(Standardized)Patient Point of View

I spent Tuesday observing the M1's in their standardized patient encounters. I didn't even realize this writer was here doing a story about it. I went through this during my first and second years of medical school and now we are required to do a certain number of hours as fourth year students observing. The SP's do a great job and are very important for practicing before we see real patients.


Standardized Patients Act Sick For Medical Students' Training

By Jon W. Sparks
Memphis Commercial Appeal
Thursday, April 9, 2009

I was not being honest with my doctor.

But it's OK -- he wasn't really my doctor. In fact, he wasn't a doctor.

He wanted to be one, however, and he was going to have to go through me if he expected to make it to his third year of medical school.

Last month, and again earlier this week, I put on one of those hopelessly unattractive patient gowns at the University of Tennessee Health Science Center's Robert J. Kaplan M.D. Clinical Skills Center. My job for a few days was to be a "standardized patient," a guinea pig trained to simulate a patient with a set of symptoms, a history and sometimes an attitude.

Standardized patients are increasingly being used in medical schools to train aspiring doctors in clinical skills, diagnostic reasoning, communication skills and working with patients. The clinical-skills segment of the U.S. Medical Licensing Exam requires prospective physicians to pass these encounters, so SPs -- established more than 35 years ago -- are here to stay.

The very fact that SPs are acting means that the job tends to draw plenty of actors. In Memphis, the Web-based eCallboard is a clearinghouse for information for the theater and film community. Jennifer Ware, SP trainer at the UT Health Science Center, often posts notices there and usually gets enough performers to fill available slots. There are few formal requirements, but the good SPs, Ware says, are articulate, give good feedback, are reliable and are conscientious. The acting skills come in because the SP must stay in character, follow the script outline as closely as possible and be able to improvise when the unexpected occurs.

And a full day may mean the SP runs through a dozen or more nervous medical students.
The students know they're dealing with actors who don't really have the symptoms and conditions described. But they play along, because the SP encounter typically accounts for a significant portion of the grade they get. Hence the nervousness. And they're evaluated on all sides -- by observers during the exam and by faculty on their conclusions afterward.

One of my second-year med students walked in and looked like he wanted to drop through the floor. I could see his mind working overtime to remember everything he was supposed to do. I wanted to comfort him ("There, there, doctor, you're going to be just fine,") but my job was to be Mr. Barnes, a working stiff afflicted by black stool and occasional dizziness.

The students covered most of the main areas they were supposed to. They greeted me properly and let me describe my complaints. Some took copious notes, some scratched just a few comments. Some were better than others in the lines of inquiry -- and my Mr. Barnes tended only to answer what he was asked. The sharper students kept eliciting information out of me until they had a truer picture of my innards.

Once the questions of symptoms and history ended, it was time for the physical exam. Yes, that's right, it's a hands-on experience. Here is where you really hope they know what they're doing and how to use whatever gizmo they're wielding (even if it's just a stethoscope).

In my case, I lay back and my especially twitchy student began to overexplain each palpation and describe all the percussion moves he was making. The thoroughness was nice, but the jargon was somewhat beyond poor Mr. Barnes' ability to appreciate. Young Kildare-to-be moved especially gingerly when he poked around the sore spot I had indicated right under rib cage. Still, I gave out with a credible moan when he hit the mark and he apologized profusely. And that was good -- he was supposed to be concerned with the present state of the patient and not just focused on the fix.

Dr. Gail Beeman, director of the Clinical Skills Center at the Health Science Center, says the students are "dealing with human emotions, but the patient's life is not at stake, so you can relax on that part, and you can focus on learning how to manage the patient."

Local actress Mandy Lane has been participating in the SP program for more than five years. As much as she's used to the drill by now, she says, "It's always funny when the students are scared or shy or feel extremely awkward asking about sexual history and reading their body language when they are about to get near, shall we say, a female region."

Most students are intent on developing the personal and professional skills needed to be a good examining doctor. But Lane does remember one student who "hadn't had a lot of sensitivity training." One of his key assignments was to tell Lane's pregnant SP character that she had no sexually transmitted diseases -- except syphilis. She was then supposed to break down crying and provide the student an opportunity to react to and manage an emotional and upsetting situation.

"He came in saying, 'Well, I've got some good news and some bad news. The good news is these tests are negative, the bad news is ya got syphilis. So, is there anything else we can help you with today?'" Lane said, "I was so taken aback that he just blew through that like it was no biggie."

It's not over when the student leaves the examining room. The standardized patient is in the rare (and coveted) position of being both actor and critic. He or she fills out a checklist noting whether certain elements were done and then writes a critique of the student's performance from the patient's standpoint. And there is the invisible person in the room, often a fourth-year medical student who observes how the exam was done from a medical standpoint.

SPs aren't used in every situation. Ware says invasive medical procedures are better done on some kind of nonliving model. Even a dedicated actor wouldn't want to be voluntarily intubated several times a day. There are, however, SPs who get additional training to participate in female breast and pelvic exams, and in male prostate exams. Those SPs also are, to an extent, instructors and are paid more. The regular pay rate is $12 an hour, but the specialized SPs can get up to $40 an hour.

The use of SPs has proven to be sound practice. Dr. Beeman said she was talking with a group of students who were reflecting on how far they'd come since the day they walked into medical school. "By the time they are ready to go see real patients," she says, "they all can appreciate how much they've learned seeing standardized patients."