How Standardized Patients Work


Standardized patients were around way before Kramer's famously nutty depiction of one on the hit TV show "Seinfeld," but that episode helped to boost awareness big time.
Standardized patients were around way before Kramer's famously nutty depiction of one on the hit TV show "Seinfeld," but that episode helped to boost awareness big time.
Getty Images/Handout

Standing in a hospital exam room, a medical student asks, "Are you experiencing any discomfort?" The patient replies, "Just a little burning during urination." The student makes a note on his clipboard. "Any other pain?"

Here's where it gets a little weird.

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"The haunting memories of lost love." The patient lights a cigarette. "Our eyes met across the crowded hat store, I a customer, and she a coquettish haberdasher ... I burned for her. Much like the burning during urination that I would experience soon afterwards."

"Gonorrhea!" cries the student. The room breaks into applause.

Those of a certain age may find this scene familiar. It's from Cosmo Kramer's stint as a fake patient in a 1998 episode of "Seinfeld." The character is part of a medical-school training exercise in which he pretends to have an illness and medical students try to diagnose him, and it comes off as absurd. But it turns out, if you remove the hammy monologue and the applause, and the smoking, we're looking at a standardized-patient interaction.

Standardized patients, sometimes called "simulated patients," have been around since the 1960s, first conceived by a neurologist who was having trouble finding sufficient real-life teaching experiences for his students [source: GVSU]. By the 1980s, standardized patients, or SPs, were a common training tool in medical schools across the United States. Now, all U.S. physician-licensing exams include a standardized-patient interaction, and there are SP programs all over the world, not only in medical schools but also in dental, pharmacy, nursing and veterinary training [source: ASPE]. (In the latter, disappointingly, it's the pet owner doing the acting.)

The concept is pretty straightforward: SPs provide a safe opportunity for emerging health professionals to learn, make mistakes and practice. A healthy person acts the part of a sick person with a specific illness, offering doctors-in-training the chance to interact with, examine and diagnose someone who won't actually suffer any harm if the student messes up.

Because There's No Crying, or Eye-rolling, in Medicine

Standardized patients play a wide range of roles in clinical simulation. They participate in interviews, answering questions about medical history and symptoms; they receive counseling regarding their assigned diseases or physical states; and they undergo physical exams [source: GVSU]. Depending on the case, they may need to get undressed [source: University of Pittsburgh]. Even then, exposure is pretty minimal: The SP is in a hospital gown, and a student may touch the bare back or partially expose the chest while applying a stethoscope [source: University of Pittsburgh]. If they're open to it, though, SPs can be assigned cases involving more sensitive interactions, like breast, pelvic or prostate exams [source: University of Pittsburgh]. In those cases, the student's instructor is always in the room [source: University of Pittsburgh]. In all cases, the SP's instructor might be there to evaluate the "patient's" performance [source: CU Denver].

More than diagnostic skills and proper speculum placement, SP interactions are about learning to communicate with patients. "Even though it is called a 'soft skill,' it is one of the hardest to master," says Valerie Fulmer, director of the Standardized Patient Program at the University of Pittsburgh School of Medicine. "Communication is at the root of proper diagnosis, patient safety and patient satisfaction, and miscommunication can lead to medical error."

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And you can't develop a bedside manner in a lecture hall. "Students may be great in the classroom, but that doesn't automatically translate into being a good health care provider," says Karen Lewis, Ph.D., administrative director of the Clinical Learning and Simulation Skills Center at the George Washington University School of Medicine and Health Sciences. "They have to be compassionate caregivers with superior communication skills to be great doctors [and] nurses."

For some students, it takes practice to approach a patient with sensitivity. For others, the hard part is maintaining a professional distance, or getting out of their own heads. Fulmer tells of one student who was overcome with emotion while interviewing an SP portraying a homeless patient.

"[He] had to take a timeout," she recalls. "He had a brother who was homeless ... and the interview was difficult for him. He reported that it was good to practice an interview such as this in a safe place where he could deal with his own emotion without having to worry about dealing with a real patient at the same time."

SPs provide that safe place; students know the patients are "patients." They also provide a pretty realistic clinical simulation, though they needn't have a medical or acting background to do it. That's what SP training is for.

I'm Not a Patient, but I Play One in the Exam Room

Can you think on your feet? Do you like helping people learn? Do you think your acting ability goes unheralded? This could be the gig for you.
Can you think on your feet? Do you like helping people learn? Do you think your acting ability goes unheralded? This could be the gig for you.
Image courtesy University of Pittsburgh

The process goes like this: A standardized patient is assigned a case. That case may be based on an actual patient, or it may be a carefully developed fictional situation [source: ASPE]. The patient may be suffering anything from mysterious back pain to an itchy rash or, well, burning during urination. He may be dying of cancer. The case documents include everything an SP might need to know to accurately portray the patient in question – medical history, symptoms, personality quirks, demeanor and physical limitations [source: GVSU]. If a patient with back pain can't stand without hunching over, neither can the SP.

SPs receive assignments anywhere from two weeks to three months in advance of the interactions, depending on the complexity of the case [sources: Fulmer, Lewis]. They study, memorize and internalize. They train with SP educators on the educational context and goal; on how to accurately portray the patient's condition and personality; and on what exactly will be required of them during the interaction [source: Lewis]. For physical exams, they learn what students should be doing during the exam, and why. If feedback is involved, they learn which types of feedback are most helpful in the given context [source: Lewis].

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Interactions are basically unscripted: The SP has his or her answers planned in advance, but there's no telling what a student is going to ask during an interview. A good standardized patient can answer questions on the fly and do it accurately.

"We had a second-year medical student who was assessing a patient for chest pain," recalls Lewis. "The student should have asked the SP if she ever woke up in the middle of the night feeling like she couldn't breathe ... Instead, the student asked, 'Do you ever wake up in the middle of the night breathing?' Without missing a beat, the SP replied, 'To the best of my knowledge, I breathe all night, every night.'"

Many standardized patients have acting backgrounds, for obvious reasons [source: University of Pittsburgh]. Being a good actor doesn't guarantee success, though. Not by a long shot.

The "Standard" in "Standardized Patient"

Standardized patients serve several training needs that are difficult to fulfill with real patients. There's the inexperience issue: If medical students are going to mess up, better to mess up on a healthy person than a sick one. There's availability: Medical schools have specific lessons to teach, and finding real patients who meet their exact curricular needs can be tough [source: GVSU]. And feedback: Real patients can't be counted on to provide accurate, constructive feedback [source: GVSU].

But perhaps the greatest advantage to using standardized patients in training and assessment is their ability to keep it, well, standardized.

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All medical students in a given class are expected to learn the certain material and then show through testing they have mastered it. In a lecture class, it's relatively simple to ensure that all students are presented with the same material and being assessed on the same factors. In a clinical setting, not so much.

Ideally, SPs provide a uniform clinical experience, offering each student the same patient, the same case details and the same type of feedback [source: University of Pittsburgh]. For SPs, this means repetition. An SP might be examined by 10 medical students in a row, and each time, the "patient" has to deliver the same performance. By the 10th time, this can be a challenge [source: University of Pittsburgh].

If this sounds a lot like what teachers have to do, that's because it is. SPs are sometimes called teaching associates or clinical educators. "Some think that this is an acting job, and so we often have to debunk that misunderstanding," explains Fulmer. "We are educators, and our approach is carefully planned and predictable."

Burning for coquettish haberdashers, then, is probably out. Kramer would have been fired.

Actually, he probably wouldn't have been hired in the first place.

A Good Fake Patient Is Hard to Find

Looks like he made the cut. That could be good experience for a few different careers.
Looks like he made the cut. That could be good experience for a few different careers.
Image courtesy University of Pittsburgh

SP recruiters are an intuitive, picky bunch, and with good reason. Standardized patients are helping to train the next generation of doctors; their feedback directly impacts medical students' careers; and the work is hard. Imagine having to keep track of assessment criteria while listening closely to a student's questions, recalling one's symptoms, hunching over in pain and trying to keep the back of a hospital gown closed.

When it comes to SP selection for a specific case, there are objective criteria [source: Johns Hopkins]. Ideally, if the patient is Asian, female and middle-aged, so is the SP portraying her, so recruiters aim for diversity in their pool of potential SPs [source: Fulmer]. Populating that pool with great standardized patients, on the other hand, is a far more subjective undertaking.

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There is no ideal background for the work, though experience and/or interest in teaching, medicine, acting or communications comes in handy [source: Lewis]. Often, it's more about personal skills and personality traits. Good SPs are often curious and detail-oriented and love to learn [source: Fulmer, Lewis]. They are energetic and positive (lest they start sagging and snapping by the 10th performance), are good communicators and listeners and have excellent memories [source: University of Pittsburgh]. They take direction well and have the flexibility to implement it: If a simulation isn't achieving the desired goal, an SP may need to make changes to his or her act [sources: Lewis, CU Denver, University of Pittsburgh]. And people who are uncomfortable around doctors or dealing with health matters probably shouldn't apply [source: University of Pittsburgh].

For those who qualify, it can be a pretty great gig. It's typically part-time work at best, and not particularly steady (curriculum needs dictate case load), but the hourly rate is substantial – usually between $17 and $35 an hour [sources: Lewis, Fulmer, Sun]. And the field has a certain draw. Student interactions can be fascinating, especially for those interested in medicine, psychology or education. It can be highly satisfying work for someone who enjoys helping people learn. It also can be prime resume material for people pursuing careers in theater, medicine or teaching [source: Lewis].

And then, there's the "You do what?" factor -- or, as Karen Lewis puts it, "It makes great dinner conversation."

Perhaps less so in the case of gonorrhea. But still.

Author's Note: How Standardized Patients Work

An acquaintance of mine is a dermatologist, and when I told her I was writing about standardized patients, she laughed. (Oddly enough, she took her standardized patient exam for licensure at the same hospital where Kramer was fictionally undergoing his exam, the Morchand Center for Clinical Competence in New York.) At that laugh, I got excited, ready to get some juicy stories for my article. My research didn't turn up much on the doctor's perspective. Sadly, she claims she doesn't remember much. It was in 2001, she says, too long ago. All she told me was, "It was bizarre." She declined to elaborate. It's killing me.

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Sources

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