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Actors pose as patients to train doctors

The fourth-year medical student enters the exam room and introduces herself to the elderly gentleman waiting inside. She’s confident and in control, asking pertinent questions and nodding compassionately when he describes recent episodes of getting lost and neglecting to turn off the burner on his stove. But soon his rambling answers lead in circles, and she can’t steer him back on course. Before she knows it, the 15-minute session is over, and she hasn’t finished her assessment or given the patient any medical direction.

The patient turns to her and asks, “How do you think it went?”

He is a standardized patient, an actor trained to play a person with a particular medical problem (think Kramer in Seinfeld). While students at the School of Medicine have been honing their clinical skills with standardized patients since the early 1980s, the simulated medical encounters are now playing an increasingly important role in training physicians. “Working with standardized patients can be an incredible teaching opportunity for a student because it’s like having a patient with real issues, but without the consequences,” says Lorraine Stanfield, a MED clinical assistant professor of medicine.

During the past two years, Stanfield has led an effort to increase the use of simulated patient encounters, giving MED students not only more experience with patients, but also better feedback on their evolving clinical skills. With other faculty, she has introduced two new examinations, at the end of the second and third years, that assess students’ clinical skills. The exams take place at the Clinical Skills Center, which opened in fall 2003 and includes 12 examination rooms similar to those found in a primary care physician’s office. Four of the rooms have video-monitoring equipment that sends images to monitors in a nearby control room, where faculty can observe students in action and record the sessions for later review.

Medical schools across the country are increasingly using these so-called Observed Structure Clinical Evaluations to prepare students for the CS 2, a clinical skills test implemented last June by the National Board of Medical Examiners. In the exam, students evaluate 10 patients with various problems, each for 15 minutes. The goal is to make sure the aspiring doctors can gather a history, perform a physical exam, diagnose the problem, and recommend treatment.

Patients evaluating students

To help students prepare for the CS 2 exam, Stanfield and other faculty designed a test to assess fundamental clinical skills, such as taking medical histories, performing physical exams, communicating with patients, documenting findings and diagnoses, and ordering appropriate diagnostic tests. The end-of-third-year exam takes a full day to complete, with each case lasting about 35 minutes. Students have 15 minutes to examine and interview the standardized patient, followed by 10 minutes to fill out postencounter paperwork. Meanwhile the patient is also completing an evaluation of the student. “There’s a whole series of questions, a check list, that the standardized patients go over after the encounter,” says Stanfield, who directs the Clinical Skills Center. “For example, if the patient came in with a cough, the form will contain questions such as, did the student ask whether they smoked, what medicines they’re on, if the patient is coughing up blood. There are all these possible things the student might have discovered.”

Students then return to the exam room and receive detailed feedback from the standardized patients and occasionally from faculty who observed the interview from the control room. The debriefing is thorough and candid. A standardized patient playing the role of a depressed elderly man tells the medical student that she didn’t ask enough probing questions. “Being a depressed patient,” he says, “I wasn’t too open with you. A little more prodding from you could’ve opened me up further.”

Matthew Russell, a MED assistant professor of geriatrics, watched the interview from the control room, and adds that the student relied too heavily on nonverbal sounds, acknowledging the patient’s answers with quiet murmurs that didn’t elicit adequate answers. “Remember, just because the patient’s depressed doesn’t mean you have to be,” Russell tells the student. “Sometimes you need to use some verbal defibrillation to liven the patient up so he can tell you about his condition.”

To help MED students make the transition to evaluating standardized patients, Stanfield and other faculty last March introduced a miniature version of the end-of-third-year exam for second-year students. There are only three cases in the end-of-second-year exam, says Stanfield, and they are easier and slightly longer.

The exams help prepare students, and they also give faculty a way of evaluating students and the curriculum. “We want to know if students have achieved a certain level of competence with regard to their interviewing and physical examination skills,” says Stanfield. “Do they know what to ask and how to ask it? Do they know how to use their diagnostic equipment? If not, then we really have to look at what we are teaching and why it’s not working.”

Learning to ask challenging questions

Along with the year-end exams, students also encounter standardized patients in smaller doses during many of the clinical clerkships they rotate through during third and fourth years. In the obstetrics/gynecology clerkship, students learn how to perform pelvic and breast exams on standardized patients; during the pediatrics clerkship, they practice taking a well-child history on a standardized patient playing the parent of a 14-year-old child, then shifting into the role of the 14-year-old. Students are expected to ask challenging questions about substance abuse, domestic and family violence, and teenage sexuality.

With funding from the Donald W. Reynolds Foundation, the geriatrics section in the department of medicine added standardized patient encounters to its clerkship last fall. According to Sharon Levine, a MED associate professor of medicine and director of education for the geriatrics section, the simulated encounters help faculty evaluate the developing clinical skills of their charges. “We instituted it as a formative evaluation in the middle of their rotation so if there were skills that we thought students could work on, there would be time to remediate,” she says. “Our goal is that they should be able to have a meaningful conversation with a patient that shows good communication skills. The way we talk to geriatric patients is important — a large segment are demented, or deaf, or blind.”

Students have responded positively to the encounters with standardized patients, Levine says. “Most students want to be effective doctors,” she says. “This is the kind of feedback that can really help students be more effective. It’s a win-win for us in geriatrics, and it’s a win-win for the institution.”