Patients Fake Ills to Teach Medical Skills

“I’ve had virtually every disease imaginable. Last month alone, I was diagnosed with a heart murmur, appendicitis, pneumonia and migraines,” says Phyllis Miles.

Some people play hooky from work by pretending to be sick. Some people, like Miles, pretend to be sick so they can work. Miles is a member of a select group of individuals who work as “standardized patients” in the Texas Medical Center.

Standardized patients, or SPs, are healthy people carefully trained to play the part of ill patients so medical students and residents, as well as nursing and dental students, can learn how to interact with those they treat. Through this practice, students fine-tune their patient communication and physical examination techniques in a “safe” environment, where there is no harm to the patient if the student asks an inappropriate question or misses a critical finding.

“SPs help students perfect their bedside manner, communicate in non-biomedical terms, recognize and respond to emotion-laden topics appropriately, and increase their sensitivity to cultural differences among patients,” says Karen Lewis, director of the Standardized Patient Program at Baylor College of Medicine. “Students practice taking a patient’s medical history, conducting a hands-on physical examination, and educating patients about their diagnoses.”

To prepare for this “pretend” participation, SPs undergo countless hours of training, learning how to act like patients with various medical maladies.

“It’s not an easy job,” says Tamara Owens, coordinator of the Standardized Patient Program at The University of Texas Medical School at Houston. “SPs must learn the symptoms of the cases they will portray – everything from chest pains and joint pains, to migraines, eczema, stomach upsets and even depression.”

These “medical mimickers” do their best to challenge the skills of future health care professionals.

“I’ve had to moan, writhe in pain, wheeze, pant, cry – you name it,” says Miles.

Besides faking illness, standardized patients evaluate students’ performances using a predetermined checklist, then provide immediate, on-the-spot feedback regarding what the student did well – and not so well. In many cases, this is the only source of information students will receive from a patient’s perspective before transitioning to real patients.

“It’s the next-best thing to the real deal, and it’s an invaluable learning experience,” says Sarah Kott, UT-Houston first-year medical student.

Fourth-year student Matthew Harting believes mistakes made in a make-believe setting now will make him a better doctor later.

“I learn so much from those mistakes,” he says.

Like professional actors, SPs memorize scripts that include their assigned character’s medical history, current medical complaint, and personal circumstances which may influence the case, such as a woman who is afraid to reveal that a broken bone is actually the product of domestic abuse.

Working from a script ensures that the interactions between SPs and students do not vary, thus “standardizing” the experience for all students.

“Before standardized patients were available, medical students were graded on their skills with real patients,” says John Rogers, M.D., a Baylor professor of family and community medicine. “Not all patients were the same, so students were not always evaluated on a level playing field.”

The standardized patient examination setting is made to resemble a real clinical environment, complete with exam tables, medical equipment, students in white coats, and standardized patients in gowns, if indicated. The only exception is the hidden video camera some programs use to record the exam.

Videotaping is done so students can watch themselves and get feedback.

“For example, a student who furrows her brow in thought while interviewing a patient may not realize that her expression is worrying the patient,” Owens explains. “But the SP, pointing to the videotape, can alert the student to this potential problem.”

Great care is taken to ensure a realistic experience, Lewis adds.

“A woman who has delivered children by cesarean section, for instance, cannot play the role of a woman who has never had children ... her abdominal scars would take away from the realism of the case.”

Performances by standardized patients are sometimes worthy of an Oscar. Some master the symptoms of brain stroke, complete with spastically curled hand, drooping lips, dragging foot and slurred speech, while others work to perfect their Alzheimer’s shuffles or breathtaking asthma wheezes. On occasion, patients are made to look sick with a spray solution that creates a sweaty appearance.

Cast of Characters

While some SPs have theatrical backgrounds, many others have widely varying interests and careers, resulting in an unconventional cast of characters. Robert Locke, for example, owns an antique store in Galveston, but fancies himself a “bit of a ham.”

“I’m artistic ... I love musical theatre, movies and drama. This is right up my alley,” he says.

Sue Hibbitts has been an SP for a dozen years, and pieces part-time jobs together to make a comfortable living. She acts in law schools’ mock trials, most recently playing the part of a mother under siege fighting for custody of her child. In her spare time, she works as a guide at the Houston Zoo, house-sits and pet-sits, and has even published a children’s poetry book.

Though they receive some compensation for their time, SPs aren’t in it for the money – they are helping the next generation of doctors become more sensitive to patients’ needs.

Standardized patients are invaluable when it comes to educating medical students, says Patricia Butler, M.D., associate dean for educational programs at UT-Houston’s Medical School.

“These people are extremely intelligent, flexible and quick-thinking. They must absorb an enormous amount of information, often without having the benefit of a medical background,” she says.

Reliability, punctuality, and ability to take direction well are essential, Owens adds. “Finding a good SP is like finding a pot of gold.”

Past and Future

The use of actors to play the part of patients for medical students started when former professor of neurology Howard S. Barrows, M.D., developed it at the University of Southern California in 1963. Since then, the practice has gained acceptance throughout the nation and the world. An April 2000 article in the Journal of the American Medical Association dubbed SPs the “gold standard” in medical education.

Standardized patient projects are so widely accepted that beginning next year, clinical skills demonstrated on SPs will be included as part of the National Board of Medical Examiner’s physician licensing exam.

This is a welcomed change, Owens says – one which highlights a current national swing toward improving physicians’ interpersonal skills.

“Too much emphasis has been placed on multiple-choice testing, and not enough on problem solving and relating to patients,” she says.

The doctor-patient relationship is even more important now that managed care frequently dictates how health care is delivered, Lewis adds.

“Physicians are required to see a certain number of patients each day, resulting in less time that they have available to spend with each patient,” she explains. “We want to make sure that our graduates have the communication skills and compassion needed to make the interaction with their patients a positive experience.“

In the meantime, Phyllis Miles stops by to pick up her next assignment. This time she’ll play a stressed-out piano teacher who develops a bleeding ulcer as her marriage dissolves and her career crumbles.

Does she ever draw upon personal experiences to help her get into a role?

“Oh, no!” she exclaims. “I’m never sick.”

For more information about Standardized Patient Programs at the following Texas Medical Center institutions, contact:

Baylor College of Medicine, Karen Lewis, Standardized Patient Program director , (713) 798-8045, kllewis@bcm.tmc.edu

Prairie View A&M University College of Nursing, Christiana Akoma, Ph.D., (713) 797-7046 or (713) 797-7017

The University of Texas Medical School at Houston, Tamara Owens, Standardized Patient Program coordinator, (713) 500-5148, Tamara.L.Owens@uth.tmc.edu

(The UT-Houston Medical School also provides SPs to UT Houston’s dental, nursing and allied health schools)

---

©2006 Texas Medical Center

---

E-Mail: tmcinfo@texmedctr.tmc.edu
URL: http://www.tmc.edu/tmcnews/04_01_03/page_01.html