AAMC Reporter: December 2006

Standardized Patients Play Their Part

A medical student works to locate the source of a standardized patient's distress

The patient in the room is a 62-year-old husband and father presenting with lower-back and abdominal pain, heartburn, and insomnia. He reports more frequent drinking as well as feelings of anxiety, frustration, and hopelessness. He has worked as a sales professional for a New England company for decades. After having achieved modest career success, he has been recently demoted, which is bringing many previously buried issues to the surface.

Meet "Jack Mann," a character portrayed by a professional standardized patient (SP), here to help students at the Yale University School of Medicine practice and hone their skills without impacting actual patients. Any resemblance to characters living or dead is purely intentional.

"When creating cases, we look to many sources to create realistic people," explained Rick Haeseler, M.D., director of Yale's standardized patient program. "We'll look to literature, which often offers well-drawn psychosocial portraits, such as a character based on Willy Loman from "Death of a Salesman." Other cases may be based on our SPs' own life experiences, or on real patients known to us."

With the addition in 2004 of a clinical skills component (which includes standardized patients) to the United States Medical Licensure Examination (USMLE), standardized patients, at one time a controversial addition to the medical school curriculum, have become mainstream, with nearly every medical school in the country operating its own SP program. And, it should be noted, the term "standardized" has universally replaced the original term "simulated" to reinforce the fact that the faux patient's situation, unlike that of the real patient, can be made fundamentally the same for every student encounter.

Different SP programs emphasize different things. Some excel in creating meticulously detailed characters to develop interviewing skills or practice delivering unpleasant news. (Speculating on a diagnosis is valued to varying degrees, but most programs consider it of secondary importance.) Other programs look to SPs purely as teaching tools, literally taking hands-on responsibilities as students practice various physical examination skills, including pelvic and other invasive exams, on them, and receive feedback in real time.

Additionally, the USMLE's new clinical skills component has spurred many schools to use SPs as more of a testing tool in addition to a teaching tool. In the testing environment, SPs stay in character throughout an interaction, offering no feedback and rating student performance afterward. Grading criteria can be as diverse as "student greeted me appropriately," or a rating of the comfort and skill with which a particular examination is performed.

SPs: Who Are They?

Nationwide, SPs are men and women of all ages and backgrounds. They are commonly people with personal interests either in performing, medicine, or both, and are usually people who, for many reasons, do not have a traditional "9-to-5" work style. SPs include actors, artists, musicians, retirees, undergraduates, nurses, and pre-med students. Most are paid hourly, usually from $10 to $20, or more for those who teach invasive procedures on themselves. Being an SP is rarely full-time work, but many report it can bring in a nice part-time paycheck.

According to Delia Anderson, president of the Association of Standardized Patient Educators (ASPE), no matter what their background, all SPs have something in common.

"Being a standardized patient takes someone who is very intelligent and an active learner," she said. "SPs are so much more than just actors. They are mastering a lot of medical training in addition to absorbing an enormous case file of family, social, and medical history. They never know what might be thrown at them and yet have to respond in character with the proper facts. This is not a job you can just fall into or take lightly."

"It's a creative job, and I'm learning things all the time, and I love that," said Jenny Finkel, a Tulane University School of Medicine SP who also works as a part-time museum docent. In addition to teaching students to perform pulmonary and other exams, Finkel is called upon to portray a number of characters, including "Susan Bernard," an emotionally disturbed young woman. This, she says, has led to some moving moments in the exam room.

"Susan had this horrible upbringing, and now her mother is pregnant again, so she is feeling like the first pancake that got ruined and tossed out," Finkel explained. "I was telling the student about how sad my life is, and the student came back with 'Maybe you can be the big sister to this baby that you never got to have.' When she said that, it was like an 'Oprah moment.' Susan—and I—just burst into tears."

Mary-Kelly Busch, a 13-year SP veteran at Yale, regularly plays "Mary Dale," a harried librarian, mother, and elder caregiver who presents with abdominal pain, nausea, and vomiting.

"The other 'characters' are real students, and you never know what they're going to say, so you need to be on your toes," Busch said. "I'm always intrigued with how the character jumps out and has a great impact on the people in the room. For me, being an SP is fun, and it's also really constructive. It affects peoples' lives, and it changes them, and that's very powerful."

Sometimes, being an SP can make an impact in a way that's totally unexpected. Take the case of Kirk Bonner, who was an SP in the late '90s while a Tulane undergraduate English major to earn some extra money. The experience was so powerful for him that he changed his career path, went to medical school, and became a physician.

"I had had no interest in studying medicine before being a standardized patient," he said. "As an SP, I was amazed by how much you can learn by giving a physical exam; and I thought, if being a doctor is listening to people, examining them carefully, and helping sort out their problems, then it would be a great way to spend your life. And it has been."

Shaky Beginning Leads to Bright Future

Standardized patients are used to hone bedside manner as well as examination skills

Today's medical students seem to be comfortable with the SP concept, with some expressing surprise that, at one time, similar encounters might have been done with actual patients.

"Real patients would never know if you're doing something right or wrong, so you won't know either," noted Mary McDonald, a third-year medical student at Tulane.

"And most would be too polite to tell you outright what they think of you or what you're saying to them. The SPs are very professional and will tell you, 'This was good, but maybe the way you said this is something you should work on.' And it benefits the patients, too. They don't have to be guinea pigs, because with SPs, we have expert guinea pigs," McDonald said.

Perhaps it was this realization that helped forward the SP concept, which, when first proposed by Howard Barrows, M.D., at the University of Southern California in the 1960s, was widely panned in the medical community for being "too Hollywood."

The turning point for widespread acceptance of SP methodology seemed to come in the late 1980s and early 1990s. The Josiah Macy Jr. Foundation was instrumental in this regard, providing funding and other resources to dozens of medical schools to begin or expand their SP programs. The AAMC helped spur the widespread adoption of SP methodology with the 1992 "Consensus Conference on the Use of Standardized Patients in the Teaching and Evaluation of Clinical Skills," which presented an in-depth introduction to the power and potential of SP programs to many medical schools around the country. And, certainly, efforts such as these were instrumental on the road to the ultimate adoption of SP methodology on the USMLE.

"At one time, the USMLE had an oral component, which used real doctors and real hospital patients, but this was dropped in the 1960s because the reliability between different raters was poor," said Ann King of the National Board of Medical Examiners (NBME). "The ability to communicate with patients is vitally important for a physician, but finding a way to test it reliably was a challenge. Standardized patient methodology seemed to offer the answer."

According to King, NBME spent nearly two decades developing and piloting the concepts to allow SP methodology to be used reliably and consistently at multiple sites. In that time, they created, tested, and refined everything from training materials for the SPs, to cases and protocols, to assessment checklists. The first exams including an SP element were given only two years ago, but King reports the board is pleased with the results thus far. The Educational Commission for Foreign Medical Graduates also helped pioneer SP methodologies.

What is the future for SPs?

ASPE's Anderson says that with SPs' escalating success in North America, her organization is experiencing a groundswell of interest from medical communities in Japan and Europe. In addition, she thinks a major evolution in the field will consist of the integration of human SPs with robotic simulators.

"Think of the complexity of the cases that could be done," she said. "A patient could explain her history of shortness of breath or chest pains, and then suddenly collapse, and the student would have to perform emergency resuscitation or insert a breathing tube on the sim as if the sim and the SP were one entity."

—By Gregg Siegel, special to the Reporter

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