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Abstract
Background Established models of serious illness communication training frequently include role play with simulated patient actors. Yet preparing for communication courses can feel challenging, as most faculty have minimal experience directing actors, and no literature exists to guide faculty in how to lead course rehearsals.
Methods A team of palliative care educators partnered with a seasoned acting teacher to design and implement a faculty guide for directing actors during communication course rehearsals. Their approach involved a series of brainstorming sessions, creation and piloting of a draft rehearsal guide and revisions based on actor and faculty feedback.
Results The actor rehearsal guide offers a stepwise approach to beginning a rehearsal, rehearsing a patient case, giving feedback to the actor and ensuring the actor responds appropriately to learners of varied skill levels. From early 2021 to late 2022, the team used the guide to prepare for 36 courses, which trained 446 clinicians. Faculty and actors noted that the guide fostered predictable and efficient rehearsals.
Conclusions A novel actor rehearsal guide can support preparation for communication courses at a single institution. Next steps include disseminating the guide to other institutions and evaluating the guide’s impact on faculty and actors’ experience of rehearsals and learners’ experience of training.
- Communication
- Education and training
- patient simulation
- faculty development
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Effective models of serious illness communication training frequently involve role play with trained actors.
However, most communication skills educators have minimal experience directing actors and no literature currently exists to guide faculty in how best to collaborate with actors when preparing for courses.
WHAT THIS STUDY ADDS
A novel actor rehearsal guide was developed to support faculty in preparing for serious illness communication courses.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The guide has been successfully implemented into course preparation at a single academic institution and may be adopted by other centres.
Further study is needed to evaluate the guide’s impact on faculty preparedness for rehearsals, actors’ preparedness for courses and learners’ experience of training.
Background
Effective clinician communication skills are essential to the care of all patients, and especially those facing serious illness.1 For most clinicians, the skills necessary to deliver serious news, respond to emotion and elicit patients’ goals of care are not innate and require deliberate practice. Established models of interactive serious illness communication training can increase clinicians’ use of key skills and preparedness for difficult conversations.2–4 Such training programmes, including those that use the VitalTalk educational framework,5 6 frequently employ role play with trained actors, who portray patient characters in simulated encounters. When simulated patient actors respond authentically to clinician variability, learners can experience communication successes, make mistakes and practise new skills within a safe educational environment. Notably, we use the term ‘simulated patient’ to refer to actors playing a patient character, who familiarise themselves with a medical and psychosocial scenario, and then respond during the encounter as the patient would authentically (in contrast to a ‘standardised patient’ who is trained to give consistent responses that change minimally from learner to learner, most commonly used for skills evaluation).7
Yet, while the impact of such trainings on clinicians’ skills can be great, rehearsing actors for these roles can be challenging. Most faculty have little or no experience directing actors and may feel ill-equipped to prepare them effectively. In our experience, even seasoned communication educators struggle with this task. Additionally, to our knowledge, no literature currently exists to guide faculty in how best to collaborate with actors when preparing for serious illness communication courses.
To address this problem, we partnered with an acting teacher to develop an actor rehearsal guide specifically designed for serious illness communication course rehearsals. Our aim was to provide faculty with clear steps for directing actors in creating authentic patient characters—and thereby enhance learners’ skill development. In this report, we describe the development and implementation of an actor rehearsal guide at our institution, initial outcomes and anticipated next steps in its dissemination and evaluation.
Methods
Our institution hosts a communication skills education programme that trains >150 medical residents, fellows and practicing clinicians annually in key skills for navigating serious illness conversations. Training occurs via half-day (3.5 hours) and full-day (6 hours) courses, in which learners participate in role-play encounters with simulated patients (actors) and debrief the encounters with a faculty facilitator and small group of peers. Small group facilitators use the VitalTalk teaching method, which includes learner goal-setting prior to the encounter, recognition of what went well and identification of what could have been done differently.5 The teaching encounters end with the learner ‘replaying’ a challenging part of the encounter and practising a new communication skill, which (when executed well) often shifts the conversation in a more helpful direction. This teaching method requires careful preparation by faculty and actors, to ensure that the clinical encounters feel authentic, and that the learner experiences a communication ‘win’ when they effectively incorporate a new skill.
In the Summer of 2020, hearing from our communication faculty that leading actor rehearsals were among their most challenging tasks, we set out to improve our rehearsal process. Two team members (AJL, LG) started by reviewing the current method that had been developed by VitalTalk.6 The steps included asking the actor about their sense of the character’s main emotions, rehearsing the encounter with another faculty member playing a learner (first a learner who makes common mistakes, and then a learner who skillfully navigates the conversation), ensuring that the actor gives the learner a ‘win’ when they practise a new skill during the ‘replay’, and concluding with feedback for the actor. They then invited a seasoned acting teacher (RA) to provide input about how to improve the rehearsal process. RA is a lecturer in Theater, Dance, & Media and has appeared in more than 60 productions at the American Repertory Theater, both at Harvard University, in addition to being a core actor in the team’s communication skills education programme. The team members and acting teacher met for four 1-hour brainstorming sessions over a 6-month period, during which they reviewed the current rehearsal process, and at each step discussed opportunities for improvement. Topics included how to begin a rehearsal, how to agree on a character’s main emotion, how to give actors space to develop a character, how to rehearse around common learner stuck points, how to give actors feedback and how to end a rehearsal. The team members distilled notes from these discussions into key points that would inform an effective rehearsal process. They used these key ideas to create a draft actor rehearsal guide.
In January 2021, the team invited the acting teacher to lead a rehearsal for an upcoming communication course, incorporating the steps of the drafted guide. All rehearsals and courses held during the guide’s implementation were conducted in a virtual environment. While course rehearsals at our institution are typically led by physician faculty, this rehearsal was led by the acting teacher, who modelled the steps of the rehearsal guide, allowing the team to ‘workshop’ the draft guide in real time. The team took notes during the rehearsal, sought informal feedback from the two other professional actors present and debriefed with the acting teacher. The team and acting teacher then met with an expert communication skills educator and researcher (JAT) to obtain additional feedback. They incorporated edits from each of the above steps into a more finalised version of the guide. Over the subsequent months, the team used the guide to direct course rehearsals and made occasional minor revisions based on spontaneous input from the programme’s core actors and faculty.
Results
The actor rehearsal guide
Using the approach above, the team created a final version of the actor rehearsal guide (figure 1). Key elements include beginning a rehearsal effectively, rehearsing a patient case in preparation for learners who can skillfully navigate the conversation, as well as for learners who struggle in their communication, giving feedback to the actor and ending the rehearsal. The course director should start by facilitating introductions, giving an overview of the course and clearly establishing that the course director will lead the rehearsal (which avoids the inefficiency caused by actors receiving direction from multiple faculty). Throughout the rehearsal, the course director may invite input from other faculty, when needed.
The Dana-Farber Cancer Institute actor rehearsal guide for communucation courses.
Most of the rehearsal will typically be spent rehearsing patient cases that will be used for skills practice during the course. After discussing the medical details of the case, the director should tell the actor what emotions they are hoping to see portrayed in the patient character. To generate emotion, the actor and director can discuss ‘the moment before’ concept; what was happening to this character just before the encounter began, which might inform why they are entering with a given type and degree of emotion.8 Next the actor and faculty should rehearse the patient encounter, with one faculty member playing the role of a learner who can perform well the skills to be practised in the course. Starting the case rehearsal with a skilled learner gives the actor space to develop the character and provides a sense of direction regarding where the encounter will go when navigated effectively. In earlier versions of the guide, we started the rehearsal with the actor playing opposite a learner who struggles to execute key communication skills (eg, giving more medical information, instead of expressing empathy, in response to high patient emotion). However, our actors found this distracting, as the scene would frequently escalate emotionally quite quickly, interrupting the actor’s ability to develop the character under more usual circumstances. To start the rehearsal of an encounter, the course director can say to the actor, ‘In this first run-through, you’ll meet a learner who can skillfully navigate this conversation. Let’s see where you take this.’ This language invites the actor to be genuine and go with their impulse. The director should take notes and let the scene run long enough to see if the actor portrays the desired type and degree of emotion, and how the character responds to a learner who can perform the desired communication skills.
Next, the director should pause the scene and give feedback, discussing first what went well and second what they would like done differently, regarding the actor’s exact words and nonverbals. If the director wants the patient to respond differently at a given moment, it can be helpful to suggest specific words to the actor. This might sound like: “When she asks you what you’re hoping for, you might say, ‘I just want more time with my son.’” In our experience, it is best for the director to simply suggest a line, and then allow the actor to interpret it with their own tone and emotion (this avoids the directing pitfall of ‘line reading’—showing an actor exactly how to deliver a line, using the director’s own intonation and energy, as opposed to allowing the actor to deliver the line genuinely as the character).9 If the director wishes for the character’s level of emotion to be different, it can be useful to use a 1–10 scale to recalibrate. Ask first what level the actor thinks the patient’s emotion is currently, then suggest an adjustment based on that number; “Ok, you feel her anxiety is currently at a 5—we want it at a 9.” If feedback after the first run-through calls for significant changes to the character, it may be helpful to rehearse the scene a second time, with the learner remaining skilled, to ensure all changes are incorporated.
The director should next guide the actor in rehearsing the scene with a learner who gets stuck in the typical spots that we have observed during courses (eg, responding to emotion with more information) and ensure that the character responds appropriately. Table 1 highlights common stuck points for learners in serious illness communication courses, drawn from our institutional experience. Which stuck points to rehearse will depend on the focus of a given course. Additionally, some serious illness communication courses allow learners to do over a challenging moment in the conversation, to practise a new skill and experience success. These do-over opportunities (often called the ‘rewind and replay’) also require rehearsal. The director should guide the actor and simulated learner in practising brief scenes in which the learner tries a new communication skill, which prompts a different response in the patient—one that signals communication success. For example, in a course focused on serious news delivery, if the rewind and replay sequence involves the learner practising an empathic statement in response to emotional distress, the patient’s response in the replay should be de-escalating emotionally, suggesting that they feel seen and understood by the learner.
Common learner stuck points in serious illness communication courses
The rehearsal of a case should end when the director is confident that the actor knows how to portray the character in response to both learners who are skilled and those who struggle in their communication. Once all patient cases have been rehearsed, the director should invite final questions, confirm logistical details of the course and express gratitude for everyone’s efforts.
Institutional outcomes
Since first implementing our guide in early 2021, we have used it to prepare for 36 courses, which in total have trained 446 clinicians (medical residents, fellows and oncology clinicians) in key skills for serious illness conversations. In our experience, this novel method has made course rehearsals feel more predictable and efficient. We routinely complete rehearsals for half-day courses (involving two patient cases) in 1–1.5 hours and full-day courses (involving four patient cases) in 2 hours. Most rehearsals and courses involve the same four actors, all of whom are now very familiar with our revised process.
Discussion
We developed a novel rehearsal guide to support healthcare educators in preparing actors to play simulated patients at serious illness communication courses. To our knowledge, no other literature exists to guide faculty in how best to partner with actors in this space. Other authors have described their collaboration with theatre students and other non-clinicians playing standardised patients—often for simulation activities and skills evaluation in healthcare training programmes.10–12 Recommended key steps in orienting standardised patients have similarities to our guide for simulated patients, including explaining the purpose of the session, describing the background of the trainees, discussing the expected flow of the encounter, rehearsing the role-play encounter in pairs with faculty observing and providing clear feedback to the standardised patient.10 Medical improvisation is another educational strategy which employs drama training techniques to teach communication skills to medical trainees.13 Best practices in preparing for improvisation sessions include orienting healthcare educators to improvisation and arranging for co-facilitation of the session by healthcare and theatre professionals.14 Del Vecchio and colleagues offer stepwise instructions regarding how educators can facilitate specific improvisation activities with nursing trainees.15
Our guide adds to the education literature by offering greater detail than any prior work regarding how to rehearse effectively with actors for communication courses—emphasising a step-by-step approach for preparing an actor to play a simulated patient role. Anecdotal feedback from our core actors and faculty suggests that the guide promotes greater clarity regarding how a given role should be portrayed and greater time efficiency during rehearsals.
Next steps should involve a more formal evaluation of the rehearsal guide’s impact on course faculty, actors and learners. A qualitative analysis could explore faculty and actors’ experience of using the guide and their sense of preparedness for a course at the end of the rehearsal. We also plan to share the guide with communication educators at other institutions, both to disseminate this approach and obtain their feedback. Additionally, as this guide was developed and implemented for virtual courses, we aim to evaluate whether the process works equally well for in-person course rehearsals. Finally, it would be valuable to understand the impact of this rehearsal guide on learners’ training experience, in terms of fostering an authentic environment in which to practise communication skills.
Conclusions
Rehearsing effectively with actors to portray simulated patients is a necessary, yet challenging, task in preparing for many communication skills courses. Our team successfully designed and implemented a novel actor rehearsal guide to support preparation for serious illness communication courses at a single institution. We believe this guide has utility for many healthcare educators who aim to enhance learners’ bedside communication through interactive skills training.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors thank Dr Anthony Back, Dr Gordon Wood and other collaborating faculty at VitalTalk for their development of an ‘Actor Training Roadmap’ which was a key resource early in the development of our rehearsal guide.
Footnotes
X @ALawtonMD
Contributors All authors contributed to conception and design of the work, drafting and revising the manuscript and approved the final manuscript. The lead author AJL attests that all listed authors meet authorship criteria.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JAT and AJL disclose relationships with VitalTalk as a founding director and faculty member, respectively.
Provenance and peer review Not commissioned; externally peer reviewed.