Photo courtesy of Nicole Martin Nicole Martin

Recasting the Actor-Patient

As a medical student, I have had numerous encounters with standardized patients. These individuals, many of whom live and work in nearby communities, are trained by our instructors to simulate illnesses and give feedback to students regarding interview style and exam techniques. Most of our exposure to these patients occurs during the objective structured clinical exams (OSCEs), which occur at the end of the second year and the beginning of the fourth year. Over the course of an afternoon, each student rotates through multiple stations, where the ailments range from abdominal pain to anxiety. These exams are intended not only to assess our skills at natural breakpoints in our education, but also to prepare us for Step 2 Clinical Skills (CS), part of the United States Medical Licensing Examination (USMLE).

After completing Step 2 CS last fall, I felt that standardized patients played a useful, albeit limited, role in clinical education. Part of the limitation is that no visit with a real patient is this straightforward. A standardized patient will never lead an interviewer astray, while a real patient may include scores of details that may or may not be significant.

I find it much harder to talk with a standardized patient, however, because the encounter feels like a charade. As the patient performs his or her assigned role, I observe and intermittently blurt out questions, nervous that I won’t make the diagnosis before time is up. I feel that I can’t connect with the patient in any meaningful way, and the disjointedness of the conversation only fuels my anxiety. As many of my classmates would agree, it’s easy to forget important questions and exam maneuvers in these situations, not to mention that bedside manner usually takes a nosedive.

In Character
One notably different standardized encounter, titled “Giving Bad News,” was held during the second-year Patient–Doctor course. After reading a clinical scenario about a gentleman with metastatic cancer, I explained the diagnosis to the actor-patient, outlined treatment options, answered his questions, and expressed my support. I was anxious in this situation, too, but for the opposite reason—it seemed entirely real.

The actor-patient, undistracted by a memorized medical history or faux physical finding, was fully in character and focused on our conversation. I understood the import of my words, so I chose them carefully. As the encounter proceeded, I gradually relaxed, and I felt that he and I were on the same page. Afterwards, the actor-patient said that he had appreciated my efforts to show concern, but I had seemed nervous. My preceptor, who had observed us, told me that it was a good first attempt, but that I had talked a lot. It was true—the silences had made me a little uneasy, and I found that words were soothing. I guess the patient didn’t agree.

Role Reversal
Last November, students in medicine and other health professions were invited to participate in a role-play for the Program in Palliative Care Education and Practice, a continuing medical education course based at HMS. Since I was curious about the experiences of standardized patients, I volunteered. The other students and I attended one preparatory session during which Dr. Joanne Wolfe reviewed the complicated medical history of Lenora, a 28-year-old woman with metastatic, terminal liposarcoma; we then practiced responding to various questions.

During the actual session, I was placed in a group with six or seven physicians and nurses. Three of them participated in the role-play at a given time, and the others observed. The first scenario was an office visit during which several end-of-life issues were addressed, including pain control, life-saving measures, and home hospice care. As I spoke, I found myself pausing frequently as I began to assume the patient’s fear and sadness. During the second scenario, I faced impending respiratory failure and needed to make an immediate decision about intubation. I nearly broke down when told that I might have to be intubated and sedated before my parents arrived. Being on the other end of the “code status” discussion for the first time, I became apoplectic.

As I imagined myself succumbing to pulmonary edema, I felt like a child—I didn’t want to know what the ICU staff would do, how long I’d be asleep, or what my chances of survival were—I just wanted them to take care of me. Given the emotional nature of the situation, I was grateful for the nurturing approach taken by the physician and nurse. They told me I had to choose quickly, but they gave me plenty of time to think and respond. I was reassured because they were calm.

Every medical student has been a patient in various contexts. Yet for those of us who have been relatively healthy throughout our lives, it’s difficult to comprehend the vulnerability of the seriously ill. It’s even more challenging to predict how a sick patient will respond to doctor-speak. By practicing communication skills in semi-scripted encounters, students can explore these issues in safe, controlled environments.

Unfortunately, Step 2 CS does little to further this goal, since empathy isn’t easily quantified. The New Pathway curriculum incorporates helpful standardized patient activities, but students should also be given opportunities to experience patienthood firsthand. By playing the patient, I learned to appreciate a well-timed phrase, a soothing tone, and a comfortable silence.

—Nicole Martin is a fourth-year medical student at HMS.

Details used in this column have been changed to protect patient privacy. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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