Mitchison & Khanna ^{Reference Mitchison and Khanna1} contribute an interesting letter to The Psychiatrist about the experience of role-playing actors, or simulated patients, who have become ubiquitous in OSCE-based examinations (such as the CASC) in medicine and psychiatry. Using qualitative methods, they briefly describe aspects of the simulated patients’ experience, but focus on one: the emotional stress the actors can experience after role-playing psychiatric patients repeatedly over the course of an examination.

The role of simulated patients in psychiatric OSCEs is a lightly researched topic. We conducted a study in 2009 looking at the role in examinations of the same population that Mitchison & Khanna describe, i.e. UK MRCPsych trainees. ^{Reference Whelan, Church and Kadry2} One finding was that simulated patients and examiners scored ‘empathy’ and ‘communication’ differently (unlike the real examination, we asked the actors to mark the candidates). In a post-hoc unpublished exploration of why this might be (by using a questionnaire with both groups), we were unable to find the answer to this question.

Having read Michison & Khanna's letter, I wonder whether the answer to the question lies in the emotionally distressed state the actor puts him or herself into while acting the role, and the perception of the candidate not responding to this sufficiently; whereas the examiner, who is not emotionally aroused, is less likely to down-score the candidate.

It is a pity that Mitchison & Khanna's findings were not published in a full-length article because I would like to know more.