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September 18, 2006
Playing sick | Actors portraying patients with maladies from headaches to cystic fibrosis are a key training tool for medical students at Maine Medical Center
By Kerry Elson
A doctor walks into an examination room and greets his patient, who tells him she's experiencing nausea, blurred vision and pounding headaches. She's never had symptoms like this before, and she's worried. So the doctor asks about her medical history, does a physical exam and comes up with a diagnosis: migraine.
Well, that's what seemed to be the problem, anyway. Turns out, the patient was only an actor playing ill. And the doctor? He knew she wasn't really sick. But at Maine Medical Center, the teaching hospital in Portland, this kind of role-playing is part of the curriculum for medical students who train there, and it's one way that staff practice treating patients.
For doctors-in-training, these simulation programs are invaluable, allowing them to practice communication skills without jeopardizing an actual patient's health, according to Jenny Skolfield, director of the program. In the past, doctors might have learned to recognize symptoms from experience in the field, but a simulation, she says, allows them to practice recognizing the signs and be better prepared once they start their residency and health is on the line. "You want to know that a resident can recognize a migraine," Skolfield says. "You want to know that they can talk to someone who is exhibiting mania and provide an appropriate plan of care for that patient."
To achieve that goal, hospitals pay actors to present hypothetical cases for every student as part of what are called standardized patient programs. Maine Medical Center, a teaching site for the University of Vermont's College of Medicine, started using standardized patients in 2002, after UVM decided to make simulation part of its curriculum. Since then, the hospital has expanded the program to include pediatric residents and staff members who care for terminally ill patients. More than 200 doctors-in-training have participated, Skolfield says, and she hopes that in the future, simulation programs will be an even greater part of training for all hospital staff. In fact, Maine Med recently completed a five-year strategic plan for medical education that requires simulation training for physicians, nurses and staff.
Maine Med isn't alone. Standardized patient programs have become much more popular since they were first developed in the 1960s, and in the last five years the number of such programs at U.S. medical schools has increased dramatically: In 1999, 70 of 125 schools used standardized patients, while today, nearly all schools do, according to surveys by the Washington, D.C.-based American Association of Medical Colleges.
Part of the explanation for that increase comes from changes in the health care industry. While students used to learn on the job by treating patients in the hospital, today many patients only go to hospitals when cases are more severe, says M. Brownell Anderson, assistant vice president of medical education at the AAMC. As a result, students don't get the chance to view minor health concerns, and don't have time to practice their technique on sicker patients. "The way the health system is set up, the patients are much sicker than they were 10 years ago, and they're not able to tolerate repeated interviews," Anderson says. "The hospital used to be the teaching site, but now so much more is done in the outpatient setting. A lot of schools started using [standardized patient programs] because they had a shortage of patients in the hospital that they could practice on."
And now, it's in the best interest of medical schools to include such programs in their curriculum: In 2004, the AAMC added a standardized patient component to its national certification exam, which all medical students take in their final year of school. It's an all-day affair, in which students travel to regional sites and, after a written test, meet with a series of mock patients to demonstrate their communication skills.
Learning to listen
At Maine Medical Center, patient simulations occur a few times a month, mostly after students complete hospital rotations. The sessions take place in a small wing of Maine Med's Family Practice Center in Falmouth. Usually, students meet there after several weeks of practice in the hospital to test how well they can recognize signs of illnesses they might have encountered during their rotation ˆ everything from migraines to strep throat, domestic violence to depression.
The center looks like a regular doctor's office: six exam rooms furnished with examination tables, a sink and a chair. There are the typical linoleum floors and fluorescent lights. There also are rooms in which students can practice gynecological exams and speaking with patients over the phone. What makes these rooms different, though, is a tiny video camera perched in a corner, recording each encounter so faculty members can watch their students on computer screens in a separate room.
The encounters, called Objective Structured Clinical Encounters, usually take several hours to complete. Students are assigned to meet with a series of six patients for 20 minutes a time. A sign on the front of each door briefs them on the situation: How the patient is feeling that day, his or her age, and if vital signs have been taken. Then the doctor enters the room and meets with the actor as though it were a real visit, asking about the patient's medical history, performing a physical exam and coming up with a plan for treatment.
At the end of the session, the student exits the room so the actor can fill out a checklist that evaluates the doctor's professionalism, listening and communication skills, and ability to take the patients medical history. Then the student returns to the room so the actor can give feedback. Students receive a score for each of the sessions, and they move on to the patient in the next room. The standardized patient then prepares to portray the same ailment for the next student.
Medical students take the sessions seriously, Skolfield says. It's not like the Seinfeld episode in which Kramer signs up to be a standardized patient at a hospital and wows the doctors with a dramatic rendition of someone with gonorrhea. (A video of the episode used to be part of orientation for standardized patients at many medical schools, including UVM, until NBC contacted program directors and told them they were violating copyright laws.) Skolfield stresses that it isn't a game of "guess the disease." In fact, students never find out what ailment the actors were portraying; they're only evaluated on how they treat the patient while working on a diagnosis.
Doctors at Maine Med have found that the sessions are a good way to practice having difficult conversations with patients. Logan Murray, a 2006 graduate of UVM's medical school and a first-year pediatric resident at Maine Med, says that by working with standardized patients, he learned skills that he might not have acquired otherwise. "It helps to learn listening skills and picking up on subtle cues from the patient and avoiding leading questions," he says.
In one session, he met with an actor playing a teenage patient who was engaging in "risky behavior," and he had to tease out how the patient was feeling. "It's nice to engage in that with a [standardized patient] so you don't have to try it for the first time with a real patient," he says. "It's about getting beyond the 'yup' ˆ one-word answers that they might give to a parent."
Julian Ginsberg, a senior pediatric resident at Maine Med, not only went through a session as a first-year resident, he's also supervised UVM students in the program. He says receiving feedback from standardized patients ˆ and watching himself on tape later ˆ was helpful. About one encounter, in which he met with the mother of a child who had cystic fibrosis, he says, "I realized I wasn't listening as well as I should have been. My expectations were different from the mother's, and I wanted to hear a certain answer."
The actors who portray the patients are trained to give feedback, sometimes traveling to UVM a couple times a year to practice role playing. For each session they receive a list of symptoms for the disease, then work with Skolfield and UVM staff to learn to portray them accurately. The actors also are given a detailed biographical sketch that includes their character's religion, medical history, and whether they have children or a spouse.
Skolfield keeps a roster of about 25 actors whom she can call on a regular basis, including stay-at-home moms, retirees and young children. She doesn't have to recruit; everyone hears about the job through word-of-mouth. The work typically pays at least $15 per hour, depending on the condition the patient has to portray.
For the actors, participating isn't just a way to make a little extra spending money. Participants say it's also gratifying because they're helping teach the students. Roxana Brophy, 54, a stay-at-home mom from South Portland, has been working as a standardized patient at Maine Med for a year, receiving $25-$35 per hour. She typically plays three different roles, determined by her age and gender: The parent of a baby who's vomiting; an older woman who's fallen and hurt her hip; and a woman who's breathing heavily and panicked.
She also works as a gynecological teaching assistant for students, in which she demonstrates on another standardized patient the correct way to perform pelvic exams. The job isn't for everyone, she says, but it helps that she's comfortable with her body and was trained as a social worker. "I think it's so important for doctors to understand that going in for your yearly physical is horrible," she says. "And I like teaching and showing doctors how to treat women with respect and help them feel comfortable."
Some actors end up taking their own lessons to heart. Cheryl Reynolds, 55, is a community theater regular who's worked as a Maine Med standardized patient for three years. Like Brophy, she says she enjoys the opportunity to teach. But when she went back to her own doctor after performing as a standardized patient, she found herself evaluating her doctor's interpersonal skills. "It was an annual exam, and everything she's doing, I'm [thinking], 'She didn't do this, this, this.' Those thoughts were running through my head," she says. "Maybe a little knowledge is dangerous, but I am thinking of changing to another physician to be honest with you."
Well, that's what seemed to be the problem, anyway. Turns out, the patient was only an actor playing ill. And the doctor? He knew she wasn't really sick. But at Maine Medical Center, the teaching hospital in Portland, this kind of role-playing is part of the curriculum for medical students who train there, and it's one way that staff practice treating patients.
For doctors-in-training, these simulation programs are invaluable, allowing them to practice communication skills without jeopardizing an actual patient's health, according to Jenny Skolfield, director of the program. In the past, doctors might have learned to recognize symptoms from experience in the field, but a simulation, she says, allows them to practice recognizing the signs and be better prepared once they start their residency and health is on the line. "You want to know that a resident can recognize a migraine," Skolfield says. "You want to know that they can talk to someone who is exhibiting mania and provide an appropriate plan of care for that patient."
To achieve that goal, hospitals pay actors to present hypothetical cases for every student as part of what are called standardized patient programs. Maine Medical Center, a teaching site for the University of Vermont's College of Medicine, started using standardized patients in 2002, after UVM decided to make simulation part of its curriculum. Since then, the hospital has expanded the program to include pediatric residents and staff members who care for terminally ill patients. More than 200 doctors-in-training have participated, Skolfield says, and she hopes that in the future, simulation programs will be an even greater part of training for all hospital staff. In fact, Maine Med recently completed a five-year strategic plan for medical education that requires simulation training for physicians, nurses and staff.
Maine Med isn't alone. Standardized patient programs have become much more popular since they were first developed in the 1960s, and in the last five years the number of such programs at U.S. medical schools has increased dramatically: In 1999, 70 of 125 schools used standardized patients, while today, nearly all schools do, according to surveys by the Washington, D.C.-based American Association of Medical Colleges.
Part of the explanation for that increase comes from changes in the health care industry. While students used to learn on the job by treating patients in the hospital, today many patients only go to hospitals when cases are more severe, says M. Brownell Anderson, assistant vice president of medical education at the AAMC. As a result, students don't get the chance to view minor health concerns, and don't have time to practice their technique on sicker patients. "The way the health system is set up, the patients are much sicker than they were 10 years ago, and they're not able to tolerate repeated interviews," Anderson says. "The hospital used to be the teaching site, but now so much more is done in the outpatient setting. A lot of schools started using [standardized patient programs] because they had a shortage of patients in the hospital that they could practice on."
And now, it's in the best interest of medical schools to include such programs in their curriculum: In 2004, the AAMC added a standardized patient component to its national certification exam, which all medical students take in their final year of school. It's an all-day affair, in which students travel to regional sites and, after a written test, meet with a series of mock patients to demonstrate their communication skills.
Learning to listen
At Maine Medical Center, patient simulations occur a few times a month, mostly after students complete hospital rotations. The sessions take place in a small wing of Maine Med's Family Practice Center in Falmouth. Usually, students meet there after several weeks of practice in the hospital to test how well they can recognize signs of illnesses they might have encountered during their rotation ˆ everything from migraines to strep throat, domestic violence to depression.
The center looks like a regular doctor's office: six exam rooms furnished with examination tables, a sink and a chair. There are the typical linoleum floors and fluorescent lights. There also are rooms in which students can practice gynecological exams and speaking with patients over the phone. What makes these rooms different, though, is a tiny video camera perched in a corner, recording each encounter so faculty members can watch their students on computer screens in a separate room.
The encounters, called Objective Structured Clinical Encounters, usually take several hours to complete. Students are assigned to meet with a series of six patients for 20 minutes a time. A sign on the front of each door briefs them on the situation: How the patient is feeling that day, his or her age, and if vital signs have been taken. Then the doctor enters the room and meets with the actor as though it were a real visit, asking about the patient's medical history, performing a physical exam and coming up with a plan for treatment.
At the end of the session, the student exits the room so the actor can fill out a checklist that evaluates the doctor's professionalism, listening and communication skills, and ability to take the patients medical history. Then the student returns to the room so the actor can give feedback. Students receive a score for each of the sessions, and they move on to the patient in the next room. The standardized patient then prepares to portray the same ailment for the next student.
Medical students take the sessions seriously, Skolfield says. It's not like the Seinfeld episode in which Kramer signs up to be a standardized patient at a hospital and wows the doctors with a dramatic rendition of someone with gonorrhea. (A video of the episode used to be part of orientation for standardized patients at many medical schools, including UVM, until NBC contacted program directors and told them they were violating copyright laws.) Skolfield stresses that it isn't a game of "guess the disease." In fact, students never find out what ailment the actors were portraying; they're only evaluated on how they treat the patient while working on a diagnosis.
Doctors at Maine Med have found that the sessions are a good way to practice having difficult conversations with patients. Logan Murray, a 2006 graduate of UVM's medical school and a first-year pediatric resident at Maine Med, says that by working with standardized patients, he learned skills that he might not have acquired otherwise. "It helps to learn listening skills and picking up on subtle cues from the patient and avoiding leading questions," he says.
In one session, he met with an actor playing a teenage patient who was engaging in "risky behavior," and he had to tease out how the patient was feeling. "It's nice to engage in that with a [standardized patient] so you don't have to try it for the first time with a real patient," he says. "It's about getting beyond the 'yup' ˆ one-word answers that they might give to a parent."
Julian Ginsberg, a senior pediatric resident at Maine Med, not only went through a session as a first-year resident, he's also supervised UVM students in the program. He says receiving feedback from standardized patients ˆ and watching himself on tape later ˆ was helpful. About one encounter, in which he met with the mother of a child who had cystic fibrosis, he says, "I realized I wasn't listening as well as I should have been. My expectations were different from the mother's, and I wanted to hear a certain answer."
The actors who portray the patients are trained to give feedback, sometimes traveling to UVM a couple times a year to practice role playing. For each session they receive a list of symptoms for the disease, then work with Skolfield and UVM staff to learn to portray them accurately. The actors also are given a detailed biographical sketch that includes their character's religion, medical history, and whether they have children or a spouse.
Skolfield keeps a roster of about 25 actors whom she can call on a regular basis, including stay-at-home moms, retirees and young children. She doesn't have to recruit; everyone hears about the job through word-of-mouth. The work typically pays at least $15 per hour, depending on the condition the patient has to portray.
For the actors, participating isn't just a way to make a little extra spending money. Participants say it's also gratifying because they're helping teach the students. Roxana Brophy, 54, a stay-at-home mom from South Portland, has been working as a standardized patient at Maine Med for a year, receiving $25-$35 per hour. She typically plays three different roles, determined by her age and gender: The parent of a baby who's vomiting; an older woman who's fallen and hurt her hip; and a woman who's breathing heavily and panicked.
She also works as a gynecological teaching assistant for students, in which she demonstrates on another standardized patient the correct way to perform pelvic exams. The job isn't for everyone, she says, but it helps that she's comfortable with her body and was trained as a social worker. "I think it's so important for doctors to understand that going in for your yearly physical is horrible," she says. "And I like teaching and showing doctors how to treat women with respect and help them feel comfortable."
Some actors end up taking their own lessons to heart. Cheryl Reynolds, 55, is a community theater regular who's worked as a Maine Med standardized patient for three years. Like Brophy, she says she enjoys the opportunity to teach. But when she went back to her own doctor after performing as a standardized patient, she found herself evaluating her doctor's interpersonal skills. "It was an annual exam, and everything she's doing, I'm [thinking], 'She didn't do this, this, this.' Those thoughts were running through my head," she says. "Maybe a little knowledge is dangerous, but I am thinking of changing to another physician to be honest with you."
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