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


  • Grace Peters Colorado State University



communication skills, discourse analysis, medical education, metadiscourse, simulation-based education, standardized 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.

Author Biography

Grace Peters, Colorado State University

Grace Peters received her PhD in Communication from the University of South Florida and is currently an Instructor of Veterinary Communication at Colorado State University. As a discourse analyst, she examines matters of communication in health contexts, striving to apply her findings to improve professional education and practice. Her most recent publication is ‘The role of standardized patient assessment forms in medical communication skills education’, in Qualitative Research in Medicine and Healthcare (2019). 


Atkins, Sarah and Celia Roberts (2018) Assessing institutional empathy in medical settings. Journal of Applied Linguistics and Professional Practice 13 (1–3): 11–33.

Atkins, Sarah, Celia Roberts, Kamila Hawthorne and Trisha Greenhalgh (2016) Simulated consultations: A sociolinguistic perspective. Biomed Central Medical Education 16 (1): Art. 16.

Barad, Karen (2003) Posthumanist performativity: Toward an understanding of how matter comes to matter. Signs: Journal of Women in Culture & Society 28 (3): 801–831.

Barrows, Howard S. (1993) An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine 68 (6): 451–453.

Bartesaghi, Mariaelena and Theresa Castor (2009) Tracing our steps through communication social construction: Six propositions for how to go on. In Gloria J. Galanes and Wendy Leeds-Hurwitz (eds) Socially Constructing Communication, 225–243. Mahwah, NJ: Hampton Press.

Becker, Kathleen, Linda E. Rose, Janet B. Berg, Hyunjeong Park and John H. Shatzer (2006) The teaching effectiveness of standardized patients. Journal of Nursing Education 45 (4): 103–111.

Bergmann, Jörg R. (1998) Introduction: Morality in Discourse. Research on Language and Social Interaction 31 (3–4): 279–294.

Blatt, Benjamin, Margaret Plack, Samuel Simmens, Joseph Lopreiato, Katherine Berg, Jacqueline Klevan and Karen Lewis (2016) Do standardized patients have concerns about students not captured by traditional assessment forms? Teaching and Learning in Medicine 28 (4): 395–405.

Boulet, John R., Andre De Champlain and Danette W. McKinley (2003) Setting defensible performance standards on OSCEs and standardized patient examinations. Medical Teacher 25 (3): 245–249.

Browning, Larry Davis (1992) Lists and stories as organizational communication. Communication Theory 2 (4): 281–302.

Caronia, Letizia and Luigina Mortari (2015) The agency of things: How spaces and artefacts organize the moral order of an intensive care unit. Social Semiotics 25 (4): 401–422.

Cameron, Deborah (2000) Good to Talk? Living and Working in a Communication Culture. London: Sage.

Committee on Quality of Health Care in America (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.

Cooren, François and Fabienne Malbois (eds) (2019) Methodological and Ontological Principles of Observation and Analysis: Following and Analyzing Things and Beings in our Everyday World. New York: Routledge.

Craig, Robert T. (1999) Communication theory as a field. Communication Theory 9 (2): 119–161.

Craig, Robert T. (2016) Metacommunication. In Klaus Bruhn Jensen, Robert T. Craig, Jefferson D. Pooley and Eric W. Rothenbuhler (eds) The International Encyclopedia of Communication Theory and Philosophy, 1–8. New York: John Wiley & Sons.

de la Croix, Anne and John Skelton (2009) The reality of role-play: Interruptions and amount of talk in simulated consultations. Medical Education 43 (7): 695–703.

de la Croix, Anne and John Skelton (2013) The simulation game: An analysis of interactions between students and simulated patients. Medical Education 47 (1): 49–58.

de Swaan, Abram (1990) The Management of Normality: Critical Essays in Health and Welfare. New York: Routledge.

Eagles, John M., Sheila A. Calder, Kristen S. Nicoll and Leslie G. Walker (2001) A comparison of real patients, simulated patients and videotaped interview in teaching medical students about alcohol misuse. Medical Teacher 23 (5): 490–493.

Fairclough, Norman (2013) Language and Power. London: Longman.

Goffman, Erving (1959) The Presentation of Self in Everyday Life. Garden City, NY: Doubleday.

Hafferty, Frederic W. and Brian Castellani (2009) The hidden curriculum: A theory of medical education. In Caragh Brosnan and Bryan S. Turner (eds) Handbook of the Sociology of Medical Education, 29–49. London: Routledge.

Hak, Tony and Fijgje de Boer (1994) Formulations in first encounters. Journal of Pragmatics 25 (1): 83–99.

Heath, Christian (1986) Body Movement and Speech in Medical Interaction. Cambridge: Cambridge University Press.

Heritage, John and J. Maxwell Atkinson (1984) Structures of social action. In J. Maxwell Atkinson and John Heritage (eds) Structures of Social Action: Studies in Conversation Analysis, 299–345. Cambridge: Cambridge University Press.

Heritage, John and Douglas Maynard (2006) Communication in Medical Care: Interaction between Primary Care Physicians and Patients. Cambridge: Cambridge University Press.

Iedema, Rick (2011) Discourse studies in the 21st century: A response to Mats Alvesson and Dan Kärreman’s ‘Decolonializing discourse’. Human Relations 64 (9): 1163–1176.

Iedema, Rick, Su-Yin Hor, Mary Wyer, Gwendolyn L. Gilbert, Christine Jorm, Claire Hooker Matthew Vincent and Neil O’Sullivan (2015) An innovative approach to strengthening health professionals’ infection control and limiting hospital-acquired infection: Video-reflexive ethnography. British Medical Journal: Innovation (1): 157–162.

Johnston, Jennifer L., Gerard Lundy, Melissa McCullough and Gerard J. Gormley (2013) The view from over there: Reframing the OSCE through the experience of standardised patient raters. Medical Education 47 (9): 899–909.

Jones, Rodney (2016) Spoken Discourse. London: Bloomsbury.

Nestel, Debra and Margaret Bearman (2015) Simulated Patient Methodology: Theory, Evidence, and Practice. Chichester, UK: Wiley Blackwell.

Marín Arrese, Juana I. (2015) Epistemicity and stance: A cross-linguistic study of epistemic stance strategies in journalistic discourse in English and Spanish. Discourse Studies 17 (2): 210–225.

Peters, Grace (2019) The role of standardized patient assessment forms in medical communication skills education. Qualitative Research in Medicine & Healthcare 3 (2): 76–86.

Polanyi, Livia and Annie Zaenen (2006) Contextual valence shifters. In James E. Shanahan, Yan Qu and Janyce Wiebe (eds) Computing Attitude and Affect in Text: Theory and Applications, 1–10. Dordrecht: Springer.

Pomerantz, Anita (1986) Extreme case formulations: A way of legitimizing claims. Human Studies 9 (2–3): 219–229.

Rees, Charlotte and Lynn C. Monrouxe (2008) ‘Is it alright if I-um-we-unbutton your pyjama top now?’ Pronominal use in bedside teaching encounters. Communication & Medicine 5 (2): 171–182.

Roberts, Celia and Srikant Sarangi (1999) Hybridity in gatekeeping discourse: Issues of practical relevance for the researcher. In Srikant Sarangi and Celia Roberts (eds) Talk, Work and Institutional Order: Discourse in Medical, Mediation and Management Settings, 473–503. Berlin: Mouton de Gruyter.

Roberts, Celia and Srikant Sarangi (2002) Mapping and assessing medical students’ interactional involvement styles with patients. In Kristyan Spelman-Miller and Paul Thompson (eds) Unity and Diversity in Language Use, 99–117. London: Continuum.

Roberts, Celia, Val Wass, Roger Jones, Srikant Sarangi and Anne Gillet (2003) A discourse analysis of ‘good’ and ‘poor’ communication in an OSCE: A proposed new framework for teaching students. Medical Education 37 (3): 192–202.

Robinson, Jeffrey D. and John Heritage (2014) Intervening with conversation analysis. Research on Language and Social Interaction 47 (3): 201–218.

Sarangi, Srikant (2010) Practising discourse analysis in healthcare settings. In Ivy Bourgealt, Robert Dingwall and Ray De Vries (eds) The SAGE Handbook of Qualitative Methods in Health Research, 397–416. London: Sage.

Sarangi, Srikant and Heidi Gilstad (2014) Midwives’ communicative expertise in obstetric ultrasound encounters. In Heidi E. Hamilton and Wen-Ying Sylvia Chou (eds) The Routledge Handbook of Language and Health Communication, 539–556. New York: Routledge.

Seale, Clive, Christopher C. Butler, Ian Hutchby, Paul Kinnersley and Stephen Rollnick (2007) Negotiating frame ambiguity: A study of simulated encounters in medical education. Medical Education 4 (2): 177–187.

Schegloff, Emmanuel A. (2007) Sequence Organization in Interaction: A Primer in Conversation Analysis, Volume 1. New York: Cambridge University Press.

Stokoe, Elizabeth (2013) The (in)authenticity of simulated talk: Comparing role-played and actual interaction and the implications for communication training. Research on Language and Social Interaction 46 (2): 165–185.

Stokoe, Elizabeth (2014) The conversation analytic roleplay method (CARM): A method for training communication skills as an alternative to simulated role-play. Research on Language and Social Interaction 47 (3): 255–265.

Streeck, Jurgen and Siri Mehus (2005) Micro­ethnography: The study of practices. In Kristine L. Fitch and Robert E. Sanders (eds) Handbook of Language and Social Interaction, 381–404. Mahwah, NJ: Lawrence Erlbaum Associates.

Stubbe, Maria, Chris Lane, Jo Hidler, Elaine Vine, Bernadette Vine, Meredith Marra, Janet Holmes and Ann Weatherall (2003) Multiple discourse analyses of a workplace interaction. Discourse Studies 5 (3): 351–388.

Tracy, Karen (2005) Reconstructing communicative practices: Action-implicative discourse analysis. In Kristine L. Fitch and Robert E. Sanders (eds) The Handbook of Language and Social Interaction, 301–322. Mahwah, NJ: Lawrence Erlbaum Associates.

Tracy, Karen and Robert T. Craig (2010) Studying interaction in order to cultivate communicative practices: Action-implicative discourse analysis. In Jurgen Streeck (ed.) New Adventures in Language and Interaction: 145–165. Amsterdam: John Benjamins.

United States Medical Licensing Examination (2019) USMLE Step 2 CS Guide. Available online:

van Zanten, Marta, John R. Boulet and Danette McKinley (2007) Using standardized patients to assess the interpersonal skills of physicians: Six years’ experience with a high-stakes certification examination. Health Communication 22 (3): 195–205.

Wilson, Nicole, Dianna Hopkins-Rosseel, Christopher Lusty, Henry Averns and Wlma Hopman (2012) Draping education to promote patient dignity: Canadian physiotherapy student and instructor perceptions. Physiotherapy Canada 64 (2): 157–166.

Wittgenstein, Ludwig (1953) Philosophical Invest­igations, edited by G. E. M. Anscombe and R. Rhees and translated by G. E. M. Anscombe. Oxford: Blackwell.



How to Cite

Peters, G. (2021). Metadiscourse, materiality and morality in communication skills training with simulated patients. Communication and Medicine, 16(3), 251–266.