Metadiscourse, materiality and morality in communication skills training with simulated patients

Simulated patients (also known as standardized patients) are commonly employed by institutions of medical education to train medical students and assess their communication skills. This article demonstrates that such patients are not translational devices that enact prima facie standards of communication skills as laid out by the institutions that use them, but rather metadiscursively transform communication practices. This is shown via a case study that closely examines a series of interactions between a simulated patient and a third-year medical student during a practice exam designed for the United States Medical Licensing Examination Step 2 Clinical Skills. I use discourse analysis to show how communication skills are transformed in three practices: (1) simulated consultations between standardized patients and medical students; (2) spoken evaluations offered by standardized patients after simulated consultations between standardized patients and medical students; and (3) written evaluations offered by standardized patients in assessment forms. In particular, by attending to how a simulated patient makes the act of draping the patient a relevant communication skill, I explicate the material elements and moral implications of clinical communication. Finally, I consider the instructive role simulated patients play in medical education and how their standards build on and often stand in contrast to communication skills techniques. I conclude by making practical suggestions for communication skills training with simulated patients in medical education.