TO THE EDITOR: As a board examiner, and also as a residency director, the question of using actors as patients on the oral board in psychiatry has been of interest to me. I was very skeptical when I heard about the possibility of using actors in the role of scripted patients on the oral psychiatry examination. This possibility was conveyed to me at the last two examinations by the section directors on my team. In order to prove that it could not work, I established a weekly mock board in which one resident was the patient and the other the candidate. At the same time, the same two staff physicians acted as examiners. The results of this exercise follow and have changed my way of thinking completely.

Because of the logistical difficulty in recruiting patients for the oral board examination in psychiatry, the American Board of Psychiatry and Neurology has explored the option of using patient actors in the oral examination for psychiatry certification. There are several factors that are involved in examining this issue. The costs in time and money for medical centers to sponsor this process are extensive. This has decreased the number of centers that are able to participate in the certification process. It has also been difficult to standardize the patients who are examined. This may give some candidates an advantage if they are able to examine a verbally cooperative patient who provides a lucid and extensive history. Although examiners are urged to factor in the difficulty of the patient in their evaluations, this is often difficult to do. Using patient actors may help to address the above problems. Although there are significant costs involved in training, compensating, and transporting patient actors, these may be offset by better quality control of the examination and the possibility of centralizing the locations of the examination to a single location or smaller number of locations. Evaluating this possibility is another aspect of the continuing process that the board undertakes to improve the reliability, validity, and standardization of its exams.

An alternative view would propose that the difficult patient is part of the examination process and can be factored in, thereby not placing certain candidates at a disadvantage. In psychiatry, there are often challenging patients, and observing how a candidate interacts with different patient types provides the examiners with important information on which to base their evaluation. It is not clear that actors can realistically portray a clinical condition they have not personally experienced. Last, countertransference is often a key aspect of the evaluation process, and this reaction may not occur to the same degree if patient-actors are used in the oral board examination. Any gains that are made in standardizing the process may be more than negated by the new variables it would introduce into the examination.

In order to address these questions, we initiated a weekly psychiatry oral board examination process for our residents at the University of Mississippi College of Medicine. This process has involved one psychiatry resident serving as the patient and another as the examination candidate. Two attending physicians, one of whom is a psychiatry oral board examiner, serve as the examiners. The usual form of the actual examination is rigidly maintained. To simulate some of the anxiety present during the actual examination, the other residents observe their peers going through the process and are allowed to give feedback at the end of the examination. This is done in a positive but honest fashion. The residents state that the process of being observed by the other residents and their residency director does increase the anxiety associated with the process.

We had several questions that we were interested in evaluating when the process began. First, would the examinee feel the examination was a fair reflection of his or her ability as a psychiatrist? Second, did the examining resident interact with the patient-actor as if the actor were an actual patient or simply a fellow psychiatry resident? Third, did the resident playing the patient gain a better understanding of the illness being portrayed and the entire process of the doctor—patient relationship by preparing and participating in this process? Thus, the first two questions evaluated whether the use of patient-actors may be valid in an examination for certification in psychiatry. The third question focused on whether this process was of benefit in the residency training experience. Our feelings are that the two issues are not mutually exclusive, but are different aspects of the same process.

At the beginning of the process, 73% of the residents (18/24) felt that the process would be flawed and not a realistic evaluation of the actual board examination. They voiced the same concerns that have previously been mentioned. They were hesitant to pursue this course, but agreed to, predominantly because of the edict of this residency director. Over the last 3 months, we have had 12 examinations, with a separate resident pair on each examination. We matched the 4th-year and 1st-year residents, and then the 3rd- and the 2nd-year residents together. The more senior resident served as the examinee, with the more junior resident being the patient-actor. No resident has yet repeated the process more than once. The resident results were evaluated by anonymous written evaluation to avoid any potential bias that might have been introduced if the residency director had asked the residents individually or in a group for their feedback. Seventy-five percent of the residents (16/24) stated that their fellow residents had been supportive and not negative toward them during the process.

Ninety-six percent of residents (23/24) have seen the process as very helpful and pertinent to their training. Eighty-three percent of the examinees (10/12) felt that the process was a fair evaluation of their abilities as a psychiatrist. Ninety-six percent (23/24) of the residents felt that the actors were believable and that the transition in their thinking took less than an average of 5 minutes during each examination. Eighty-three percent of the residents (20/24) now viewed the activity as the most important formal teaching activity of the residency. Of interest, all 12 of the patient-models had a positive experience playing the role of the patient. They felt that it accomplished several things. The residents stated that they learned more about the condition under discussion than if they had read about it in a book or heard about it in a lecture. All 12 claimed to better understand what their patients might experience in the doctor—patient relationship after having served in the patient role. Eighty-seven percent of the residents (21/24) recognized that a degree of transference or countertransference had developed during the examination. This process involved 100% (12/12) of the residents in the patient-actor role and 75% (9/12) of the residents in the examinee role. The specific emotions evoked were not evaluated for in this study.

Our experience at the University of Mississippi has been overwhelmingly positive. As a residency director, the process has given me a better idea of the progress of my residents by viewing them in both the role of the examinee and patient. Residents have gained a better idea of how the board process works and what it will be like to take the actual certifying examination. My perception is that it has been a unifying experience for our residency program. I am aware that there is a vast difference regarding what may be a good educational experience for a resident in training and an attending physician taking the boards for certification. It is also not clear whether residents are better able to simulate patients than would trained lay actors.

Our experience would suggest that the use of qualified patient-actors may be effectively used during the actual oral board examination in psychiatry. The process was not interpreted by the residents as artificial and was viewed as valid for evaluating their clinical abilities as psychiatrists. It is hoped this experience will encourage other residency directors to initiate a similar process in their programs. We have found it to be very helpful and well received. This may also give the American Board of Psychiatry and Neurology more information in potentially considering this method of evaluation for the oral certifying examination. Clearly, more study and experience are needed before firm recommendations can be considered.