Theatre of the Abnormal—Playing Sick
Perhaps no body of knowledge is more challenging to learn than medicine—and then arrives the moment of truth. The student comes face-to-face with a patient for the first time, and is asked to call upon that knowledge to propose a solution to an authentic medical problem. No student wants to face that responsibility unprepared. Enter the standardized patient.
Standardized patients (SPs) are carefully trained individuals instructed to replicate the symptoms and characteristics of an actual patient. They depict cases based on authentic encounters physicians experience with patients. SPs are also trained to provide feedback to the medical students, in skill areas ranging from interpersonal communication to history taking, physical exams, patient counseling, and other exercises.
“Students won’t practice as physicians if they can’t pass a national high stakes standardized patient exam in their fourth year,” explains Mary Donovan, who heads up the School of Medicine’s Standardized Patient Program. The National Board of Medical Examiners runs the exam, known as the “Step 2CS,” which measures clinical skills.
Perhaps among the most difficult skills to teach in medicine is how to communicate with patients. How to ask questions that help disclose vital information. How to project confidence and professional competence. Maybe most challenging, how to deliver devastating news.
“That’s why SPs are essential,” says Donovan. “You can’t learn these skills from a book. Students need to interact with real people, and they need a safe environment where they can learn from their mistakes before dealing with actual patients.”
Some mistakes are instructive indeed. SPs tell of students becoming flustered trying to explain things in non-technical language, or of shaking uncontrollably while trying to guide an otoscope into the ear. One student, losing complete track of time, spent an eternity washing his hands. Another stood like a statue and spoke in a monotone. Helpful feedback often begins with encouragement from the SP, and advice to smile more, or act more confident, or try to appear more relaxed. But it also includes technical evaluation, such as “you forgot to feel under my armpits for swollen lymph nodes,” or “you didn’t ask me if I experienced dizziness.”
Donovan adds, “I've even seen a student in a first-ever encounter, look up to the ceiling and address the camera! ‘Now I'm going to listen to the patient's heart,’ he shouted, looking into the camera. Then again, there are students who so completely forget the visit is ‘fake,’ they'll actually get tears in their eyes with an emotional SP.”
GUMC’s program is geared for first-, second-, and third-year students. The exercises become progressively complex and demanding. First-year students begin by interviewing SPs, learning the skill of creating patient histories. During their second year, they also demonstrate fundamental physical exam skills. By the third year, they are practicing presenting the patient a preliminary diagnosis and a possible treatment plan. Fourth-year students, who by this time will be seeing actual patients in their clinical rotations, will take their Step 2CS exam by mid-year.
Standardized patients often are professional actors. As part of their teaching role, they are precisely the same “character” each time they interact with students so the students—and the faculty educators—will have accurate, measurable, real-life clarity about the case.
“There are objectives designed for each case,” Donovan says. “Each patient comes in for a precise reason and the student outside the door has only a little bit of information about the patient.
“Maybe a nurse or admitting person just jotted down the reason a patient arrived in one sentence. Maybe recorded some vital signs. And then the student must take a history, do a physical exam, go on to counseling, follow whatever instructions their attending physicians have given them,” she says.
The SP is trained to provide responses based on the students’ knowledge and ability to pay close attention in this realistic situation. If students are too vague or general, the SP cannot provide the information the students need to assess the case and achieve a good score. “For example,” she explains, “In a gastrointestinal case, an objective may be to have the student think of asking if there is ‘blood in the stool,’ not just ‘are there any changes in your bowel habits?’”
Training actors to portray specific disorders is a collaborative effort between Donovan and the professors. She must ask such questions as, “An older patient who has Parkinson’s, would he wobble with his eyes closed or would he just sway on the axis?” With the help of content experts such as Shyrl Sistrunk, MD, medical director for the Integrated Learning Center, where the sessions take place and are recorded, she is able to impart very specific behaviors and responses, even involuntary reflexes that may be needed to mimic certain conditions.
SPs are taught to adhere to specific terms when describing symptoms. To do otherwise may lead the student down the wrong path. SP Carole Schaefer remembers such an incident. “The very first case I did was for the nursing school at Johns Hopkins, and I was portraying a perimenopausal woman. I was supposed to say that I would wake up in the middle of the night ‘sweating.’ Trying to be helpful, I added the word, ‘flushed,’ and the student started asking me all these questions about heart problems. I learned early on to stick to the script.”
As important as they have become to medical school education in this country, Standardized Patient programs date back only a couple of decades.
“The licensing step actually started with foreign medical graduates,” Donovan explains. “Foreign graduates were required to demonstrate that they could converse with a patient, be able to uncover critical patient information, and do all of it well enough to begin residency at an accredited medical center.
“And at some point, the National Board realized that it might not just be foreign medical graduates that should be reviewed.”
In the last 10 or 15 years, cameras and microphones are providing real insight to professors about how students' interact and think during patient encounters. The revelations, Donovan notes, “are sometimes curriculum-changing.” Professors assumed students had learned examination basics such as how to palpate correctly, or ensure the stethoscope touched the skin.
“Now schools are taking harder looks at their curricula and revising when necessary to better prepare students before they begin dealing with real patients. SP programs are an integral part of this contemporary review process.”
Actors who work as SPs may never win an Emmy, but their performances are marvels of verisimilitude and, in the end, good for what ails you.
By Frank Reider, GUMC Communications
