By Playing a Role, Standardized Patients Help Future Doctors Improve Their Skills
Eleven years ago, Joyce Haley sold her construction company “way before retirement age,” as she described it, and started looking for what she wanted to do next. She spoke about it with her doctor, who was also a good friend, and he asked if she knew what a standardized patient was. She didn’t.
“He told me to go watch the Seinfeld episode about standardized patients, and then realize it's nothing like that,” she said. “So, I watched it and laughed, then I called him and said, okay, what is it really like?”
After the call, Haley trained as a standardized patient, or SP, someone who is paid to take on patient personas in a medical setting to help train medical students, and sometimes other medical professionals such as residents or nurses, in certain skills. She is one of many SPs who work with Tufts University School of Medicine students on the Boston and Maine campuses. Haley also is a Gynecologic Teaching Associate (GTA). At Tufts, GTAs instruct medical students to perform breast and pelvic exams correctly.
“Students at the School of Medicine work with standardized patients throughout the curriculum, but particularly in the first three years,” said Laura Baecher-Lind, dean of education affairs and professor of obstetrics and gynecology at the School of Medicine. “Standardized patients are most helpful with three domains of learning objectives: history taking, physical exam, and interpersonal skills. We get really rich feedback on those three areas from our standardized patients.”
Standardized patient events at the School of Medicine in Boston take place in the Camilla Bessey Thompson and Paul D. Thompson, M.D., Clinical Skills and Simulation Center (CSSC). For Maine Track students, they take place at Maine Medical Center in the Hannaford Center for Safety, Innovation & Simulation.
“In both Boston and Maine, we have dedicated exam rooms that look just like exam rooms that you would encounter in a medical office. Typically, there is a standardized patient in each exam room, and students go from room to room to engage in those encounters,” said Baecher-Lind. “There are simulation rooms adjacent to the exam rooms, and sometimes we will have students do, for instance, an eye and ear exam in a simulation room following a standardized patient encounter.”
Getting Familiar with Standardized Patients
Students’ first encounter with SPs takes place just one month into their medical school education, during which students practice interviewing SPs in a medical interviewing course before going through the process with actual patients. In another course on clinical reasoning, Baecher-Lind and other faculty assess students after encounters with SPs by asking questions like, what do you think is the most likely diagnosis for this patient, and what tests do you want to order and why?
Standardized patients are also involved in medical students’ core clerkship year, when they participate in objective structured clinical exams, also known as OSCEs. These assessments are fact-based and involve taking a patient history and performing physical exams.
Some of the SP encounters are formative, which means they are for student learning only and do not count toward a student’s grade. Other encounters are summative, which means students are evaluated on their performance as part of their grade, and SPs contribute to those evaluations. Typically, Baecher-Lind said, it takes a year to develop new SP cases and then another year to pilot them. But such efforts are critical to make sure the cases are sound, that there's no ambiguity, and that the standardized patients can assess the students consistently.
“When students are in their clerkship, their encounters with actual patients will vary,” said Baecher-Lind. “As faculty, we need a way for students to have an objective and standardized patient encounter, so we know we're evaluating them for competency and proficiency. That’s where SPs come in.”
A team of Tufts educators in Maine and Boston will present the work they’ve done with standardized patients and OSCEs in the clerkships at the international Association of Standardized Patient Educators (ASPE) conference in June in Vancouver, British Columbia.
Taking On an Important Role
Eight-year veteran standardized patient Bob Ackley describes the role as having two components.
“One part is performance, though I have no acting background and had to learn that. The other is giving feedback to learners, and a big part of that is professionalism,” Ackley said. “I used to be a controller before I retired from the corporate world, and I had to give a lot of performance reviews and feedback. That was my strength.”
SPs usually have two types of encounters with medical students. One example is the OSCE, and the other batch of cases are more emotionally driven, as Ackley called them, and may involve students telling an SP that there was an error in someone’s care, or that they will need palliative care.
SPs typically have about six weeks’ notice before an encounter with medical students. First, Ackley said, he receives an email with a broad outline of a case, including any demographic requirements, and the approximate timing of the event. SPs have the option to say no, especially since sometimes cases can be sensitive, but Ackley said most of them try to say yes as much as they can.
About a week after accepting the opportunity, he receives the full case and learns more about the patient role he will be playing. A month before the event, there’s a training session for all the SPs playing the case, during which they look at the objectives and specifics. The SPs must be able to answer questions about the person’s social history, family history, medications, locations of pain, and anything else the doctor may ask in an exam room.
“Sometimes there are pop quizzes during the trainings, and instructors will ask, ‘Hey Bob, how old are you?’ Just to make sure we're on top of our game,” said Ackley. “You really need to know about that person, and that includes the emotional side of that person.”
Each case has door instructions, which is what the medical students review before their encounter with an SP. During the training, SPs review the door instructions, so they know what information and level of detail students have when they're coming into the room. The idea is to help the students learn how to ask questions and make inquiries to get the information they need from the patient.
During their training, SPs review a checklist of questions developed by the faculty that they will have to answer after each encounter, such as did the student check your glands, or did the student ask about your family medical history, with many of the questions geared toward patient communication. They also review videos of other SPs performing the case and discuss what feedback they would give to the learners in the scenarios.
On the day of the event, a standardized patient is typically required to work with and assess several students. Most cases have been run previously, and all encounters are recorded.
“Within an event, we might play our role six or seven times in a row,” said Ackley. “By the time we see the fifth student, sometimes SPs can experience cognitive overload, a term we use a lot at training. Each SP has tricks for how to keep everything straight, but it can be difficult.”
“Working with standardized patients is a great opportunity to practice what we’re learning, and it makes going out onto the hospital wards a lot less stressful.”
- Emma French Stevens, M25
Providing Feedback to Improve Outcomes
“Students start by reading the door sheet outside the exam room,” explained Ackley. “They knock, we have our interaction, they leave, and then I fill out the checklist on a computer. Afterward, I go from Bob Smith the patient to Bob Ackley the person, and we sit down, and I give them feedback on how it went. We mostly talk about communication, empathy, body language, voice timber, and how they generally made me feel.”
Haley focuses on tone in her role as a gynecological teaching associate, too, as she guides students through the process of providing pelvic exams to other standardized patients.
“We've all had exams where there's very little personal communication,” she said. “But taking the time to set the tone so the patient is relaxed and trusting is so much better. We try to teach them the language and the flow of the exam so that when they actually go to do the physical portion of the exam, the patient is ready.”
She closely monitors students as they conduct physical exams, anticipating their every move. If she thinks they are about to do something that will cause pain, she stops them. And the SP receiving the physical exam gives feedback to students in real time and communicates when they experience discomfort.
“Working with standardized patients is a great opportunity to practice what we’re learning, and it makes going out onto the hospital wards a lot less stressful,” said Emma French Stevens, M25. “I found it especially helpful for how to structure sensitive conversations and sensitive exams, like the breast and pelvic exams, and how to have hard conversations that will be stressful for patients. It’s good to know what to say, and also what not to say.”
Providing feedback is a significant part of being an SP. Ackley said that’s part of why he loves the job so much—he feels like he’s making a small difference in medicine. But sometimes SPs have to give feedback that is not easy to provide.
During sessions where students practice delivering bad news to standardized patients, Haley always addresses a phrase some students choose to use.
“My trigger is when they say something ‘fell through the cracks,’” said Haley. “After I describe to them how that affects me, they usually tell me they will never say that again. That little nugget isn’t much in the grand scheme of what they’re getting from Tufts School of Medicine, but it's going to make a difference to somebody at some point.”
On the other hand, she takes great joy in telling a student when they hit a home run. She shared this anecdote from a recent session where students practiced delivering bad news.
“A student leaned forward and said to me, as the patient, ‘I'm going to be with you every step of the way through this. You're going to get tired of seeing my face,’” she recalled. “I told them to say that every single day for the rest of their medical career. They grinned, and I think they will.”