Med students learn biology, chemistry, and physiology, but what about bedside manner? In a modern medical education, there are exams for that, too.
I’m standing in a pitch black observation room looking through double-sided glass. On the other end, a doctor in a white lab coat talks to a woman in a blue hospital gown.
“It started like a week and a half ago maybe,” says the patient, who has short black hair and glasses. “I just kind of feel like I can’t catch my breath sometimes.”
“That’s pretty frustrating, and kind of scary too,” the doctor says. “I’m sorry about that. When does this happen?” After a few more minutes, he walks over to the sink to wash his hands, and then he starts to examine her.
Eventually, the doctor diagnoses the patient with asthma, prescribes her an inhaler, and heads out the door.As soon as the door closes, the patient jumps down from the table and sits at the doctor’s desk. She starts clicking around on the computer and pulls a book out of a drawer.
Microphones hang from the ceiling, and a voice overhead says, “Please close all stations.” The announcement signals the end of a simulated exam.
The doctor in the room isn’t actually a doctor. At least, not yet. He’s a third-year medical student at Drexel University, and the woman he is examining isn’t sick. She’s a “standardized patient”—medical lingo for an actor, someone who follows a script and pretends to have a certain disease. The student knows she’s acting and he is being graded on how he diagnoses her.
From the observation room, I can see 10 student exams at the same time through 10 panes of double-sided glass. Dr. Dennis Novack, the associate dean of medical education at Drexel, gestures to one of the rooms.
“She has diabetes but has a high copay on her insurance, so she can’t afford the meds,” Novack says. “So her sugar is way off and the student has to figure out that’s what’s going on and try to address it.”
To graduate medical school, students have to pass tests where they examine and diagnose standardized patients. During their board exams their third year, the budding doctors have to do 12 simulations in a row.
Standardized patient exams are about more than medical knowledge, Novack says. They also test future doctors for empathy and interpersonal skills.
“What’s the major complaint that you hear from patients about their doctors?” Novack asks. “‘My doctor doesn’t listen.’ So we actually teach students listening skills. And standardized patients can give feedback on whether or not they feel heard. That’s part of empathy.”
That all sounds great, but it’s not always easy to show empathy to someone you know is acting. Students sometimes have trouble taking standardized patients seriously, Novack says. When he hears that, he shows them some tough love.
“When I talk to them I say, ‘First of all, you need to get over that,'” he says. “‘These standardized patients are real patients of somebody else. And they’re really pros. For the 15 minutes they work with you, they are that patient. And they judge your ability to relate to them by how they would feel if you were really their doctor.'”
I caught up with some of Dr. Novack’s students after a seminar. They said they’ve learned a lot from working with standardized patients. For one thing, the simulated exams give them a chance to mess up without killing or traumatizing someone.
“We learn all the basic sciences and the academic part of it and the lectures and what not, and being able to apply it to a real person, which is what we’ll be doing in the future, is a big step,” says Jonathan Richina, a third year student.
The simulated exams can also help students practice how to respond when a patient gets emotional, says Rachel Hess, another third year student.
“One lady was a great actress, and she was just crying cause you had to break the news that her baby was going to die in the ICU,” Hess says. “She just broke out in tears and you’re sitting there like ‘oh, I’m sorry. I don’t know what to do.’ But it was great to get that experience before going to a patient and having to do that for the first time.”
‘Academy Award’ potential?
Some standardized patients get really into the whole thing. “My students sometimes talk about how we should give Academy Awards for certain students,” Novack says. One standardized patient named Felecia Myers plays a young mother whose child has several disabilities and uses a ventilator. “[Felecia] cries real tears ten times in a row, and our students are really moved by her,” Novack says.
Myers has been a standardized patient for 13 years. “I’ve actually turned it into a bit of a career,” she chuckles. She works at several medical schools in Philadelphia, including Drexel.
When I met her, she was sitting in the observation room watching student exams. Myers says she and other standardized patients buy into the scenarios.
“We believe in what we’re doing, and we enjoy the educational part of it,” she says. “So from our perspective, if you’re not taking it seriously, it’s offensive.”
It isn’t hard for Myers to suspend disbelief. “If I’m in that real position, somewhere down the line, I want somebody to break that news to me in an empathetic way,” she says. “I don’t want somebody to just stare at me, say I’m another name on the docket and say ‘you have cancer’ and walk out the door.”
An opportunity for feedback
There’s one scenario where she has to pretend she has just been diagnosed with HIV. She begs her “doctor,” the med student, not to tell her husband, who is also supposedly a patient at the practice.
“There have been cases where the students are just like, ‘Well you’re just screwed if you don’t want me to tell him, because I have to tell him.'” she says. “And I was actually taken off guard because I was like, ‘Did you just say I’m screwed? How is that going to help me deal with this, even in a scenario?'”
Myers got to give the student feedback after the test. She says that part isn’t about calling students out; it’s about educating them.
In some programs, standardized patients also use their own bodies to teach students how to do physical exams. The standardized patient might say, “Here, rotate my arm like this,’ or ‘You need to check for my heartbeat in these four places.”
Sometimes Myers teaches a student how to do an exam and then runs into that person two years later in a testing scenario.
“You have that moment where you’re like ‘You remember!’ Even though you can’t say, ‘I taught you that.’ And sometimes it’s sort of a look you share in that moment,” she says. “But then you have to go into character and say ‘I’m somebody else right now,’ and you two don’t acknowledge it. You’re doing your job, they’re doing their job, and it’s all about good medicine.”
Back in the observation room, the patient with the black hair and glasses is still sitting at the doctor’s desk, reading her book. As the thirty second warning sounds, she throws her book in a drawer, scrambles up, and hops onto the table, ready to greet another student.