standardized patient acting class response paper

The show must go on? Patients, props and pedagogy in the theatre of the OSCE Gerard J Gormley,1 Brian D Hodges,2 Nancy McNaughton3 & Jennifer L Johnston1

ABSTRACT According to Shakespeare, all the world’s a stage, and all the men and women merely players. The objective structured clinical examination (OSCE), that most ubiquitous form of assessment in health professions education, offers us a particular instance of this maxim. Comprising at first glance a world of psychometric data, detailed checklists and global rating scales, the OSCE sets out to facilitate the assessment of a candidate’s com- petence in a highly standardised and objective fashion. Despite this clear intention, OSCEs also offer a rich vein of (often unacknowledged) social and cultural processes. In this commentary, we draw on Goffman’s dra- maturgy metaphor and our experiences to undertake a wry examination of some of the least intended conse- quences of OSCEs. We take a satirical look at both the potential impact on patients and the pedagogical implications of this form of assessment. We now urge you to sit back, settle in and enjoy the show, as we raise the curtain on this one-night-only performance!

OVERTURE AND BEGINNERS

Opening to rave reviews in 1979 and playing to large audiences across medical schools ever since, the objec- tive structured clinical examination (OSCE) could rival Agatha Christie’s The Mousetrap for longevity and popu- larity.1–3 Perhaps this is because it embodies so many of the scientific aspirations of the era in which it first appeared. It’s all in the catchy acro- nym: OSCEs are meant to facilitate objective and structured assessments of clinical competency. Additionally, OSCEs have become irrevocably asso- ciated in the collective consciousness with another ‘S’ – for standardisation. With precision and reliability hailed as pillars of good practice,4 the OSCE has become the quintessential assess- ment procedure of the psychometric era. The quantitative splendour of

the OSCE’s psychometric possibilities has promoted its current position as the dominant voice in both assess- ment and assessment research. Of course, it is thanks to this positivist assessment discourse that we now have fairer medical exams. However, as OSCEs become ever more ubiqui- tous, even hegemonic,5 the research pendulum is beginning to swing towards qualitative methods, usher- ing in the post-psychometric era. Entering stage left with little fanfare, this emerging stream of work is opening up new thinking about this most universal form of assessment.6,7

OSCEs are part of the establishment, even part of our collective sense of identity. As critical researchers, it always behoves us to question the sta- tus quo. Post-psychometric research offers a way into studying socially and culturally determined interac-

tions and processes of power and control. Most importantly, it relates assessment to pedagogy in new ways.

If your interest is piqued by this pre- view, or if you believe, as we do, that learning is not and cannot be con- tained within the classroom, then we invite you to take your seats for tonight’s gala performance. Story- telling is core to clinical practice and patients’ stories are at the heart of medicine. We present here, with apologies to Goffman,8,9 a selection of their finest productions within the human theatre of OSCEs. We share these few real-life anecdotes in the hope of opening up our own mean- ing-making processes to further dia- logue. Audience participation is not only allowed, but actively encouraged.

1 Centre for Medical Education, Queen’s University Belfast, Belfast, UK 2 Department of Education, University Health Network, University of Toronto, Toronto, Ontario, Canada 3 Standardised Patient Programme, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Correspondence: Gerard J Gormley, Department of General Practice, Queen’s University Belfast, Dunluce Health Centre (4th Floor), 1 Dunluce Avenue, Belfast BT9 7HR, UK. Tel: 00 44 289 020 4252; E-mail: [email protected]

1237ª 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2016 50: 1237–1240

assessment

Medical Education 2016: 50: 1237–1240 doi:10.1111/medu.13016 Discuss ideas arising from the article at www.mededuc.com discuss.

THE CURTAIN RISES

Scene 1: Certifying death is not as easy as it looks

Candidate is instructed to demon- strate life is extinct, using a plastic manikin. [Producers’ note: we choose to ignore for now the irony of declaring the life of a plastic manikin extinct.]

Candidate [faces manikin ner- vously, washes hands maniacally]: ‘Dear Sir, I’m a medical student and I hope you don’t mind if I could gain your permission to con- firm that your life is extinct?’

Manikin: [remains silent. . .]

As in many other forms of compe- tency-based assessment, OSCEs can induce test-taking behaviours.7

Repeated rehearsals without the input of a critical director can often pro- duce a ritualised candidate perfor- mance. This is never more apparent than in the opening act: hand-wash- ing, introductions and gaining per- missions become an automated process. In awareness of the fact that these ‘items’ are often on the OSCE checklist, this automated process is intended to maximise box ticking. Con- text, however, is ever important!

Scene 2: On your marks, get set, go. . .

Candidate is instructed to take a chest pain history. We pick up the scene towards the end of this station.

Candidate [speaking very fast]: ‘Are you taking any prescribed medications?’

Simulated patient (SP): ‘No.’

Candidate: ‘Great, great. Good. Now, do you have any drug aller- gies?’

SP: ‘No.’

Candidate: ‘Good, good. Can we move quickly on now to your fam- ily history. Do any medical condi- tions run in your family?’

SP: ‘Well. . . actually my father died last month of a heart attack.’

Candidate: ‘OK, great. Now then, can I explore your social circumstances – so do you smoke?’

OSCE candidates strive for effi- ciency, scoring as many items as they can in the given time period. Checklists attempt to itemise

doctor–patient interactions in a reductive, linear fashion. A candi- date’s focus can be directed to the checklist rather than the life experiences of the person sitting in front of them. In real life, patient- centred consultations involve a partnership in care. Both parties contribute to creating a shared understanding of the illness expe- rience and its management. This dialogic relationship is predicated on acknowledging the patient as a person, and is mediated by such

simple means as listening and reflecting back. While global rating scales may help mitigate against the box-ticking behaviour so associated with checklists, the constructed real- ity of the OSCE, with its carefully scripted and standardised patient cues, cannot simulate the give and take of the real-life patient consulta- tion. In OSCEs, perceived compe- tence rather than patient-centred care is the aim of the game. In fact, OSCEs have potential to promote ex- aminer-centred care. Rave reviews by service users are less important.

Scene 3: It’s all about the context. . . again

Candidate is asked to examine the patient.

Candidate: ‘Can I ask you your name and what problems brought you here today?’

Male SP [wearily, speaks in deep male voice while wearing a breast manikin device]: ‘My name is Jane Smith and I’ve been experiencing breast pain. . .’

Candidate: ‘Thank you Mrs Smith. Do you mind if I go on to exam- ine your breasts?’

Following the standardisation agenda to a logical, if rigid, conclu- sion, a situation like this may arise thus: the manikin device is used to demonstrate an important clinical skill. The manikin device is attached to the human for greater ‘authentic- ity’.10 Female human (SP) sched- uled to be attached to manikin device calls in sick. Male human (SP) steps into the breech, and the breast manikin device, to save the day and rescue the OSCE. Our experience suggests most candidates will play along without questioning the lack of authenticity, focusing on the process and the prop more than on the patient. Aside from the femi- nist implications of this particular anecdote, which we will save for another day, we should consider how we routinely sacrifice the infi- nite variability of human experience at the altar of psychometrics. We

1238 © 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2016 50: 1237–1240

G J Gormley et al

have deliberately picked an extreme historical example, but in myriad smaller ways we continue to main- tain SPs in subordinate positions through our routine assessment practices.

CURTAIN CALL

In a medical consultation, there are traditionally two leading roles.11 In OSCEs, these are expanded to (at least) a m�enage �a trois. The candidate takes on the doctor role, the doctor plays the examiner role, and the SP plays – well, the patient. We have argued before that patients are dehuman- ised and disempowered within the framework of the OSCE, which deprioritises their voices and stories in favour of a Foucauldian clinical gaze.6 Rather than leading actors, they are relegated to the status of props instead of being recognised as actors within the drama of the OSCE station.6 They still play a crucial role – where would Ernest be without Lady Bracknell’s handbag?12 – but their essential humanity is effaced in the industrial process of standardi- sation.

If partnership with patients really is a cornerstone of medical prac- tice, then the need to protect the voice of the patient is a vital issue for medical education. In all the anecdotes we offer, we have tried to foreground the importance of the clinical relationship, and con- sider what students may be learn- ing from its simulated proxy in OSCEs. Patient voices need to be raised within medical education.13

We use the plural deliberately, to emphasise the existence of not just a collective community but also of multiple individual voices. Simulated patients are rightly becoming more professionalised and legitimised in health profes-

sion education, as they bring patient voices to student learn- ing.14 Simulated patients are engaged in a quest to nurture the next generation of good doc- tors, thereby benefiting the patients these doctors will serve. For example, female SPs have vol- unteered to have their breasts examined for the benefit of stu- dents’ training experience. The breast manikins now reside in storage cupboards.

What do our students learn about the clinical encounter, and the rel- ative positioning of its chief actors, in assessment environments? Although they may not be the only assessment show in town, the hege- monic position currently enjoyed by OSCEs means they are the most high-profile production, showing to sell-out crowds worldwide. It has become a truism that assessment drives learning, but we argue that OSCEs (at least as they stand in common usage) may be driving learning in the wrong direction. Candidates’ success in OSCEs is contingent on their performances being congruent with examiners’ expectations. If we attach more importance to standardisation and ratings than to our patients, then we run the risk that students will learn to perceive the practice of medicine in this manner. The risk is of dehumanising doctor–patient relationships.

Although our stories are both individual and anecdotal, they bring into sharper focus some of our broad concerns about the unintended consequences of this most powerful form of assess- ment. The standardisation agenda and reductionist research approaches have the potential to render complex human interac- tions invisible within assessment. Neither assessment nor any other practice of medical education

occurs in a vacuum. OSCEs are socially situated activities: humans interact with humans; aspiring doctors interact with patients. We draw tonight’s performance to a close with a final curtain call. At least in its current form, we have given the OSCE a bad review as theatre and as pedagogy. Having enjoyed a long and uninterrupted run, perhaps it is time to dim the footlights and consider what the next form of this show might be?

Contributors: GJG conceived the idea for the paper and produced the first draft. All authors contributed to the subsequent drafting and critical revi- sion of the paper and approved the final manuscript for submission. Acknowledgements: We would like to thank Dr Helen Reid for her ‘critic’ review of our article before its ‘opening night’. Funding: none. Conflicts of interest: none. Ethical approval: not required.

REFERENCES

1 Boursicot K, Etheridge L, Setna Z, Sturrock A, Ker J, Smee S, Sambandam E. Performance in assessment: consensus statement and recommendations from the Ottawa conference. Med Teach 2011;33 (5):370–83.

2 Newble D. Techniques for measuring clinical competence: objective structured clinical examinations. Med Educ 2004;38 (2):199–203.

3 Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ 1979;13 (1):39–54.

4 Pell G, Fuller R, Homer M, Roberts T; International Association for Medical Education. How to measure the quality of the OSCE: a review of metrics – AMEE guide no. 49. Med Teach 2010;32 (10):802–11.

1239ª 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2016 50: 1237–1240

Patients, props and pedagogy in OSCEs

5 Regehr G. Trends in medical education research. Acad Med 2004;79 (10):939–47.

6 Johnston JL, Lundy G, McCullough M, Gormley GJ. The view from over there: reframing the OSCE through the experience of standardised patient raters. Med Educ 2013;47 (9):899–909.

7 Hodges B. Assessment in the post-psychometric era: learning to love the subjective and collective. Med Teach 2013;35 (7):564–8.

8 Goffman E. The Presentation of Self in Everyday Life. London, New York, NY: Doubleday 1959.

9 Hodges B. OSCE! Variations on a theme by Harden. Med Educ 2003;37 (12):1134–40.

10 Cleland J, Abe K, Rethans J. The use of simulated patients in medical education. AMEE guide no. 42. Med Teach 2009;31 (6):477–86.

11 General Medical Council. Good Medical Practice. London: GMC 2006.

12 Wilde O. The Importance of Being Earnest, 2nd rev. edn. London:

Bloomsbury Methuen Drama 2015.

13 General Medical Council. Patient and Public Involvement in Undergraduate Medical Education: Advice Supplementary to Tomorrow’s Doctors. London: GMC 2009.

14 McNaughton N. The Role of Emotion in the Work of Standardized Patients: A Critical Theoretical Analysis. Berlin: LAP Press 2012.

Received 11 September 2015; editorial comments to author 9 December 2015, accepted for publication 14 January 2016

1240 © 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2016 50: 1237–1240

G J Gormley et al