Recruitment, Retention, and Training of African American and Latino Standardized Patients: A Collaborative Study

INTRODUCTION

The use of standardized patients (SPs) in medical, dental, nursing and other health professions education is widely documented.^1-10 However, the use of Latino and African American SPs are few and far between. Based on personal communication with other SP educators, African American and Latino SPs reflect less than 30% of their total SP databases. There is a gap between recruitment and retention of Caucasian SPs compared to minority SPs. African American and Latino groups were chosen for this study because of their increased numbers in the U.S. population,¹¹ under-representation in current SP databases, and the ongoing challenges associated with the recruitment, retention, and training of these populations.

In an effort to identify factors that affect the recruitment, retention and training of Latino and African American standardized patients, the Center for Studies in Clinical Excellence (CSCE) at the University of Colorado and the Keck School of Medicine of the University of Southern California (USC KSOM) partnered with independent researchers to conduct telephone interviews with Latino and African American Standardized Patients. The perspective of these Standardized Patients on recruitment, training, and retention was the focus of the interviews.

MATERIALS AND METHODS

In May 2002, ¹⁷ African American and nine Latino standardized patients who currently work or had previously worked in the standardized patient program at the University of Colorado (CU) were interviewed. The same study was repeated at the University of Southern California (USC) in October 2003, where ten African American and ten Latino standardized patients were interviewed. The telephone interviews elicited issues that affect recruitment, retention, and training from the SPs’ perspective.

A list of potential SP participants was developed from current standardized patient databases. At USC, African Americans and Latino SPs form about 15% of the total SP pool; in Colorado, they form about 20%. The selection criteria were based on demographics: race/ethnicity, English speakers, males and females, aged 20 and older, and current or past employment in a standardized patient program. Phone calls were made to African American and Latino standardized patients to explain the purpose of the study. Subsequently, 68 letters were sent which included the purpose of the study, the process to become a study participant, the consent form, and the promise of a $25.00 check to all participants who completed an interview. Forty-six SPs responded and were scheduled for an interview with an African American or Latino interviewer respectively.

An interview was administered to all volunteer subjects that focused on recruitment, training and retention issues. Recruitment questions included how they had heard about the program, their previous experiences with the health care system, and their reasons for deciding to become a standardized patient. To elicit information about the training of SPs, participants were asked about their preferred learning styles, any aspects of the training that made them feel uncomfortable as well as how the training could better prepare them to be SPs. Interviewers also asked what could be done to improve retention of SPs. Trained interviewers used open-ended and probing techniques to elicit information from the participants (Table 1). The phone calls were audio taped, transcribed and later analyzed.

Interview transcripts served as the primary data source for analysis. The Microsoft Word transcript files were entered into Atlas Ti qualitative data analysis software and analyzed using an “open coding” or “editing” approach.¹² This analytic process includes use of transcripts to identify key themes in each interview and subsequently to determine whether these themes are common or unique.¹³ Members of the analysis team (two qualitative researchers: a Ph.D. social psychologist and an MPH social worker) independently read through the transcripts, highlighting particular issues, examples, or quotes each considered important. The analysts were not associated with either of the SP programs, and could therefore be determined as objective and non-biased. The analysts met to discuss preliminary themes, and subsequently re-reviewed transcripts to confirm or disconfirm initial themes and codes. The team then organized these results into a summary report.

Institutional Review Board (IRB) approval was obtained for this study from both CU and USC.

RESULTS

Six common themes emerged from the interviews. They are Strategies for Recruitment, Impact of Personal Experience, Decisions to Become a Standardized Patient, Training of Standardized Patients, Retention of Standardized Patients, and Perceived Benefits of Being a Standardized Patient. The following quotations are actual SP comments related to the themes. Latino comments are identified by (L) and African American comments are identified by (AA).

Strategies for recruitment
Of the 46 African American and Latino standardized patients who participated in the study, nearly all the USC interviewees described themselves as actors, and many had heard about the SP program through their acting teachers or colleagues. At USC, 70% of the SPs were recruited through colleagues and 30% through acting teachers. This was not surprising as it was in Los Angeles. In Colorado, 70% were recruited by fellow SPs or through colleagues, 20% were recruited by targeted e-mail lists, flyers, or Spanish newspapers, and 10% through acting groups.

“I first heard about it through another Standardized Patient, who was an actor friend of mine and we belonged to the same theatre group”. (AA)

“It was actually in my theater class about maybe a year ago. My theater teacher – she told us about the program and she asked us if any of us would like to do this and she put our name down.”(AA)

“It was through a Head Start Newsletter.”(L)

“I was actually in an elevator in the University of Colorado Health Sciences Center School of Medicine and saw a flyer.” (AA)

“My husband…saw an ad in La Voz.” (L)

“First on the Internet. On the Health Centers where they sent out announcements for recruiting.” (AA)

Impact of Personal Experience with the Health Care System
Some of the interviewees reported previous positive experiences with the health care system; others had negative experiences, or disappointments with the system, or had heard stories from family members or friends about lack of respect or inadequate treatment in the health care system. For many, these experiences created a personal motivation to improve the health care system by becoming a Standardized Patient.

Table 1. Interview Questions for Standardized Patients Study

Before we begin the interview itself, I wanted to ask you if you are currently a Standardized Patient? (If not, how long did you participate in the Standardized Patient Program?)

Thank you. Now I will begin the interview by asking you some general questions about how you were recruited as a Standardized Patient.

1. Would you tell me how you first heard about the Standardized Patient program?
   • What made you decide to apply? What influenced your decision to apply/participate in the Standardized Patient program? ($, service to community, fun, meeting new people, curiosity, etc.)
   • Were you recruited by a minority Standardized Patient or a minority Standardized Patient educator?
   • How did this recruitment influence your decision to apply or participate?
   • Usually when people make decisions they look at both the pros and cons of doing something. What would you say are some of the “cons” to being a Standardized Patient?
   • Would you describe how trust or lack of trust might have influenced your decision to apply or participate in the Standardized Patient program?
   • How have your previous experiences with the health care system influenced your decision to apply or participate in the Standardized Patient program?

2. The next set of questions asks about the Standardized Patient training. (Note: All Standardized Patients should be asked question #1. If the Standardized Patient has not participated in any training sessions then proceed to #3, retention questions.)
   • What is your preferred learning style? (Note: If minimal or no response, interviewer may say: “Do you learn best when you hear information, see or visualize information or when you can have hands on interactive experience?”)
   • How did the training fit with the way you like to learn?
   • Describe any aspects of the training that made you feel uncomfortable.
   • Describe particular ways the Standardized Patient training could better prepare you to be a Standardized Patient.

3. The last part of this interview has to do with retention“what keeps Standardized Patients on and what causes them to leave. (Note: All Standardized Patients should be asked the questions below.)
   • Have you been confirmed for a case simulation or portrayal? If not, can you tell me what’s kept you from participating? If so, please describe any aspects of the training or portrayal that made you feel uncomfortable.
   • Describe what you consider to be the most important factors in retaining Standardized Patients.
   • How could the communication or interactions around orientation/interviews, scheduling, training or project participation be improved? (Note: If minimal or no response, interviewer may say: “We’ve heard from some SPs that they didn’t feel supported, had been offended, intimidated or embarrassed during the interview, training or portrayal. Can you tell me about any of these that you might have experienced during your time as a Standardized Patient?)
   • Are you still working as a standardized patient?

   If no, what made you decide to leave the program? If yes, proceed to question #4.

4. Is there anything else you’d like to tell me about your experiences in the Standardized Patient program?

Thank you so much for your help with this interview. Again, your comments will remain confidential and will not be linked with your name. The information from these interviews will be used to help make improvements in the Standardized Patient Program. I will include your name on the list of people who have been interviewed and you will receive a check from the Standardized Patient Program.

… past experiences with some health care providers and not feeling like an important person in their office while I’m there. I want to be involved (as an SP) so the future medical providers get to see diverse people in the community so they will be able to work with other sorts of patients in the future.” (AA)

“our people do suffer from lack of education, resources, lack of a lot of things and I feel that maybe by doing the SP thing that maybe somewhere I can help a doctor better understand our culture, our language, how we interact with other people.” (L)

“I know there is a real mistrust of the medical community from my generation and generations before because of past experiences with feeling used as guinea pigs for research, but once I got into the program I saw where my being in the program would make a positive out of this.”(AA)

“I have had really bad experiences, things that were probably avoidable had doctors been on the job. So it has impacted my whole life thanks to the medical community, so yes, it heavily influenced my decision – I mean it’s nice to complain, but it’s good to have the opportunity to be part of the solution. Save the next poor sucker!” (AA)

Decision to become a Standardized Patient
A number of themes emerged: altruistic motivations – their desire to improve the way doctors interact with patients of color; interest in becoming involved in the medical school activities; the appeal of being part of an academic setting; financial rewards; acting opportunities with new roles and a chance to work on acting skills.

“One of the good things about the program is that you have a chance to maybe do something about how doctors perceive and how they treat patients. You can help make it to where it is not … doctors coming in and you being treated like a number or just another insurance claim. At this stage of the doctor’s development, the potential doctor’s development, you have a chance to let the student know that you are a human being and a live encounter, or whatever. So that’s certainly a reason why I entered into it”. (AA)

Well, I think that there are some cultural obstacles to minority people availing themselves of opportunities to improve their health and I felt by being involved I could contribute positively to more people – minorities – taking advantage of the opportunities to live healthier lives. (AA)

…what I’m hoping we are doing is, I’m hoping we are helping the future doctors to refine their interpersonal skills. What I’ve found is that a lot of these kids are high in terms of book knowledge, or in terms of the medical knowledge but a lot of them are sorely lacking in how they deal with people on a 1-1 basis and what good is it to be a brilliant physician if you don’t know how to talk to your patient? (AA)

Well, again, it goes back to being a service. They need to get used to Black people if they are not already. So, you know, I might as well be the one to extend that opportunity. (AA)

“I think…being in touch with the medical field, it is very, very important to get feedback from a neutral person on how somebody that wants to be in the medical profession handles their bedside manner, care and how they talk to a patient. I think that feedback is good for them [medical students] to know, to help better their education and their being a professional…just to be a help.” (AA)

“Money…I did not know anything much else about it other than they were paying actors.” (L)

“I thought it would be really interesting and fun and…you get paid for it, and I personally enjoy being around medical students and the facilitators–most of them. The facilitators I thought were pretty intelligent people and I just enjoy being in that atmosphere with that kind of educated people…I appreciated being at the University of Colorado.” (AA)

“Just meeting new people, curiosity, I guess.” (L)

“I am an actress and it was something to do that would be fun…”(L)

Training of Standardized Patients
Participants expressed diverse opinions in their assessment of training. Most felt it was quite good, while others suggested that it could be made better. The preferred style was “hands on” learning and role-play. Common themes included the need to practice, to review videos, and to receive ongoing feedback.

“They would act it out, or what’s good, what is positive feedback, what is negative feedback for the student… and then just from hearing them talk about it and telling us what they needed to do or what works or what doesn’t work. I know that I’m a visual learner. If I just hear and don’t see, that doesn’t work very well for me.” (AA)

“Hands-on works a little bit better for me. It’s almost like working on stage as opposed to sitting down and reading the script. I learn better because I’m participating and able to see and understand exactly what it is I’m doing as opposed to reading something and trying to imagine it. I can actually read it and then take all that in and then do it and then be able to verbalize it. So it’s all three [learning styles] combined.” (AA)

“I think if you had actual licensed physicians teaching the cases and doing the training as opposed to another SP Trainer training you, then…so if there are certain medical questions that come up that we don’t understand, he can answer them. Whereby another SP who is training you wouldn’t be able to. They would have to go, “Oh I’m not really sure, so I need to check with Dr. So and So.”(AA)

“…the more portrayals that I perform, the better SP I become … it just becomes more comfortable and gives the student at better chance of success with what they are trying to accomplish. .. I’m more in the groove instead of six months or six weeks and then having to pop back into it again.” (AA)

“I think maybe a more in-depth explanation including a video tape of previous session examples of what goes on, would make somebody better prepared and more aware of what was expected of them…I think that it would be beneficial to understand what it is that the student MD’s are looking for, so that learning the script you can be better able to gauge what is important. I’ve spent a lot of time learning specifics that are never used in the actual exams.” (L)

“…finding out the education (level) of the people’s background, how far they’ve gone with it and how much they need to go on. When you are an older person it is harder to catch the material and sometimes you are slower.” (L)

“I think they were going to fast and I am a slow learner…give me a little more time to understand the material.” (L)

Retention of Standardized Patients
Common themes related to retention were structural changes and procedural improvements. Structurally the SPs would like increased frequency of work, higher and timely payments, and more opportunities for rehearsal or practice before portraying with the students. They also wanted increased attention to refreshments, including water, especially when they were doing multiple portrayals.

Procedural improvements included increased communication and feedback from the SP program as well as a mechanism for sharing feedback with the learners. SPs wanted to know how they were doing and expressed the desire to have their portrayals observed by physicians and given an opportunity to ask questions. They also wanted an opportunity to understand their portrayal from a medical perspective. They wanted to be assigned to cases that match their individual SP strengths and wanted more “colorblind” cases. They wanted appreciation and respect from the doctors and more professional treatment by students.

“Only that it has been by and large very positive…I’d like to get paid a little quicker and I’d like to get paid a little more, but other than that, it has been a very positive experience.” (L)

“The monetary factor is a big one. Not necessarily for me but I think for the majority. Financial compensation would be a priority for retaining people… at least try to keep people involved in the process. Even if there are no cases coming up, maybe sending information just to keep their interest sparked, to keep them wanting to participate.” (AA)

“I prefer to be paid twice – once at the end of training, and once after I have done the gig.” (L)

“Some schools pay more than others – There should be a standard set for the payment.” (AA)

“I would like to see more minority cases portrayed. And possibly more contemporary concerns of minorities…sexual dysfunction, Sickle Cell Anemia, cultural obstacles such as diet and life style. Things of that nature.” (AA)

“One of the problems I have and one of the complaints that I have is sometimes the cases that are only given to people of color, or cases where that particular illness or disease is more prominent – for example, hypertension. Usually, I always get hypertension cases. I understand that the percentage of hypertension runs higher in African American communities, but I’d like to be able to do some cases that are colorblind. Where race doesn’t have anything to do with it.” (AA)

“Gaining their (SPs) trust, building up the trust between the coordinators and the patients. Making them feel comfortable in their portrayals and that they will be protected. Also working on cases that I know are really, really relevant…relevant to the concerns of the community…”(AA)

“I know of a particular case where the gal didn’t want to do one particular portrayal only because she had a very strong accent and the doctor made her feel so uncomfortable she was practically in tears…they are uncomfortable with how the doctors may view them.” (L)

“Know what your SPs weaknesses and strengths are and if you have an SP that has a particular strength and you have a case that correlates with that particular strength, then give that case to that SP. Try to give them cases that they will find challenging. Because a lot of times as an SP you get tired of doing the same case year after year after year, so switch it around sometimes. Offer them a different case. Offer them something that is more challenging to them. What happens after awhile if you’ve done the same case over and over again, I think you have a tendency to try to just walk through it.” (AA)

“I might have had a lack of trust when I first started, but as I got to know the program and met the people I met, I built up more trust than I had when I started. I ended up thinking that it (my participation as an SP) did make a difference and that I wouldn’t mind staying in a program like this.” (AA)

A Latina standardized patient who is no longer in the SP program told an interviewer: “A lot of the girls in the SP program were from Colombia and I have learned to hate Colombian women because of the SP program…because I was speaking what I knew about how to say a word and they would correct me and say…this is how we say it. …That is how they speak Spanish in Colombia. I wasn’t born in Colombia. I’m not Colombian. …I speak the Spanish that I was taught by my mom and dad and they wanted me to speak Colombian Spanish…The girls that are in there are very, very intimidating. I mean they intimidated me to where I didn’t go.” (L)

Perceived Benefits of Being a Standardized Patient
Several participants spoke of the benefits they’ve experienced from being part of the SP Program, including what to look for when choosing a physician and becoming more flexible with acting.

“Well, my experience is basically that I’ve learned to know what to expect from my own physician. I happen to have a good physician now. I’ve been in pain over the last year and a half and I’ve been able to tell from working with the medical students, what to appreciate and what to look for in a physician and that helped me out on what to ask them and what to expect from them…so it made my relationship with the real doctors that I’ve met to work on me, more fluid and more vivid. Because we can communicate better as far as what I’m looking for as a patient and what I’m expecting from them as a service from them as my physician. That’s how it’s helped me out.”(L)

“…as a performer – as an actor – it made me more flexible in a way that I can turn on a dime or be more improvisational, even though we are all scripted, but it has helped me as a performer as well, to be more flexible and more real in dealing with people.”(AA)

DISCUSSION

Our goal was to identify factors that affect recruitment, retention, and training of African American and Latino standardized patients. The study is based on a sample of SPs from two medical schools – one public and one private, with different pay schemes for SPs.

This study has provided “IN THEIR OWN WORDS” ways to enhance AND sustain diversity within our SP Programs and in medical education. While we chose to focus on African American and Latino Standardized Patients, we realize that the data is useful in recruitment, retention, and training of other targeted groups.

King, Perkowski-Rogers and Pohl¹⁴ stated in their paper that recruitment was conducted through their clinical faculty patient population: volunteer, retirement and community organizations, disease-focused foundations, theatre groups, and existing sources within medical centers and hospitals. Referrals from practicing SPs were reported as their best source, by experienced trainers. Our findings suggest that recruitment strategies of minority SPs would follow somewhat similar lines but would need to be based on the target population. Use of local language newspapers, flyers, and theater groups from the respective communities was found to be invaluable. Referrals from fellow SPs were also a valuable resource.

Training of SPs usually follows the method suggested by Barrows¹⁵ with three training sessions, where in the first session, the SP is oriented to an overview of the patient that the SP will be portraying, focusing on the history. The second session is the review of the SPs simulation of the history and coaching on simulation of the physical findings. The third session is a quick review of both history and physical findings, with further fine-tuning by the expert. Last is the “dress rehearsal” with a clinician unfamiliar with the case. The SPs who participated in the study discussed the need for more time to learn the material, evening or weekend training sessions, the desire to view videotapes of previous SPs portraying the patient, the desire for “hands-on” training; and for more feedback. The authors do not feel that these issues are pertinent only for minority SPs but to all SPs as they are all adult learners. The desire for feedback, the viewing of videos, and “hands-on” learning are all related to “situated cognition” – a recent theory of learning emerging from cognitive psychology.¹⁶ This theory states that activity in which knowledge is developed and deployed, is not separable from or ancillary to learning and cognition. Rather, it is an integral part of what is learned. Situations might be said to co-produce knowledge through activity. Learning and cognition are thus fundamentally situated. The implications of situated learning are that the instructional designer moves from the organization of content and sequence to the creation of environment that induce, then facilitate, understanding; and the teacher assumes a different role: from a knowledge transmitter to a coach or facilitator of students’ understanding.^{17, 18} These could prove to be useful strategies in training SPs.

Retention of SPs is an issue that has not been widely discussed in the literature. This study shows that minority SPs are more likely to remain active if there are consistent opportunities to portray cases, sensitivity and respect to cultural and class difference, and ongoing feedback. The SPs in this study wanted more opportunities to portray cases so they could count on and plan for the work. For many of them, their SP work was in addition to a regular job. They are interested in cases that would teach better interpersonal and cross-cultural communication skills to the health sciences learner, and prefer fewer cases that simply stereotype the social, cultural, or economic dimension of their race, including language. Some prefer to portray more cases that do not focus primarily on specific diseases that are prevalent in their race such as hypertension or sickle cell disease. Meanwhile others were interested in cases that teach cultural awareness and sensitivity. They want to portray cases that address real life issues happening in their family or in their community.

The SPs said they liked to receive timely feedback on their overall performance including their standardization and checklist accuracy. SPs who provide verbal feedback to learners like to receive training on how to give effective feedback as well as receive suggestions on their feedback technique and style.

Other retention strategies discovered in this study were the importance of paying standardized patient for their training and portrayal time, providing food and water especially on long days and having their parking paid. They also appreciate knowing when they will receive payment for their work and may prefer to be paid at the completion of training instead of at the end of the entire project. Several of the USC interviewees talked of working for more than one SP program in California and that their compensation varied among the schools. A competitive wage may also contribute to SP recruitment and retention.

CONCLUSIONS

There is an increased need for diverse standardized patients in medical education as curricula continues to reflect the changing demographics and increased cross-cultural exchanges taking place daily in hospitals, clinics and throughout the community. This study brings to light potential barriers to recruitment, retention, and training of African American and Latino standardized patients and offers effective strategies that could prove useful in enhancing the experience of learners in the health professions as well as influence the future of medical education.

This project received funding support from the Center for Studies in Clinical Excellence (CSCE) and the Association of Standardized Patient Educators (ASPE).

REFERENCES

1. Adamo, G. Simulated and standardized patients in OSCEs: Achievements and challenges 1992-2003. Medical Teacher. 2003; 25(3): 262-270.
2. Barrows, H.S. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine. 1993; 68: 443- 451.
3. Ferrell, B.G. Clinical Skills Assessment with standardized patients. Medical Education. 1995; 31(2): 94-98.
4. Williams, R.G. Have standardized patient examinations stood the test of time and experience? Teaching and Learning in Medicine. 2004; 16(2): 215-222.
5. Swartz, M.H. and Colliver, J.A. Using standardized patients for assessing clinical performance: An overview. The Mount Sinai Journal of Medicine. 1996; 63: 241-249.
6. Zraick, R.I., Allen, R.M. and Johnson, S.B. The use of standardized patients to teach and test interpersonal and communication skills with students in speech-language pathology. Advances in Health Sciences Education. 2003; 8: 237-248.
7. Hampl, J.S., Herbold, N.H., Schneider, M.A. and Sheeley, A.E. Using standardized patients to train and evaluate dietetics students. Journal of the American Dietetics Association. 1999; 99: 1094-1097.
8. Logan, H.L., Muller, P.J., Edwards, Y. and Jakobsen, J.R. Using standardized patients to assess presentation of a dental treatment plan. Journal of Dental Education. 1999; 63: 729-727.
9. Stroud, S.D., Smith, C.A., Edlund, B.J. and Erkel, E.A. Evaluating clinical decision-making skills of nurse practitioner students. Clinical Excellence of Nurse Practitioners. 1999; 3: 230-237.
10. Ebbert, D.W. and Connors, H. Standardized patient experiences: evaluation of clinical performance and nurse practitioner student satisfaction. Nursing Education Perspectives. 2004; 25(1): 12-15.
11. National Center for Health Statistics. “Health, United States 2002, with health and aging chartbook.” http:www.cdc.gov/nchs/data/hus/hus02cht.pdf [accessed 2004]
12. ATLAS-ti (Computer Software). Scientific Software Development: Berlin, 1999.
13. Addison, R.B. A grounded hermeneutic editing approach. In Doing Qualitative Research, Crabtree, B.F., Miller, W.E. (eds). Sage Publications: Thousand Oaks, CA. 1999.
14. King, A.M., Perkowski-Rogers, L.C. and Pohl, H.S. Planning standardized patient programs: case development, patient training, and costs. Teaching and Learning in Medicine. 1994; 6: 6-14.
15. Barrows, H.S. Simulated (Standardized) patients and other human simulations. Springfield, Illinois, 1987.
16. Merriam, S.B. An update on adult learning theory. San Francisco: Jossey-Bass, 1993.
17. Jeong-Im, H. M. Situated Cognition and learning Environments: Roles, Structures, and Implications for design. http://tecfa.unige.ch/staf/staf-e/pellerin/staf15/situacogn.htm [accessed 2003]
18. Smith, M. K. Communities of practice. The encyclopedia of informal education. 2003 www.infed.org/biblio/communities_of_pratice.htm [accessed 2004]