The use of adolescent standardized patients to teach psychosocial risk assessment and its impact on medical student self‑efficacy

Abstract

Background

While effective adolescent health care requires clinicians to initiate and navigate conversations about sensitive topics including substance use, sexuality, mood, and safety, trainees frequently report low confidence in addressing these topics. We designed and evaluated a workshop using adolescent standardized patients (ASPs) to improve medical students’ self‑efficacy in adolescent communication.

Methods

Graduate medical students on a core pediatrics rotation at a tertiary pediatric hospital in Singapore completed a three‑hour ASP workshop using coached role‑plays with structured feedback. Self‑efficacy (primary outcome) was assessed using a single-group pretest-posttest design. Surveys were conducted immediately pre‑workshop and four weeks later using an adapted, previously published instrument (4‑point Likert scale; higher scores reflect greater confidence). Perceived usefulness of workshop components was collected post‑workshop (10‑point scale). Internal consistency was estimated using Cronbach’s alpha. Pre–post changes were analyzed with paired t‑tests.

Results

A total of 147 students participated (50% female), with a mean age 27.1 ± 2.6 years. The self‑efficacy scale showed excellent reliability (α = 0.957). Both composite self-efficacy (26.60 ± 6.21 vs. 38.86 ± 3.83, p < 0.001) and self-efficacy across all individual domains increased significantly from baseline to four-week follow-up. Confidence in interviewing adolescent patients rose from 1.88 ± 0.66 to 2.81 ± 0.39 (p < 0.001), and confidence in discussing confidentiality increased from 1.90 ± 0.72 to 2.82 ± 0.39 (p < 0.001). Content-area gains included sexual history (1.60 ± 0.58 to 2.55 ± 0.53, p < 0.001) and sexual orientation (1.66 ± 0.60 to 2.51 ± 0.53, p < 0.001). Students rated ASP feedback (8.47 ± 1.47) and role‑play (8.23 ± 1.51) as highly useful.

Conclusions

An ASP‑based workshop embedded within a pediatrics rotation was acceptable and associated with significant improvements in self‑reported self‑efficacy for adolescent communication. Findings support the feasibility of ASP‑based teaching in an Asian context and highlight the need for future studies incorporating objective performance measures and clinical behavior outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09718-2.

Background

Asia currently hosts 29% of the world’s adolescent population. The weight of this demographic, coupled with uneven coverage of adolescent-friendly services, underscores the need to scale youth-responsive care in the region [1]. A key component to the provision of adolescent-friendly health care is effective and non-judgmental communication. Young people commonly require both psychosocial risk assessment and anticipatory guidance as part of routine health care, yet many are reluctant to initiate conversations about sensitive topics with their health care providers [2–4]. As a result, opportunities for health behavior counseling may be missed [4, 5]. Due to the developmental changes in adolescence, health concerns frequently encountered during this period include health risk behaviors such as mental health problems and sexual health that have the potential for both short-term and long-term impacts [6–8]. Clinicians must therefore be prepared to initiate and skillfully navigate these discussions.

Despite this need, medical students, residents, and practicing physicians often report both discomfort and a skills gap in discussing sensitive topics with adolescents [4, 9–11]. Consequently, important screening and counseling may be avoided, with potential adverse effects on adolescent health [12]. Multiple educational strategies have been evaluated to improve trainees’ competence and self‑efficacy in adolescent communication, including didactic teaching, case‑based learning, and standardized patient (SP) encounters [13–15]. Higher clinician self-efficacy has been shown to be an important antecedent of improved screening and counseling behaviors [16–18].

Standardized patients are a well‑established modality for teaching communication and counseling [9]. Prior work has shown SP‑based curricula can improve behavior‑change consultation skills and enhance learners’ confidence in adolescent communication [10–12]. Work has also highlighted the importance of structured SP feedback [11, 13–15] in improving self-efficacy and communication scores. Increasingly, adolescent standardized patients (ASPs) have been utilized [16] with studies reporting gains in learner self‑efficacy and competency following ASP encounters [11–13, 17]. ASP programmes have been described in several regions; however, to our knowledge, no published reports describe ASP programmes in Asia [16, 18]. It is therefore important to assess the acceptability and educational impact of these programmes in an Asian context, where stigma surrounding mental health and sexual health remains relevant both in the broader community and among health professions learners [18–22].

We report on the design, implementation, and evaluation of an ASP workshop intended to improve medical students’ self‑efficacy in conducting psychosocial risk assessments with adolescent patients.

Design and methods

Study design

The evaluation used a single group pretest-posttest design. As the workshop was part of the medical school curriculum, a control group was not feasible.

Participants and setting

Graduate medical students in their first clinical year of training at a tertiary pediatric hospital participated between March 2017 and December 2019. Students completed the workshop in serial cohorts of 10–15 during their core pediatrics rotation. The study was approved by the SingHealth Institutional Review Board. All procedures were conducted in accordance with the ethical standards of the SingHealth IRB (Ref: 2016/2754) and with the 1964 Declaration of Helsinki and its later amendments. Written consent was obtained from all participants and written parental consent was obtained for minor ASPs.

Standardized patients

ASPs were recruited in partnership with a local junior college and a youth theatre program. While the ASPs all played the role of a sixteen-year-old patient, the ASPs themselves ranged in age from 17 to 22 years old. In a two-hour group training session, they received training on the character role, on giving effective feedback, and on the desired characteristics of medical student communication. As part of the training, the ASPs practiced assuming the SP role and received feedback from peers and drama faculty to standardize their portrayal. Drama faculty also attended the medical student workshops and would provide coaching for the ASPs as needed. For their participation, the ASPs received a modest honorarium to cover travel and meal expenses.

Scenario design

Adolescent medicine physicians collaborated with a drama educator to develop the character and scenario. ASPs subsequently reviewed and refined the materials to improve authenticity and alignment with youth perspectives.

In the scenario, a sixteen-year-old patient has been referred to a pediatric clinic after being seen by a general practitioner several weeks earlier for an asthma exacerbation [13]. The patient is accompanied by their mother. Over the course of the scenario, the patient discloses several health concerns to the medical students. These issues include challenging family relationships, tobacco use, pressuring messages and social media comments, and recent consensual sexual intercourse. As the scenario unfolds, the medical student learns about the history of consensual sexual intercourse and social media pressures. The medical student then learns that the “asthma exacerbation” was in fact a panic attack that was provoked by these concerns. The scenario hinges on the provision of non-judgmental communication regarding sex and sexuality. Importantly, the scenario is designed to accommodate a male or female patient role depending on the identified gender of the ASP.

Workshop structure

The three‑hour workshop began with a brief didactic overview of adolescent development, confidentiality (and its limits), and principles of adolescent consent. This thirty-minute lecture was delivered by an adolescent medicine physician who was a member of the medical school teaching faculty. Two adolescent physician faculty members as well as one drama coach facilitated each workshop. The interactive component lasted two hours and emphasized the HEADSSS framework (Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/Depression, Safety) as a tool for adolescent psychosocial assessment [23, 24]. At the end of the session, thirty minutes was used to debrief the medical students and emphasize the key communication skills.

During the workshop, medical students were then paired with an ASP, conducting a HEADSSS assessment in a stepwise fashion with facilitated interludes for ASP and faculty feedback [14, 15]. Medical students were randomly paired with an ASP at the start of the session.

“Fishbowl” demonstrations, faculty‑coached, observed interviews with selected student–ASP pairs, were also used [13]. Fishbowl teaching was used to complement paired practice. During individual role-play, facilitators identified medical student–ASP pairs who were effectively demonstrating targeted communication skills and privately obtained their verbal consent to participate in a fishbowl demonstration. Paired practice was then paused, chairs were rearranged in a circle, and the selected student–ASP pair demonstrated a portion of the interview for the larger group. During these demonstrations, faculty provided real-time coaching and highlighted key communication strategies for the observing students. Faculty aimed to maintain a positive, fun atmosphere during these demonstrations. When learners encountered difficulty, faculty occasionally stepped into the role-play to model specific techniques. Each workshop typically included three fishbowl demonstrations focused on key components of the adolescent interview: the introduction and explanation of confidentiality, discussion of substance use, and discussion of sex and sexuality. Approximately 45 min of the two-hour interactive portion were devoted to fishbowl teaching, while about 75 min were allocated to paired practice with intermittent individualized feedback.

Targeted communication skills included: (1) explaining confidentiality and exceptions with an adolescent and parent; (2) using non‑judgmental, developmentally appropriate language; (3) applying third‑person normalization; and (4) offering a “shopping list” of options as a strategy to elicit adolescents’ responses. In line with prior work on standardized patient safety [25], suicidality and depression were covered didactically to minimize potential risk to the ASPs.

Instruments

The primary outcome was change in self‑efficacy. Self‑efficacy, the belief in one’s capability to organize and execute specific actions [25], has been associated with increased adolescent psychosocial screening and physician counseling behaviors and thus was targeted as our primary outcome [9, 26]. We measured students’ self‑efficacy immediately before the workshop and four weeks later at the end of their pediatricrotation. The survey instrument was developed by adapting items from two previously published instruments assessing medical students’ adolescent communication skills; one measuring self-efficacy and the other competence (Supplementary file 1) [27, 28]. Items were selected based on their alignment with the skills and content covered in the workshop and their relevance to the local adolescent context.

The analyzed self-efficacy questionnaire comprised fourteen items assessing confidence in conducting adolescent psychosocial assessment (5 items) and discussing specific sensitive topics (9 items). Each item was scored on a 4-point Likert scale from 1 (“not at all confident”) to 4 (“very confident”), with higher scores indicating greater self-efficacy. Items were analyzed individually as well as summed into a composite score, and pre- and post-workshop mean item scores were compared. No items were reverse scored. Individual items were summed to generate a total self-efficacy score, with possible scores ranging from 14 to 56; higher scores indicated greater self-efficacy.

Prior to use, face validity of the adapted instrument was established through expert review by adolescent medicine and medical education faculty. Reviewers evaluated whether the items were understandable and appeared to reflect the domains of confidence targeted by the workshop, including communication with adolescents and discussion of sensitive psychosocial topics. Minor revisions to wording were made before final administration.

After workshop completion, we utilized a previously published instrument to assess perceived usefulness of workshop components (10‑point scale with 1 = not useful; 10 = extremely useful) and overall recommendation (5‑point Likert scale) [13]. Internal consistency (Cronbach’s alpha) for the self‑efficacy questionnaire was 0.957; for the post‑workshop teaching methods survey, 0.973.

Analysis

Demographics and post‑workshop feedback were summarized with descriptive statistics. Pre‑/post‑workshop differences were analyzed using two-tailed paired t‑tests. The significance level was set at p < 0.05. Pre-post analyses were restricted to participants with complete survey data at both time points. Analyses were conducted in SPSS (Version 30.0.0.0).

Results

A total of 147 medical students participated; one student dropped out, leaving 146 students in the final analysis. 50% (n = 73) were female, and the mean age was 27.1 ± 2.6 years.

Of these, 93% of students (n = 136) completed the post-workshop survey rating feedback from ASPs (mean 8.47 ± 1.47) and the opportunity to role‑play (8.23 ± 1.51) as especially useful (Table 1). Participants indicated strong overall endorsement, with a mean recommendation score of 4.18 ± 0.72 on a five‑point scale.

Table 1.

Rated usefulness of specific workshop activities (n = 136)

	Mean ± SD	Distribution of Likert Responses, n (%)
		1–3	4–6	7–10
Opportunity to role-play	8.23 ± 1.51*	2 (1.5%)	12 (8.8%)	122 (89.7%)
Watching others role-play	8.13 ± 1.42*	1 (0.8%)	11 (8%)	124 (91.2%)
Facilitator coaching and replay during fishbowl activities	8.11 ± 1.44*	2 (1.5%)	9 (6.5%)	125 (92%)
Comments and feedback from the ASPs	8.47 ± 1.47*	2 (1.5%)	9 (6.5%)	125 (92%)
Comments and feedback from peers	8.04 ± 1.66*	4 (3%)	13 (9.5%)	119 (87.5%)
Discussion following the activity	8.21 ± 1.41*	2 (1.5%)	9 (6.6%)	125 (92%)
	Mean ± SD	Distribution of Likert Responses, n (%)
		1–2	3	4–5
Your recommendation as to whether this exercise should be undertaken by future medical students	4.18 ± 0.72**	3 (2.2%)	16 (11.8%)	117 (86%)

*10-point Likert scale (1 = not useful, 10 = extremely useful)

**5-point Likert scale (1 = absolutely not, 5 = definitely)

All 146 participants completed the self-efficacy questionnaire 4 weeks after the workshop. Composite self-efficacy summed from all domains increased significantly from 26.60 ± 6.21 to 38.86 ± 3.83 (t = 22.81, p < 0.001) from baseline to four weeks after the workshop. Moreover, specific domains of self‑efficacy increased significantly between these time points (n = 146) (Table 2). Confidence in interviewing adolescent patients increased from 1.88 ± 0.66 to 2.81 ± 0.39 (p < 0.001), and in discussing confidentiality from 1.90 ± 0.72 to 2.82 ± 0.39 (p < 0.001). Content‑area confidence increased for sexual history (1.60 ± 0.58 to 2.55 ± 0.53, p < 0.001), sexual orientation (1.66 ± 0.60 to 2.51 ± 0.53, p < 0.001), mood (2.17 ± 0.68 to 2.86 ± 0.35, p < 0.001), suicidality (1.76 ± 0.68 to 2.65 ± 0.53, p < 0.001) and several other domains (see Table 2).

Table 2.

Change in self-efficacy scores by adolescent interview skill and topic (n = 146)

	Before Workshop (Mean ± SD)	After Workshop (Mean ± SD)	t*	df*	p*
Interviewing Skills (4-point Likert scale 1 = not at all confident; 4 = very confident)
Interviewing an adolescent	1.88 ± 0.66	2.81 ± 0.39	15.415	145	< 0.001
Confidentiality discussion	1.90 ± 0.72	2.82 ± 0.39	13.864	145	< 0.001
Establishing rapport	1.90 ± 0.63	2.79 ± 0.41	15.682	145	< 0.001
Speaking with the adolescent alone	1.86 ± 0.63	2.68 ± 0.47	14.156	145	< 0.001
Discussion of family situation	1.97 ± 0.61	2.76 ± 0.43	13.103	145	< 0.001
Adolescent Health Topics (4-point Likert scale 1 = not at all confident; 4 = very confident)
Eating Habits	2.40 ± 0.62	2.90 ± 0.30	9.482	145	< 0.001
Exercise Habits	2.45 ± 0.59	2.90 ± 0.30	8.776	145	< 0.001
Tobacco Use	2.24 ± 0.67	2.86 ± 0.35	10.253	145	< 0.001
Alcohol Use	2.27 ± 0.68	2.87 ± 0.34	10.137	145	< 0.001
History of sexual activity	1.60 ± 0.58	2.55 ± 0.53	16.257	145	< 0.001
Sexual Orientation	1.66 ± 0.60	2.51 ± 0.53	14.112	145	< 0.001
Sleep patterns	2.43 ± 0.62	2.90 ± 0.30	8.999	145	< 0.001
Mood	2.17 ± 0.68	2.86 ± 0.35	11.327	145	< 0.001
Suicidality	1.76 ± 0.68	2.65 ± 0.53	15.457	145	< 0.001

* Two-tailed paired t tests; df = 145; α = 0.05

Discussion

The ASP workshop was highly acceptable to medical students and was associated with significant improvements in self-reported self-efficacy across domains clinically relevant to adolescent-friendly care. The largest gains occurred in areas deliberately emphasized in the curriculum, including discussing confidentiality, conducting adolescent interviews, as well as addressing sexual activity and sexual orientation. Baseline confidence in discussing sexual activity, sexual orientation, mood, and suicidality was relatively low, consistent with prior literature describing trainee discomfort with these sensitive adolescent health topics [21, 22, 29, 30]. This highlights the importance of increasing self-efficacy in addressing these topics through structured curricular approaches as such discomfort or uncertainty may contribute to avoidance, incomplete screening, or missed counseling opportunities, with potential implications for adolescent health care. By allowing learners to rehearse these discussions with feedback before encountering them independently in clinical care, ASP-based teaching may help normalize sensitive psychosocial assessment as a routine component of adolescent care while supporting the development of respectful, non-judgmental, and youth-centered communication skills [31].

ASP-based teaching may be especially useful for developing adolescent communication skills as these skills are difficult to teach through didactic strategies alone. Students need opportunities to practice explaining confidentiality and its limits, asking to speak with an adolescent alone, introducing sensitive topics, using non-judgmental language, responding to disclosures, and managing their own discomfort. Although our scenario was fictitious, it mirrors many adolescent health encounters. Adolescents may not present with clearly labeled mental health, sexual health, or psychosocial concerns; these issues often only emerge if the clinician establishes confidentiality, trust, and rapport through a respectful communication style [32]. In particular, the workshop emphasized confidentiality as a gateway skill because explaining confidentiality and its limits can enable further discussion of sensitive topics such as sexuality, mood, suicidality, and other adolescent concerns [33]. Thus, ASP encounters allow students to move beyond learning the content areas of psychosocial assessment toward practicing the relational and communication skills that help adolescents feel comfortable making sensitive disclosures [34].

The observed gains in self-efficacy align with evidence that coached SP encounters with structured feedback can improve learner self-efficacy and communication performance [14, 15]. The workshop design likely supported self-efficacy through several mechanisms. In keeping with Bandura’s model, students had opportunities for mastery experience, vicarious learning, verbal persuasion, and management of emotional arousal [25]. Students gained mastery experience through direct practice conducting psychosocial assessments with ASPs. They also had opportunities for vicarious learning as they observed peers during fishbowl demonstrations; watching peers navigate these interviews successfully may have made sensitive conversations feel more achievable. Feedback from ASPs, faculty, and peers may have served as verbal persuasion by reinforcing students’ ability to conduct the interview and refine their communication approach. The coached and supportive environment, together with the stepwise structure of the role-play, may have provided affective support by helping students manage the emotional reactions that can arise when practicing sensitive communication skills, while giving them opportunities to make mistakes, receive feedback, and try again in a safe learning environment.

Rather than functioning as a simple role-play, the workshop incorporated repeated opportunities for concrete experience, observation, feedback, reflection, and active experimentation, consistent with Kolb’s experiential learning theory [35, 36]. Given the scenario’s emphasis on sexual health, these structured opportunities for rehearsal, observation, and feedback may have been particularly valuable in improving learners’ confidence in discussing sexual activity and sexual orientation. Confidence in discussing mood and suicidality also improved, although these topics were addressed didactically rather than through direct role-play. This suggests that multiple instructional approaches within the curriculum may have contributed to gains in self-efficacy, while experiential practice and feedback may have played a particularly important role in the domains most directly rehearsed. Together, these elements provide a plausible educational explanation for the observed gains in self-efficacy, consistent with Bandura’s self-efficacy theory and Kolb’s experiential learning theory.

One distinctive aspect of the workshop was the use of ASPs as educational partners in both workshop design and implementation. ASPs contributed to the authenticity of the scenario and provided feedback to medical students on their communication. The interactive components of the workshop, including role-play and ASP feedback, were among the most highly rated elements, supporting previous research that ASP-based teaching can provide developmentally authentic learning encounters [12–14, 16]. Feedback from ASPs may be especially valuable because young people can comment directly on how students’ tone, language, and assumptions are experienced by adolescents. ASPs offer a complementary perspective to faculty feedback on whether the interaction felt respectful, awkward, judgmental, or trustworthy. In this way, ASPs functioned not simply as standardized patients, but as youth-informed educational partners in the development of students’ adolescent-centered communication skills [13].

Involving adolescents or young adults as standardized patients requires careful attention to emotional safety and role boundaries [37]. Our program incorporated several safeguards, including ASP training, drama faculty support, and close supervision during workshops with medical students. We also obtained ASP consent or assent and parental consent where relevant. The selection of role-play content was deliberately considered. In particular, the decision to address suicidality didactically rather than through direct ASP role-play reflects the need to balance authenticity with participant safety [38]. Future ASP programs should consider ASP wellbeing as part of both curriculum design and evaluation. These considerations are important for programs seeking to implement ASP-based teaching within routine curricula.

Embedding the workshop within a core pediatric clerkship offers a practical model for routine curriculum integration, rather than leaving exposure to adolescent communication to chance clinical encounters. This approach ensures that all students can learn and practice adolescent communication skills, rather than only those specific students who may seek out related clinical opportunities. Nonetheless, ASP programs require specific resources, including ASP recruitment and training, faculty facilitation, logistical coordination, safeguarding processes, and honoraria or reimbursement for ASPs’ time or transportation costs. Implementation and scalability may be supported through several mechanisms. Partnerships with schools, theater groups, or youth organizations can facilitate ASP recruitment and, importantly, provide support for ASPs through the presence of trusted teachers or facilitators as well as a cohort of peers participating together. Scalability may be further supported through reusable standardized scenarios, ASP and faculty training guides, and training sufficient faculty to provide ongoing program support. Integration into existing clerkship teaching time, rather than a standalone course, may also support sustainability. Where resources are limited, a scalable model could combine didactic or online preparation with live ASP encounters focused on the most challenging communication tasks.

Taken together, these findings add to the limited published literature on ASP-based adolescent communication training in Asia, an important contribution given regional efforts to build adolescent-responsive health systems [1]. Our experience demonstrates that ASP-based teaching can be locally implemented within a Singapore medical education context through youth partnerships, scenario adaptation, and integration into an existing pediatric clerkship. These features may also support adaptation to other Asian health professions education settings, particularly where institutions seek to strengthen adolescent communication training within existing curricula. Adapting scenarios and training priorities to local contexts, with ASPs involved as co-developers, may help ensure that the teaching scenarios remain authentic to the experiences of local adolescents.

This study has several limitations. Because the workshop was integrated into the core pediatric rotation, a control group was not feasible. The observed increases in self-efficacy should therefore be interpreted with caution, as they may partly reflect other clinical experiences during the clerkship. However, adolescent clinical exposure likely varied across students, whereas the direction and magnitude of change were consistent across domains, particularly those emphasized in the workshop. This pattern suggests that the workshop may have contributed to the observed improvements, although future research incorporating a control group would be needed to better assess the workshop’s specific impact.

In addition, the evaluated outcomes were limited to self-reported measures of self-efficacy, corresponding primarily to lower levels of the Kirkpatrick evaluation model, and did not include objective measures of behavior change or patient outcomes [39]. Nevertheless, clinician self-efficacy is a key antecedent of screening and counseling behavior, and higher self-efficacy has been associated with greater delivery of these practices across diverse clinical settings [40–43]. Thus, self-efficacy is an important initial target for evaluation. Future research should incorporate objective measures of learner performance, clinical behaviors, patient-centered outcomes, and, where feasible, the impact of participation on ASPs themselves. Finally, social desirability bias is possible because faculty were involved in workshop delivery, although we attempted to mitigate this through anonymous survey collection by a research assistant without prior connections to the students. Overall, the findings should be interpreted as evidence of feasibility, acceptability, and educational potential rather than definitive evidence of improved clinical behavior.

Conclusions

Our experience supports the feasibility and acceptability of an ASP workshop embedded within a core pediatric clerkship in Singapore. The workshop was associated with improved student self-efficacy in adolescent psychosocial assessment, including domains central to adolescent-friendly care such as confidentiality, rapport building, sexuality, mood, and suicidality.

These findings suggest that ASP-based teaching can provide developmentally authentic, feedback-rich practice for communication tasks that may be difficult to teach through didactic methods alone. Embedding the workshop within an existing pediatric rotation offers a practical model for integrating adolescent communication training into routine curricula, while structured scenarios, youth partnerships, and faculty facilitator guides may support future scalability. Future research should examine whether improvements in self-efficacy translate into improved communication performance, clinical screening behaviors, and adolescent patient experience. Overall, ASP-based communication training appears to be a promising and adaptable approach for strengthening adolescent communication skills training in Asian medical schools.

Authors’ contributions

CD and KR conceived and designed the study. CD and KR developed the curriculum and oversaw implementation. CD curated data and performed analyses. CD drafted the manuscript. All authors critically revised the manuscript and approved the final version.

Funding

Funding was received from the AM-Ethos Medical Simulation and Inter-Professional Learning Project Grants Award from Duke-NUS Medical School. The funder had no role in study design; data collection, analysis, and interpretation; or writing of the manuscript.

Data availability

The datasets used and analysed in the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the SingHealth Institutional Review Board (2016/2754). Written informed consent was obtained from all participants and written parental consent was obtained for minor ASPs.

Consent for publication

This is not applicable as no identifying information on individual participants was included in the publication.

Competing interests

The authors declare no competing interests.