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Playing The Role

One of the most time-honored pedagogical tools in medicine is the “role play.”  The concept is simple:  one individual plays the part of another person (usually a patient) while a trainee examines or questions him or her, for the purposes of learning ways to diagnose, treat, and communicate more effectively.

Last week I had the privilege of attending a motivational interviewing training seminar.  Motivational interviewing (or MI) is a therapeutic technique in which the clinician helps “motivate” the patient into making healthy lifestyle choices through the use of open-ended questions, acknowledging and “rolling with” the patient’s resistance, and eliciting the patient’s own commitment to change.  The goal is to help the patient make a decision for himself, rather than requiring the clinician to provide a directive or an “order” to change a behavior.

MI is an effective and widely employed strategy, frequently used in the treatment of addictions.  Despite its apparent simplicity, however, it is important to practice one’s skills in order to develop proficiency.  Here, simulations like role-playing exercises can be valuable.  As part of my seminar, I engaged in such an exercise, in which our trainer played the part of a methamphetamine addict while a trainee served as the clinician.

The discussion went something like this:

Clinician:  “How would you like things to be different in your life?”
Patient:  “Well, I think I might be using too much meth.”
Clinician:  “So you think you’re using too much methamphetamine.”
Patient:  “Yeah, my friends are urging me to cut back.”
Clinician:  “How important is it for you to decrease your use?”
Patient:  “Oh, it would really make things easier for me.”
Clinician:  “How confident are you that you could cut back?”
Patient:  “Well, it would be tough.”
Clinician:  “What would make you even more confident?”
Patient:  “If I had some support from other people.”
Clinician:  “Who could provide you with that support?”
Patient:  “Hmm… I do have some friends who don’t use meth.”
Clinician:  “I see.  Can you think of some ways to spend more time with those friends?”
Patient:  “I do know that they go swimming on Thursday nights.  Maybe I can ask if I can join them.”
Clinician:  “I think this would be a good decision.  Can I help you to do this by giving you a telephone call on Wednesday?”
Patient:  “Yes, thank you.”

Of course, I’m paraphrasing somewhat.  But the bottom line is that the whole exercise lasted about ten minutes, and in that ten-minute span, the trainee had taken an ambivalent methamphetamine addict and convinced him to spend an evening with some non-meth-using friends, all through the magic of motivational interviewing.

In real clinical practice, nothing is quite so simple.  And none of us in the room (I hope) were so naïve as to think that this would happen in real life.  But the strategies we employed were so basic (right “out of the book,” so to speak), we could have used this time—and the expertise of our trainer—to practice our skills in a more difficult (i.e., real-world) situation.

It reminded me of a similar exercise in a class during my psychiatry residency, in which our teacher, a psychiatrist in private practice in our community, asked me to role-play a difficult patient, while he would act as therapist and demonstrate his skills in front of our class.  The patient I chose was a particularly challenging one—especially to a novice therapist like myself—who had a habit of repeating back my questions word-for-word with a sarcastic smile on her face, and openly questioning my abilities as a therapist.

During the role-play, I played the part quite well (I thought), giving him the uncomfortable looks and critical comments that my patient routinely gave me.  But this didn’t sit well with him.  He got visibly angry, and after just a few minutes he abruptly stood up and told me to leave the class.  Later that day I received a very nasty email from him accusing me of “sabotaging” his class and “making [him] look like a fool.”  He called my actions “insubordination” and asked me not to return to the class, also suggesting that my actions were “grounds for dismissal from the residency.”

[He also went off on a tangent about some perfectly reasonable—even amiable—emails we had exchanged several weeks earlier, accusing me now of having used “too many quotation marks” which, he said, seemed “unprofessional” and “inappropriate” and demanded an apology!!  He also wrote that in the several weeks of class I had shown him a “tangible tone of disrespect,” even though he had never said anything to me before.  While I believe his paranoid stance may have betrayed some underlying mental instability, I must admit I have not spoken to him since, although he continues to teach and to supervise residents.]

Anyway, these experiences—and others over the years—have led me to question the true meaning of a role-playing exercise.  In its ideal form, a simulation provides the novice with an opportunity to observe a skilled clinician practicing his or her craft, even under challenging circumstances, or provides a safe environment for the novice to try new approaches—and to make mistakes doing so.  But more often than not, a role-playing exercise is a staged production, in which the role-player is trying to make a point.  In actual practice, no patient is a “staged” patient (and those who do give rehearsed answers often have some ulterior motive).  Real patients have a nearly infinite variety of histories, concerns, and personal idiosyncracies for which no “role playing” exercise can ever prepare a therapist.

I’m probably being too harsh.  Role-plays and simulations will always be part of a clinician’s training, and I do recognize their value in learning the basic tools of therapy.  The take-home message, however, is that we should never expect real patients to act as if they’re reading off a script from our textbooks.  And as a corollary, we should use caution when taking our patients’ words and making them fit our own preconceived script.  By doing so, we may be fooling ourselves, and we might miss what the patient really wants us to hear.

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9 Responses to Playing The Role

  1. Iatrogenia says:

    I like the idea of motivational interviewing.

    Excellent point, Dr. Steve, about doctors molding and interpreting conversations with patients into what they want to hear. I’ve experienced this many times myself, and I’m a pretty clear and direct communicator — the doctor stubbornly refusing to hear what I’m say or, infuriatingly, reintepreting it to fit his or her preconceptions.

    When people tell me about these kinds of experiences with their doctors, my suggestion is to tell the doctor you want to develop a relationship of mutual respect. The hope is the doctor will get the hint. If not, it’s a sign to find another doctor.

    In reality, you’ll probably find most people just give up when you don’t listen to what they say — which is probably what most psychiatrists are comfortable with anyway, the silent compliant patient.

  2. Randall Sexton says:

    “And as a corollary, we should use caution when taking our patients’ words and making them fit our own preconceived script.”

    And we should do the same with all theoretical frameworks…not try to fit them to a patient or fit the patient into the theory. I almost puked when studying CBT, MI, narrative therapy (except for Lewis Mehl-Madrona’s narrative therapy), and others. Most of this “stuff” just paralyzes any spontaneous growth. Luckily, I ran into Bradford Keeney and found my “theoretical framework.”

  3. Interesting post. At my medical school, I had a very different experience with role playing, in part because the school employed semi-professional actors who played the same roles over and over again for years. Most of the actors got really into their parts and could be just as challenging as any real patient I’ve faced. I think it’s like any other teaching method – the utility is determined by how well it’s done.

  4. If I were an analyst, I might offer the interpretation that your teacher obviously did not know how to handle the patient you were playing so brilliantly, and instead of admitting his inadequacy, attacked you.

    • Agreed, even non-analysts should see that. It’s hardly unique to the medical or psych setting, though. I’ve been in other classes where the instructor hoped to demonstrate something with a “difficult” Other, and sought a volunteer from the audience. The volunteer then had to walk a tightrope between “tanking” (i.e., being too easy) and resisting more than the instructor was comfortable with. Too much deviation in either direction and the volunteer is blamed for ruining the teaching point.

    • Iatrogenia says:

      I sense competitiveness with Dr. Steve and hostility towards his cleverness and independence. Dr. S wasn’t behaving in a cooperative, predictable way either. Teacher has major control issues that probably led him into psychiatry in the first place.

  5. Carol Levy says:

    I wonder if the difference between the resident vs an actor playing the role is that the actor does not have the same info that the professional ‘docs’ do. They improvise just like a real patient does and so come across like real patients.
    Sorry to always go back to the same example but many chronic pain patients have said they wish their docs could know what it feels like to be us, not only to have chronic pain (can’t think of a way to facilitate that experience, thankfully) but to see what it feels like to be misheard, misinterpreted, disbelieved/dismissed. (For all specialties as far as that goes.)

  6. AA says:

    Hi Carol,

    On a related note, when I worked at a special ed school, we had a session that simulated the conditions of different disabilities. Unfortunately, it didn’t seem to make a difference with changing the attitude of employees. Those who got it, continued to get it and those who didn’t, never did.

    I assuming the same would apply to doctors and that the only thing that might change their attitudes is if they personally experienced a similar type situation.

  7. Carol Levy says:

    AA
    I know some schools have programs where the med students have to ‘be’ a patient so they can practice on each other. Agreed about those who can get it, get those who can’t, can’t. I guess it is a matter of empathy.
    I have heard a lot of people say doctors should have to go through the same experience as they in getting diagnosed or being in the hospital but I can’t think of an ethic that would permit inducing a short bout of diabetes or heart failure. Would that there was a way to safely do that.

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