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The Moral Aesthetics of Simulated Suffering in Standardized Patient Performances

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Abstract

Standardized patient (SP) performances are staged clinical encounters between health-professional students and people who specialize in role-playing the part of patients. Such performances have in recent years become increasingly central to the teaching and assessment of clinical skills in U.S. medical schools. SP performances are valued for being both “real” (in that they involve interaction with a real person, unlike written examinations) and “not real” (in that the SP does not actually suffer from the condition portrayed, unlike an actual patient). This article considers how people involved in creating SP performances reconcile a moral commitment to avoid suffering (to keep it “not real”), with an aesthetic commitment to realistically portray it (to keep it “real”). The term “moral aesthetic” is proposed, to indicate a sensibility that combines ideas about what is morally right with ideas about what is aesthetically compelling. Drawing on ethnographic research among SPs and SP program staff and medical faculty who work closely with them, this article argues that their work of creating “realism” in simulated clinical encounters encompasses multiple different (and sometimes conflicting) understandings and practices of realism, informed by three different moral aesthetics: (1) a moral aesthetic of induction, in which an accurate portrayal with a well-documented provenance serves to introduce experientially distant forms of suffering; (2) a moral aesthetic of inoculation, in which the authenticity and emotional impact of a performance are meant to inoculate students against the impact of future encounters with suffering; (3) a moral aesthetic of presence, generating forms of voice and care that are born out of the embodied presence of suffering individuals in a clinical space. All are premised on the assumption that risk and suffering can be banished from SP performances. This article suggests, however, that SP performances necessarily raise the same difficult, important, fundamentally ethical questions that are always involved in learning from and on human beings who are capable of suffering, and who need and deserve recognition and respect as well as care.

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Notes

  1. More specifically, “Step 2” of the OSCE, which tests “clinical skills,” relies on SP performances (as opposed to Step1, which tests “clinical knowledge” through a written examination). The SP portion of the OSCE is sometimes referred to as the “Step 2-CS.”

  2. For proposing the term “moral aesthetic,” I gratefully acknowledge Todd Nicewonger and Lesley Sharp.

  3. With the full approval of the Human Subjects committee at the University of Washington I have since August 2008 conducted some 27 interviews to date, most of them with people who work as SPs themselves, and/or who currently work with SPs in a supervisory or training role. I have also interviewed several medical school faculty and, thus far, one medical student. Each of these interviews has been 1–2 h in length, some in-person and some via telephone, and all have been tape-recorded and fully transcribed. In addition, I have been subscribed to a listserv devoted to discussion of SP simulation, and I have attended two national conferences of “Standardized Patient Educators,” and one conference on virtual-reality simulation in medicine.

  4. Moulage is the term used to refer to the makeup techniques, many of them borrowed from the theater, that are used to create simulated injuries. Pre-made latex wounds that are designed to be applied to the body’s surface, as well as models of grievously injured arms and other body parts, which may be artfully arranged to appear as if they are part of an SP’s own body, are also considered forms of moulage. In this instance, Wikipedia proves to be a more helpful source than more authoritative dictionaries: see http://en.wikipedia.org/wiki/Moulage, accessed 4/15/2011.

  5. In keeping with the research and writing traditions of anthropology, I have assigned pseudonyms to individuals quoted here, instead of using their real names. The rationale behind doing so is twofold: first, the focus of anthropological research is not so much on individuals as on the social and cultural phenomena in which individuals partake; and second, pseudonyms help prevent the possibility of harm to individuals that could conceivably result from their participation in anthropological research. In my ongoing research, I will continue to adhere to this practice, except in cases where I am citing published studies, or when individual research participants explicitly request that I use their real names instead of pseudonyms (as some, seeking public recognition for their words and contributions, occasionally do).

  6. Casting SPs to portray members of ethnic groups to which they do not themselves belong, for purposes of “cultural competency” training, may be similarly problematic. Recognizing this, many SP programs strive to recruit a diverse pool of SPs, though program staff also often describe this as difficult.

  7. In keeping with the research protocols approved by the Human Subjects committee at the University of Washington, I have sought and received, from the author of each of the messages quoted, explicit permission to use it as data for research purposes.

  8. For an example of how these issues are discussed within the medical education literature, see Everett et al. 2005.

  9. Seton (2006) has coined the term “post-dramatic stress” to describe the after-effects risked by actors who employ such Sense Memory methods. He cites an editorial published many years earlier by Alice Brandfonbrener (but to which there had been little response), naming theater actors as “the forgotten patients.” Brandfonbrener wrote that, “even the most mature, stable, and experienced actor suffers the effects of playing Willy Loman night after night, and this is not confined to what transpires on the stage.” (Brandfonbrener 1992, p. 102).

  10. This is not something that can necessarily be taken for granted; in many places, institutional incentives favor investment in high-tech simulation labs and equipment such as computerized mannequins, even if they are far more expensive, over investment in SP programs and the people who staff them.

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Acknowledgments

My sincere thanks are due to the many people working in the field of SP simulation and medical education, who have generously shared with me their time and knowledge. For their encouragement of this project from its earliest stages, I am grateful to Brian Hodges, Nancy McNaughton, Lorna Rhodes, Lesley Sharp, Susan Shaw, and Jennie Struijck—though I would stress that they may not agree with my analysis, and are certainly in no way responsible for any errors or shortcomings it may contain. For helpful comment on earlier versions of this essay, my thanks to Nancy McNaughton, Uta Poiger, Jeannette Pols, Priti Ramamurthy, Michele Rivkin-Fish, Lesley Sharp, and Lynn Thomas, as well as Lochlann Jain and others who attended a public presentation of this argument in the Department of Anthropology at Stanford University. Sincere appreciation to the editors and anonymous reviewers of Culture, Medicine and Pyschiatry, and especially to Scott Stonington, Seth Holmes, and Angela Jenks as guest-editors of this special issue.

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Correspondence to Janelle S. Taylor.

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Taylor, J.S. The Moral Aesthetics of Simulated Suffering in Standardized Patient Performances. Cult Med Psychiatry 35, 134–162 (2011). https://doi.org/10.1007/s11013-011-9211-5

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