Volume 16 Number 4, SUMMER 1999

staged encounters
by kristin weidenbach

Related stories:
Playing Sick
Intimate Subjects

WHEN MEDICAL STUDENT EUNICE CHEN SAW THE BRUISES ON CELIA MAURICE'S ARMS, NECK AND STOMACH SHE BEGAN TO SUSPECT THAT HER PATIENT WAS THE VICTIM OF DOMESTIC VIOLENCE. Her complaints about sleeplessness and stomachache hinted to problems at home, and the riotous bruise stretching from hip to ribs was difficult to explain away. Nevertheless, Chen dubiously accepted her patient's explanation of a roller-blading accident and concluded the appointment without directly broaching the subject.

Fortunately for them both, Maurice is not a real patient but a simulated one -- an actor paid to portray a patient for the sake of medical education.

Known as standardized patients, these pretenders with make-believe personal histories and symptoms are brought before students who must examine them, identify their symptoms and offer a correct clinical diagnosis for the made-up malady. They have been part of the medical school curriculum at Stanford for the past five years, included in the Preparation for Clinical Medicine course and in several clerkships. The familiarity that the students have gained by interacting with them during this time means that they should feel comfortable working with standardized patients when they are introduced into the United States Medical Licensing Examination for the first time in 2001 or 2002.

"Our students will be ready," says Elliott Wolfe, MD, associate dean for clinical advising. "They will know how to behave and treat them like real patients."

Wolfe is an enthusiastic supporter of standardized patients in medical education -- though not all students share his view. As co-director for Preparation for Clinical Medicine, he ushers second- and third-year students through their first standardized patient experience. By the time they have completed their midterms and final exams each student will have seen and "diagnosed" 12 standardized patients. "This class is turning out to be a benchmark for their career," says Wolfe, explaining that this is the first time that each student is alone with a "patient" with few clues to their medical conditions beyond what they can glean from the subject.

"It is a good experience of going into a room and not knowing beforehand what the patient is there for," says Chen after her midterm exam, when, like the others in her class, she examined four different standardized patients. Visiting patients in a hospital ward provides you with some initial ideas about why they are seeking treatment, she explains, but having no forewarning of the patient's condition forces you to develop your history-taking skills. "So early in our careers, we don't know what to leave out and what to put in -- and you forget to ask some of those really pertinent questions," she adds.

Like the student who idly commented on Maurice's abdominal bruise but neglected to ask her how it had happened: The student focused instead on her complaint of persistent tiredness and prescribed sleeping pills to ease her condition. "I wish I'd asked her what caused the bruising," he says, shaking his head, during the post-examination debriefing with course co-director Lisa Gervin, MD. "I couldn't fit in the lack of sleep. I thought maybe Munchausen's syndrome," he says, referring to a rare mental disorder where patients induce physical signs of an illness on themselves.

"Take the bruise in isolation, think more obvious, think social," says Gervin, who had silently sat in on the student's session with Maurice and was now recapping the experience with him. "How could she get a bruise like that?" she asks.

"Well, somebody hit her," the student responds.

"How would you link depression and trauma?" Gervin prompts again.

"Well, a strong history of family violence," he replies.

"And that's what this is," Gervin announces. She explains to the student that he was right to first exclude medical disease but reminds him that the reason the domestic violence case is included in the course is that it is frequently missed during diagnosis.

The remaining cases on the schedule were more straightforward -- a female patient with systemic lupus erythematosus and a low platelet count, a middle-age man with gall bladder disease and pancreatitis and a male patient with hyperthyroidism. Wolfe says that the cases portrayed by the standardized patients have become more complex as the skills of each successive class of students have increased. In fact, the scenario of a patient presenting with symptoms of a mild stroke was retired because it was not challenging enough for the students. "At this point in their education they are at a higher level of skill development because of the intensity at which we're teaching the patient examination and medical interview," he says.

For fourth- and fifth-year students doing their psychiatry clerkship, practicing their interviewing techniques is just as important as honing their physical examination skills. Robert Matano, PhD, assistant professor of psychiatry, hopes that by working with standardized patients, students will learn to ask awkward questions and explore sensitive issues with real patients. Matano's teaching module is the first time at Stanford that the actors have been used to teach students some of the skills needed to effectively interact with patients suffering from alcoholism or substance abuse. "The experience gives students a chance to reflect on the frustrations and challenges presented by this population," says Matano, who directs Stanford's alcohol and drug treatment center. "We can talk about it but this is a good way to practice it and there are no concerns about the confidentiality of the case."

Matano uses the actors to present two typical cases to the class: an anxious, depressive patient for whom a highly structured intervention program works best and an example of a so-called cunning, manipulative patient who is more likely to respond to a firm but caring approach. Fourth-year student Reini Jensen's interview with a "patient" in the latter category was a highly charged exchange that she admits left her feeling frus trated. But it was an experience she learned from. "It was something I'll think about a lot and I'm sure I'll encounter patients like that down the road," she says.

However, the psychiatry students have mixed feelings about the overall value of standardized patients to their medical education. Many of them resent any authority the actors may have in the assessment process as they feel that too often the standardized patients are rating them on their personal qualities rather than the ability to practice medicine. "Are they going to make me a standardized doctor?" one student interjected during a discussion following the class. "I don't want to be a standardized doctor. Practicing medicine is a very individualized thing." These students believe that working with standardized patients is an acceptable alternative to a written exam, but that the best way to learn how to interact with patients is to work with real patients while a faculty physician looks on.

Wolfe admits that when standardized patients were first introduced to Stanford, there was a lot of skepticism among the students. But they have become accustomed to their inclusion in courses such as Preparation for Clinical Medicine and clerkships in internal medicine and family medicine. "There is a small percentage of students per year that find it too artificial," he says, but the number is decreasing with each year that standardized patients are used.

Wolfe also strongly believes that utilizing professional actors has made a tremendous improvement to the credibility of the standardized patient cases. In the past, the school used lay people interested in portraying patients, says Wolfe. But the school now uses only professional actors in the program, which has resulted in "a vastly improved experience because of their ability to act."

Stanford's standardized patient coordinator, Julianne Arnal, recruits actors from theater groups throughout the Bay Area. News of the opportunity, which pays $18 to $20 per hour, seems to spread quickly through the drama community by word of mouth, says Arnal, who currently has 60 standardized patients on the books. "Standardized patients are cropping up in different parts of the curriculum," she says. "We try not to use people too often. We don't want students to recognize the same patients in different roles."

Lately, Arnal has been busy training a new clutch of pretend patients for Stanford's potential role as a testing station for the standardized patient exam slated to be included in the United States Medical Licensing Examination in 2001-2002. Since 1998, this Clinical Skills Assessment, as it is called, has been a requirement only for graduates of foreign medical schools who want to take up residency or fellowship positions in the United States. Students who graduate from medical schools in the United States need only complete each step of the USMLE, which currently consists of three separate multiple-choice computer-assessed exams.

FOREIGN GRADUATES TAKING THE CLINICAL SKILLS ASSESSMENT EXAM MUST EACH VISIT 11 STANDARDIZED PATIENTS. MALE AND FEMALE ACTORS OF DIVERSE AGE AND ETHNICITY ACT OUT CLINICAL SCENARIOS DESIGNED BY PRACTICING PHYSICIANS AND MEDICAL EDUCATORS. A mother of a 1-year-old child with diarrhea, a 24-year-old female brought in by colleagues because of a seizure at work and a 59-year-old male complaining of blurry vision are typical cases that the candidates may encounter. Candidates have 15 minutes in which to examine the patient and ask questions about the patient's symptoms and medical history. They then have 10 minutes to write a patient report recording the findings, an initial diagnosis and any tests they would order.

Stewart Cooper, MD, a research fellow in the departments of structural biology and microbiology and immunology, who soon will begin a clinical appointment in the gastroenterology division, traveled to Philadelphia in May to take the Clinical Skills Assessment exam and found the entire experience particularly "irksome." In his opinion, the standardized patients did not always portray the physical signs authentically and in such an artificial situation he found it difficult to establish a rapport with patients. "I believe the standardized patient system is intrinsically limited and unnecessary," says Cooper, who practiced clinical medicine in Britain for 10 years before coming to Stanford. He too believes that having candidates visit real patients while a physician examiner observes the exchange is a much better way to gauge a doctor's clinical skills.

But with changes on the horizon for the USMLE, soon anyone wishing to practice medicine in the United States will be first required to examine and correctly diagnose a group of standardized patients. Fifth-year student Richard Thunder, who began an internship in orthopedic surgery at Stanford in June, believes it is probably a change for the better because being tested on standardized patients is one step closer to the real thing. "You can study for the paper exams and pass them," says Thunder. But that does not necessarily mean that you will be a good clinician, he says.

Like other students, Thunder worries that the pretend patients may not be sufficiently objective when it comes to rating one student after another, and he questions whether the cases can be truly standardized. "Students will be asking themselves, 'Did I really do worse than the next guy or was my examiner just hard on me?' " he says.

Still, the use of assessments incorporating standardized patients is a trend in medical education that appears to be on the rise and it's gaining a growing, if somewhat reluctant, acceptance. "You're on the spot and really confronted with what you know and what you don't know," says Thunder. "You can't just skip that question and go on." SM