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Poked And Prodded Again And Again
PREFACE: Patients and doctors alike revere the blend of empathy, communication, and authority that is universally called "bedside manner." None of us receives medical care without reflecting on the demeanor of the physicians who care for us and their ability to instruct and console us. Yet teaching bedside manner has proved difficult. Although precise methods for teaching and testing students’ acquired medical knowledge have been developed, the staples of teaching about doctor-patient relationships have long remained exhortation and (not always good) role modeling. During recent decades, this shortcoming has been rectified in large part by adopting a novel teaching technique in medical schools: the standardized patient. Barbara Ucko, who works as a standardized patient, writes that her role feels akin to being an unappointed medical faculty member and reveals what it’s like from her perspective as a patient. Steven Wartman, a nationally noted medical educator, describes his mother’s evolution from an overdoctored patient to a zealous and effective actress-patient. Taken together, these stories chronicle a quiet revolution in medical education.
UNDER NORMAL CONDITIONS, few things make me feel more vulnerable than sitting in a doctor’s office wearing only a hospital gown. Gone are my funky clothes and handmade jewelry that show who I am. All that’s left is a quiet, middle-aged woman feeling anonymous and exposed. There are times, however, when I am gowned and seated on an examining table that I feel far from vulnerable. In those instances, I’m in a small, windowless room on the sixth floor of the George Washington University Medical Center in Washington, D.C. That’s the location of GW’s Office of Interdisciplinary Medical Education in the Clinical Skills Center for the School of Medicine and Health Sciences. There I am calm, with a pleasant sense of anticipation, for I, a woman who has trouble getting the attention of sales clerks, am about to strike fear into the most resolute of medical students. The hands about to examine me might be cold and shaky, the voice might quaver, the stethoscope might slide from a cocky perch on the shoulder to a humiliating heap on floor. I am, at these times, no ordinary woman in search of medical advice. I am a "standardized patient," a part of the students’ medical education. I’m a powerful force for good; it’s almost like being Wonder Woman.
THE STUDENT ENTERS. "Hello, Mrs. Johnson," he says. "Or would you rather I call you Beth?" I tell him that either will be fine. We’re off to a good start. In making sure he gives no offense in how he addresses me, he has already demonstrated the art of asking rather than assuming. "My name is Jason Eames," he continues (all of the names here have been changed). "I’m a second-year medical student at GW. Excuse me, please, while I wash my hands." Again I’m encouraged. He has remembered to wash his hands, and he is telling me what he is going to do before he does it. That one-two process invariably is reassuring—whether the student is talking about hygiene or explaining how he’ll be checking my heart. "What brings you in today?" he asks. I give him the opening statement that the other standardized patients and I have been trained to deliver for this case. It’s usually something simple, like, "My foot hurts," or "I have a headache." And we’re off. The student has anywhere from ten to thirty minutes, depending on the case, to figure out what’s wrong with me and to recommend next steps. I then have anywhere from five to twenty minutes to let that student know how well I think he did. By seeing dozens of standardized patients as a part of their training and exams during their years in medical school, medical students get a preview of how similar and how varied their actual patients will be. They can begin to see a pattern of what in their approach makes patients happy and compliant versus what irks them and makes them resistant to following treatment plans. As a standardized patient, one day I might be assigned to be a self-important corporate lawyer furious about being kept waiting for an hour. Another day I might be a lonely widow who can’t stop talking about her childhood. At other times I might be too depressed to speak, or too poorly educated to articulate clearly what’s wrong with me, or too confused to understand what the student is saying. (I should note here that, with a few exceptions, the cases I’m involved in are used from one year to the next, so the content must remain confidential. I’ll be referring obliquely to parts of cases and, in one instance, to the content of a case that is commonly used in training, but not in exams.) While a student examines me, in my head I check off what he or she is doing right, doing wrong, and forgetting to do altogether. If I were a real patient, my doctor would probably never know whether the session satisfied me, but because I’m a standardized patient, I provide feedback structured for medical students’ optimal learning. Sometimes it’s written, sometimes verbal, sometimes both. Sometimes it’s private, and sometimes it occurs in front of a group of students and faculty. You can see why students might be nervous about dealing with standardized patients, and why the experiences might—and should—make a lasting impression. Recently, as a real patient, I visited a respected specialist who asked what I did for a living. When I told him that I worked part time as a standardized patient, he groaned. "Oh, I remember those days," he said. "I learned a lot of things my professors could never have taught me, but those sessions were incredibly stressful. You’d have to pay me a million dollars to go through that again."
ALTHOUGH MANY MEDICAL SCHOOLS, such as the one my specialist went to, have been using standardized patients for years, I’d never heard of the concept until four years ago, when I attended a Parents’ Day for my daughter-in-law at GW’s medical school. My husband and I had recently moved to D.C. from Kansas City, Missouri, where I’d left behind piano students and friends, and I was looking for a new way to feel useful. My only acting experience had been a bit part in a high school play, but working as a standardized patient sounded like a fine way to meet interesting people. I could continue to feel like a teacher, and it would be a privilege to feel in some part responsible for guiding medical students into becoming better doctors. Finally, medical conditions have always fascinated me. I was one of those kids who liked looking up diseases in encyclopedias, and as an adult, I’ve been entranced by books such as Berton Roueche’s The Medical Detectives, even The Merck Manual. My daughter-in-law gave me the name of a woman at GW to call, and my career as a standardized patient—which is usually referred to as an SP—began. After several of hours of orientation, a few weeks later I arrived for my first four-hour, afternoon gig. When I went into the break room, there were half-a-dozen SPs who had worked the morning session, and the room throbbed with conversation about their encounters with young doctors. "I told her my mother had died a month ago, and she says ‘OK’." The woman let out a splutter of indignation. " ‘OK’? If I’d told her my entire family had been slaughtered the day before, she probably would have said ‘OK’ to that, too." Another woman chimed in. "I had one who kept coming back to my sexual history," she said. "What does that have to do with my foot?" At the end of the break-room table, a woman bent over a musical score was humming softly. "They all want to know your sexual history," she said without looking up. I felt as if I’d just stepped into a party with unusually colorful guests. Many of the SPs get into the work because they are actors or musicians who are between jobs and looking for a way to pay the rent, but it doesn’t take long for them to become deeply involved in the process. What I was hearing wasn’t idle chatter. The complaints and praise provide invaluable information on what rubs other SPs the right or wrong way. The SP trainer entered the room. She assigned SPs to each of several cases, then went over the cases with us, asked for questions, and gave us time to rehearse with one another. For those of us who were new to the profession, she also reviewed feedback protocol. In the years since, I’ve learned that it’s tempting to think of myself as an unofficial member of the medical faculty. Experienced SPs know a great about what constitutes good or bad medical practice. But it’s also always important for SPs to remember that our role is to respond as we would if we were the real patients we are pretending to be. That’s why the feedback component follows a highly structured format in which SPs comment on how specific behavior makes them feel. For example, in a positive situation, I might say, "When you asked me how I keep busy now that my husband’s gone, I felt comforted." The format for a negative situation adds additional information after a complaint: "But if you had done x, I would have felt y." Sometimes the formats feel frustratingly restrictive, but they package the feedback in a way that’s been shown to be especially helpful for students. In addition to verbal feedback, we fill out computer-generated feedback forms. In most cases, one form focuses on technical skills and medical knowledge ("Did the student check your ankles for pulse?"), and another focuses on the kinds of interpersonal skills that make up bedside manner ("Did the student greet you warmly?"). For each case, an SP is trained to begin with a memorized opening statement and told to use a certain level of emotional intensity; all of the SPs will do the same thing when presenting the same case. We’re usually advised to volunteer no information and to answer without elaboration. Because of their training, actors often are the most easily standardized—and because of their personalities, they sometimes are the most resistant to standardization. Once, for instance, while watching a monitor in the observation room, I saw an actor respond to the question, "How old are you?" by saying, "I’m about to hit the Big Five-O. Yep, the Big Five-O. Not looking forward to it." That reply might result in camaraderie between SP and medical student that differs from what other SPs and students involved in the case experience. Saying "fifty" isn’t nearly so much fun, but it’s what the actor was supposed to have said, and it was the one-word answer that made us standardized. SP training can last from a few minutes for a simple case to many hours for more complicated cases. Usually I see as many as four students in succession. If I saw more than that without a break, the students undoubtedly would blur together, and it would be hard to remember whether the next-to-last student washed her hands, or checked my lungs properly, or asked if I had other concerns. The other SPs and I find ourselves living our assigned cases with all the intensity of an actor falling in love with a costar. "Don’t you and the students know you’re just pretending?" I’ve been asked. No, we don’t. Less than a minute into a session, both the medical student and SP have suspended disbelief. In one recent case, I was pretending to be severely depressed. "Have you considered suicide?" the student asked. "Yes," I answered. "I was thinking about jumping off Key Bridge into the Potomac, but I’m not sure the bridge is high enough." The student fled without completing the interview. She returned for feedback, along with her instructor, who gently recommended that she explore what made the case so difficult for her. That had been a hard case for me, too, as my mother has a history of depression, and I was thinking of her as I performed my role. The only SP case I don’t enjoy is smoking cessation counseling. In the smoking case, I tell the student that I’m trying to quit smoking after a forty-year, two-pack-a-day habit. Ideally, I should do about half the talking. I should explain why I still smoke, which smoking rituals would be hardest to give up, what motivators could help me, and what deadline for giving up smoking is most likely to succeed. Sometimes that happens, but usually I find myself listening as students give elaborate descriptions of how to chew nicotine gum, even though my standardized-patient preference—had I been asked—would be for a patch. I also hear about the dangers of smoking, which are well known to me even as the nonsmoker I am. Some students will aggressively pursue a quit date before we’re even a minute into the interview. The case seems to bring out the worst in many of them, in that they take up 95 percent of the conversation space and make too many assumptions. Much as the other SPs and I like to complain about things that go wrong during sessions, such as in the smoking-cessation case, most of us prefer the good interactions. It seems to give us bragging rights to encounter a good student, especially someone we’d worked with before. Surely, we think, some of that phenomenal compassion, thoroughness, and interviewing grace must be thanks to us.
SEEING AN SP PROGRAM IN ACTION, it’s hard to believe that standardized patients were considered a waste of time when the concept originated in Los Angeles in 1963. That’s when Howard S. Barrows, a neurologist and medical educator at the University of Southern California, began using what he called "simulated patients" as part of teaching his third-year neurology clerks. Initially, he met with resistance from the faculty. According to Peggy Wallace, who wrote a history of standardized patients in medical education, "he was seen as doing something quite detrimental to medical education, maligning its dignity with ‘actors.’ " It didn’t help that the program began near Hollywood. A 1965 Los Angeles Herald-Examiner headline declared: "Hollywood Invades USC Medical School," and the San Francisco Chronicle wrote about "scantily clad models...making life a little more interesting for the USC medical students." Despite negative reactions from medical schools throughout the country, Barrows was convinced that the program worked. His students loved the approach, and he was learning things about his students that he wouldn’t have known otherwise. Eventually, Barrows began to develop cases that were more than simulations, standardizing them so that he could better evaluate his students in relation to each other. Barrows also developed a feedback checklist for both the standardized patients and his own observations. The use of standardized patients spread slowly, then took off with a roar after a June 1984 conference called "How to Begin Reforming the Medical Curriculum," which was cosponsored by the Josiah Macy Jr. Foundation and the Southern Illinois University School of Medicine. Also around then, the focus shifted to assessing the set of skills that make up bedside manner in addition to reviewing students’ medical performance. Today using standardized patients is the norm; they even showed up in an episode of Seinfeld. Even after four years as an SP, I occasionally hesitate to speak my mind, especially when it’s about something as subjective as bedside manner. Recently, for instance, I had a complaint about a student that I was embarrassed to mention in the break room because it seemed trivial, possibly even culturally biased. When it occurred, I had been in a room full of medical residents plus two faculty members. Because the residents had four years of medical school behind them, my expectations were high. One of the residents came toward me and took my right hand in both of his. Perhaps his two-handed clasp—with one hand beginning to slither up my wrist—was his way of showing warmth, but it struck me as sleazy. Was I reminded of a disgraced politician I’d seen on TV? A bad date from many years ago? He didn’t seem to notice that I was taken aback, even repelled by his action. I tried to block out the overly familiar handshake and concentrate on the interview. During the oral evaluation, I almost said something about it, but there were other aspects of the interview that seemed more important to discuss. A few weeks later, I had a second encounter with this resident. I was lying on an examining table, draped in a sheet, a bandage on my head, a situation where I still can’t help but feel vulnerable. The resident entered and pulled a chair over to the foot of the table. How curious, I thought. This was a disturbing case, one in which he would have to give me bad news. Shouldn’t he be close to my head so that there could be eye contact? After I delivered my opening statement, the resident began to talk about what had gone wrong, and, as he did so, I felt a curious sensation. Good heavens, I realized, he’s rubbing one of my feet. The fact that I was lying down and hadn’t seen his hand approaching my foot (which was, after all, at the opposite end of my body from my "injury") was creepy. I wanted to snap at him, "Cut that out, and get up here where I can keep an eye on you." I kept quiet, however; my reaction could wait for the feedback questionnaire. Other parts of the session also disturbed me. I began to wonder where he’d gone to medical school; seemingly it was a rare somewhere that didn’t use standardized patients with its students. He spoke quickly, offering what sounded more like excuses than explanations. He failed to ask how I felt about the hard choices I had to make. Finally, he offered—a bit too eagerly—to have another doctor take over my case. I felt as if he couldn’t wait to wash his hands of me, especially the hand that had been fiddling with my foot. The encounter ended. The resident left the room. I was alone with my computer-generated questionnaire. Like all good questionnaires, this one had a space for additional comments. He was a resident. It was important that I offer feedback before it was too late. I was no longer a woman lying on a table wondering why a stranger was rubbing her foot and when he would stop. No, I was a standardized patient, with a wide-open space for comments before me. I had the potential to be as powerful a force for good as Wonder Woman. I began to type.
Barbara Ucko (barbara.ucko{at}verizon.net) lives in Washington, D.C., and works part time as a standardized patient at the George Washington University Medical Center.
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Becoming Standardized
Past And Present
