Communication skills and the problem with fake patients

Susan was sitting in the clinic room as I entered, her head in her hands. Appearing to fight back tears, she looked up at me expectantly. Moments earlier she’d discovered that her pregnancy had ended prematurely, and it was up to me to explain to her that she’d had a miscarriage.

Sitting down with her, I found myself trying to care. Or, more accurately, trying to show that I cared. If I’m sounding cold hearted, it’s because I’m worried that medical school might be training me to be so.

Susan wasn’t a real patient. She was an actor at an objective structured clinical examination (OSCE) station—a medical school examination that uses role play to test a student’s ability to practise as a doctor.

The use of OSCEs in medical schools is controversial. They’ve been called “box ticking exercises,” and condemned for promoting a narrow understanding of clinical medicine.1 Some dislike the artificial nature of the exams. “It doesn’t seem like real life; you forget things that you would normally do,” remarked one student in a study on the topic.1

OSCE stations that test communication skills are particularly open to criticism. Although OSCEs can simulate clinical examinations or history taking scenarios with relative ease, encounters that test students’ ability to express empathy provide other challenges. A friend told me how a mixture of nerves, poor acting, and the gesture of giving a patient an imaginary leaflet—something many tutors encourage their students to do—had provoked a giggling fit during the exam. Another had failed a station because he misunderstood the brief, given to him seconds before the test, and did not play the character he was supposed to.