LD Role Players in Medical Exams
It is widely recognised that people with learning disabilities receive a poorer quality of healthcare than their non-disabled counterparts. The confidential inquiry into premature deaths of people with learning disabilities (CIPOLD, 2013) highlighted unacceptable inequalities in healthcare for this group and found that 37% of deaths of people with learning disabilities could have been avoided. It followed the publication of Death by Indifference (Mencap, 2007), which again exposed unequal healthcare and institutional discrimination of people with learning disabilities within the NHS. The purpose of our work was to pilot and create an OSCE station to use actors with learning disabilities as simulated patients in the assessment of trainee psychiatrists.
Many doctors report that they lack confidence in working with people with learning disabilities and a poll conducted by the General Medical Council showed that more than half of the doctors believe that people with learning disabilities receive a poorer standard of healthcare and that they feel they lack the resources and appropriate training to deliver equal healthcare to this group of patients. The GMC website http://www.gmc-uk.org/learningdisabilities/ now has a dedicated web page with an interactive learning module on issues relevant to treating patients with learning disabilities.
With this in mind, the first station using actors with learning disabilities was in the ‘treatment explanation’ category. A ‘boundary violation’ component was incorporated, where the role player asks the candidate one or two personal questions which they should avoid answering directly in order to maintain appropriate professional boundaries.
- Recruiting and training role players with learning disabilities through PRP+ LD Course
- Piloting a station before use in the Clinical Assessment of Skills and Competencies (CASC) Examination
- Successfully implementing a new station requiring actors with learning disabilities for the CASC Examination
PRP recruited actors with learning disabilities and held a PRP+ Induction Course in London to educate them on the difference between acting and role play as this concept is a fundamental requirement in making the exam a success. For the pilot they required one actor, who was sent a description of the character in advance of the pilot day. PRP created a bespoke PRP+ LD Course which involved teaching our 4-stage standardisation model, multiple rehearsals and learning about the job requirements, environment, timetable, content and structure of the exam. During the pilot, the scenario was run with mock candidates 6 times at Bart’s Hospital, London. The station was observed by several psychiatrists who looked at consistency, content and delivery. With this they were able to demonstrate that an actor with learning disabilities was able to learn the scenario and deliver a realistic performance. From the pilot session, we observed each performance in a controlled setting to produce a station that is quality assured.
The first CASC incorporating a station using actors with learning disabilities took place in January 2013. To run 8 parallel circuits, more actors were needed and were sourced by PRP. Bespoke PRP+ LD Courses were run in London, Leicester and Bradford. PRP+ LD training included dividing the group into pairs to role play a seven minute mock trainee psychiatrist-patient interview. By taking turns in playing both the trainee psychiatrist and patient roles they were able to gain firsthand experience of the time limitations candidates would face and also how it felt to be a doctor asking questions and a patient delivering answers. Calibration of the role was paramount to ensure that each candidate experienced a similar performance, thus helping to make sure the examination is fair and reliable.
The first time we used the station in the MRCPsych examination in 2013, the role play went extremely well. The actors were requested to arrive early for a pre-exam rehearsal. The PRP facilitator divided the actors into small groups and they worked with a volunteer psychiatrist who performed the role of the candidate. This finalised the calibration of the role play prior to the exam starting. The CASC required 8 parallel stations and 14 actors, so that they could be given breaks for contingency planning.
Feedback from examiners was extremely positive; believing it was a good test of candidates’ communication skills. They suggested that more stations with actors with learning disabilities should be included in future examinations. The external Lay Observer commended the College on the inclusion of the station and said that she was impressed by the care taken of the role players by PRP. By the second time using this station the Observer commented on the excellence of the role player briefing and special practice sessions that PRP and our facilitators ran on the day of the examination.
The inclusion of our role players with learning disabilities in assessment of psychiatry trainees has so far received excellent feedback and is breaking new ground in assessments.
A more detailed report has been written by S. Soni, I. Hall, P. Doulton and P. Bowie which can be found here: https://www.europsy-journal.com/article/S0924-9338(16)00816-6/abstract
CIPOLD (2013) “Confidential Inquiry into premature deaths of people with learning disabilities final report”, University of Bristol, available at: http://www.bristol.ac.uk/cipold/fullfinalreport.pdf (accessed 25 March 2014)
Mencap (2007) “Death by indifference”, available at: http://www.mencap.org.uk/sites/default/files/documents/2008-03/DBIreport.pdf (accessed 25 March 2014)