,” she said. “It’s really a lesson in being able to stay in character and move forward to achieve your objective.”
Shenoy has written a play based on her work as a Standardized Patient. Titled “Esspy” (a phonetic equivalent of SP), her play has had readings at select theaters around the country, including NJ Rep. “I wrote it because I thought there was something sort of absurd in what we do, but also so meaningful,” said Shenoy. “I do think it’s a very valuable service that we’re providing. Maybe we’re part of making things better.” After the reading, audience members asked her where she got the idea for the play. “When I told them it was because I do this work, they were surprised this was a real job. They thought I made it up.”
“For me, what comes into play is investing my mind, my body, and my soul in who I’m playing and what she cares about,” said Hurst, “the physicality, the emotional state, the life circumstances. It’s all about committing to who you are.” She continued: “Plus, you’re not interacting with a fictional character. You’re talking with a real person and have to be believable. I think this has helped me to be more grounded in my approach to working as an actress.”
“You need to talk to people who have a variety of communication skills, and actors have a really unique way into that,” said Shenoy. She approaches each simulation with a focus on connecting with the other person in the room. “That’s my job. So, ‘What can I share of my experience that will help you do better in yours?’”
A Unique Perspective on Pharmaceutical Training
When Margaret McGovern was a theater student at Rutgers University, she was part of a team of actors doing SP role play for the University’s Medical College. She quickly realized that these simulations could play a significant role in pharmaceutical training and founded Simulations, Inc. in 1978. The company, now celebrating its 45th year, designs and produces educational events using highly skilled, professionally-trained actors.
The company’s early focus was patient simulations. But McGovern and her team quickly saw that role play training had other relevant applications. “We came to realize that the conversations between pharma representatives and physicians or between managers and their direct reports were also key,” said Janet Quartarone, Simulations, Inc.’s Vice President & Director of Marketing. The company expanded its offerings and now focuses. on three pillars: patient simulation, health care provider (HCP) simulation and coaching, and internal communication.
Internal simulations help onboard new hires; they also work with pharma reps to improve their communication skills and better understand the issues healthcare professionals face, as well as help managers explore ways to better support their teams. Each role play is carefully crafted to ensure that it meets the client objectives. While pharma companies have done similar training with internal personnel, trained simulators can offer unique expertise and a more nuanced perspective. “We know that they’ll have a much better outcome if they use Simulations actors,” said Quartarone.
Specificity and extensive preparation are key to Simulations, Inc.’s interactions. The team rehearses extensively, reviewing the product details and using improv to test and refine their approach. “We’re given a profile and then we immerse ourselves,” Quartarone stated. “You won’t necessarily know how a question may come at you, but you trust that you have the information and that you’ll know how to answer it when it does.”
As with SP work in an academic setting, Simulations, Inc. actors are trained to deliver feedback directly to the client to help them improve their communication skills. “Feedback from the actors is so valuable,” said Quartarone, “It’s really important for us that all of our actors are comfortable doing that.”
For example, in a simulated sales call, role play actors note if the rep put them at ease and listened to their needs and concerns. The actor will speak from the character’s perspective, and cite specifics from the encounter, such as the use of open-ended questions, and if the trainee responded with empathy. “Many times we’re picking up things that weren’t spoken,” said Quartarone. “We just feel it.”
Many of Simulations, Inc.’s actors have been with the company for 15 to 20 years. “We look for strong actors who are truthful and have the ability to think on their feet,” said Quartarone. “We’re also looking for someone with expertise in structured improvisation, because that’s so much of what we’re doing.” She noted that the work is inherently educational, which adds another dimension to the necessary skill set. “We’re looking for someone who has a teacher’s head.”
New Simulations, Inc. clients are sometimes skeptical of an actor’s ability to realistically step in for a doctor or other healthcare professional and participate in these detailed interactions. “They think the process sounds interesting,” said Quartarone, “but they question how an actor could possibly know what they need to know.” She recognizes they’ve done their job when the client approaches the actor after the simulation is over and asks “You’re not one of the actors, right? Aren’t you a doctor?”
Stating the Case For Future Lawyers
As Standardized Patients became more and more integrated into Medical Schools’ curricula, their law school colleagues took notice. As Douglas Frenkel, who now serves as Director of Mediation Clinic at Penn Carey Law at the University of Pennsylvania, stated, “When we began to learn about the availability of actors who were then assuming the early days of standardized patient roles at the medical center, I said to myself, ‘Why can’t we avail ourselves of that kind of talent here?’”
Actors serving as simulated clients and witnesses are now a standard part of law school programs, and are used by law firms as well. They play key roles in helping to train and prepare lawyers for sensitive interactions including client interviews, depositions, cross-examination, negotiations, providing counsel, and more.
Actor and Casting Director Helene Galek has been working with a law school in New York for more than a decade. Through role play she helps students build the skills that are required to interview clients efficiently and provide effective counsel. “We are given the outline of a case with the important details,” said Galek. “Then we rehearse.”
Actors are instructed not to give the whole story away, but to let the student dig and to rely on the questioning techniques they’ve been trained to utilize. The class simulations generally last around 20 minutes, and as the actors improvise, they modulate their behavior in response to what they receive from the student, based on their knowledge of their character’s backstory and what it reveals about their main concerns.
Galek enacts a wide range of cases, they include: a teacher who is worried about her liability because her cousin, to whom she rents an apartment, is dealing pot; a tenant who has been without heat or hot water for months; a tech worker on medical leave who was let go when she tried to return to work and wants to sue for damages; a mother of two school-aged, special needs children who wants to sue the school district for lack of services; and an imprisoned woman seeking options when her partner refuses to allow her to see her child.
As with SP simulations, the actors interact with the student and give feedback. Once the simulations are completed, Galek writes a detailed assessment of her experience based on specific criteria the student is required to meet. Unlike SPs, their comments go to the program’s supervisors, not to the students themselves.
Program managers ask the actors to note whether the student introduced themselves using their full names; if they used an ice-breaker, if they made her feel comfortable, and if they employed the funnel technique, beginning with broad questions and then gradually narrowing the scope of the inquiry. It’s also important that the student makes sure they understand the client’s concerns and discusses what laws may be applicable. Galek noted that recapping the conversation before it ends is key: “Did they wrap up our meeting with a clear indication of the next steps?”
Galek will also assess whether the student questioned without judgment and showed empathy. She will note if the student gave answers that were inaccurate or made disallowed promises about delivering a positive outcome of the case. “They have to be encouraging, but they should say they need to do more research and they’ll get back to me.”
Simulations may include mock trials, which allow students to hone their examination skills. One of the more interesting aspects for actors is that they are given relevant statements and the police report, but not the outcome. On a personal note, I once participated in a case in which I played a girl accusing her uncle of abuse. As I read the materials and committed aspects of the case to memory, I began to see some inconsistencies and to doubt some of my character’s story. But it wasn’t until a student lawyer exposed the gaping holes in my story during cross-examination that I realized the charges the girl made were, in all likelihood, false.
The adversarial nature of a mock trial creates a unique experience for the actor, which Melissa Hurst found disconcerting. When she participated in a simulated cross-examination for Summer Associates at a local law firm, her character was caught in a lie. As the transcript noted, she testified that her employer was not in the office at a certain time when in fact he was. “The lawyer said, ‘So, you lie,’” said Hurst. “’You’re a liar. You lied in that situation and you probably lie in others.’” Hurst was surprised by her reaction. “I felt nervous being on the witness stand,” she recalled, “I never thought I would.”
The use of professional actors in simulations trainings in academic and professional contexts has become widely implemented and accepted since the introduction of Standardized Patients in 1963. The learning opportunities and applications continue to expand.
The third part of this series will explore role play in the corporate setting and its range of uses, from DEI training to leadership cultivation.
DARA O’BRIEN is a playwright and actress based in New York City. Her article “Company Managers: Women at Work” was published in WIT Journal in July 2016. Her plays have been presented or developed at The Cherry Lane Theatre, Urban Stages, the Abingdon Theatre Company, Resonance Ensemble, and HB Studio. She received the Thomas Barbour Playwrights Award for her play “Early Sunday Morning,” which had a staged reading featuring Melissa Errico by The Schoolhouse Theatre, and was featured in the Naked Angels Tuesdays@9 Reading Series. She is also an actress whose work includes the New York premiere of “Gidion’s Knot” by Johnna Adams, directed by Austin Pendleton at 59E59 Theatres, and Lady Capulet in “R&J” for Web Series Shakespeare. When she isn’t acting or writing for the theatre she is blogging about food at daraobrien.medium.com. AEA, SAG-AFTRA. Dramatists Guild of America.