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August 28, 2008

Standardized patients help train med students

Over the past three years, Dave Crawford has been alcoholic, suicidal and a sufferer of chest pains, back pains and belly pains.

And he liked it all.

Crawford is among about 100 people Pitt hires to portray such maladies for its medical students, who learn how to examine and interact with a variety of patients.

Standardized patients, or SPs as they are called, fill a crucial role in helping medical students prepare for national board testing and in teaching activities that train future doctors how to communicate and perform basic physicals and genito-urinary examinations before they interact with real patients.

In addition to working with students, SPs also are used in faculty training, portraying students and patients to help facilitators learn how to lead the sessions.

The SPs primarily serve the medical school in course-related settings, but also role-play with medical residents, nurse practitioners and smoking cessation counselors, and are poised to branch out into other disciplines.

“We’re like audiovisual aids, show and tell,” Crawford quipped.

An actor (currently portraying Sherlock Holmes in Prime Stage Theatre’s production of “The Hound of the Baskervilles”) and teacher for the Civic Light Opera Academy, Crawford is among many SPs with acting experience, although theatre experience is not required.

Valerie Fulmer, the program’s trainer/educator, acknowledged that many SPs are actors —Fulmer herself has theatre and directing experience — but “we also hire anybody,” she said, noting that the ranks of Pitt’s SPs include retired professors, teachers, homemakers and restaurant servers. “We need people with good communication skills,” she said. It’s important not only to be able to portray the character and his or her condition, but also to be consistent and observant in order to offer feedback. The roles, many details of which must be adhered to closely, offer little opportunity for ad libbing, which can be difficult for some actors, she said.

Crawford noted that being an SP differs from stage performances in which actors are thinking of their next line, working with what fellow cast members are doing and checking audience reaction. “It’s very specialized. There is some ‘living in the moment’ and being ready, but a big part of the mind is devoted to what the student is doing and how you need to react,” he said. When students ask for feedback, the SP needs to be prepared with something helpful.

Fulmer started working as an SP at Pitt in 2001, just as the in-house program began. For about 25 years, Pitt instead had used actors hired through an outside agency. A handful of the contracted actors made the transition to the new program, Fulmer said.

A recent training session brought about 30 SPs to a classroom in Scaife Hall earlier this month. The population was diverse: black, white, male, female, fit and not so fit. Some with gray hair, others who could pass for preteens (although all must be over 18), most appearing to be somewhere in between. About half were experienced SPs opting for training, the remainder were newcomers to the program. Because demand for the program is growing, Fulmer constantly is seeking new SPs. She wants to further broaden the group’s diversity to better reflect the demographics of the local population — Latinos, for example, currently are underrepresented, she noted.

The program operates through the Office of Medical Education, which offers information on SPs online at Because SPs are classified as temporary employees and are paid by the hour for their time, current University employees aren’t eligible to participate in the program.

SPs at Pitt portray about 300 different cases — some of which are written in-house, with others developed via the Association for Standardized Patient Educators. The cases provide background for the SPs on who they will portray: a summary of the case, the patient’s presentation, emotions, lifestyle and habits, as well as medical and family history.

SPs are pre-screened for health conditions. Those with “normal” physical abnormalities such as heart murmurs are used in cases in which their conditions won’t conflict with the case they’re portraying, Fulmer said.

New SPs receive basic training that totals 16-20 hours. In the sessions, they learn how to listen and give verbal feedback and how to portray the cases and remain in character. Additional sessions precede new activities.

Gina Preciado, an SP for about four years, said good SPs are self-aware, flexible, empathetic and able to put themselves both in their character’s place and the students’ place. They also need to be good listeners and extremely observant. In addition, “You have to care,” she said.

A member of the improv comedy group the Amish Monkeys, she finds the combination of improvisation, acting and teaching makes being an SP appealing to her. Juggling the portrayal of the character while observing the student and considering how she will give feedback in character on how she felt in response to what the student did always presents a challenge, she said. “It’s always a new student. That keeps it fresh. No encounter is ever the same,” Preciado said.

In the acting world, roles for women typically decrease with age, but it’s quite the opposite for SPs — Preciado has portrayed women in their 40s and 50s, including a mom with an adolescent daughter who doesn’t want to be in the doctor’s office. Bilingual, she has played a translator who assists a Mexican patient who speaks no English. She also has taken on the role of patients with mental health issues such as bipolar disorder, post-traumatic stress and schizophrenia.

The hardest part, she said: wiping the slate clean between students.

She especially recognizes the importance of being accurate in the details relevant to the case. “You have facts that cannot change,” she said, emphasizing that new students who have never seen certain cases likely will long remember the SPs’ portrayals of them.

Preciado has been involved in improvisation since the 1990s but becoming an SP has improved her improv skills “because I listen,” she said. “You have to be so aware of the students.”

Among the first classes new med students encounter is an introduction to medical interviewing. For many, it can be a welcome break from textbooks and lists to memorize that make up so much of academic work but, for those lacking people skills, it can be a frightening experience. That’s where the SPs can help.

William I. Cohen, a professor of pediatrics and psychiatry who co-directs the medical interviewing course with professor of family medicine Donald B. Middleton, compares the SP program to Pitt’s Peter M. Winter Institute for Simulation Education and Research (WISER) Center, which uses lifelike computerized mannequins to enable students to practice emergency and anesthesia techniques in a safe environment. In the same way, the SP program enables students to practice their interpersonal skills before they interact with actual patients.

Decades ago, students learned interviewing with real patients but, Cohen said, got no detailed training on how to get to know the patient, recognize emotion or deal with patients much older or younger than themselves, let alone how to talk about sensitive subjects such as sex, drugs and alcohol, or chronic disease.

That’s all changed. The introductory medical interviewing course consists of seven weeks of three-hour sessions with two facilitators, two SPs and nine or 10 students.

Cohen said the greatest value in the course lies in creating a safe environment in which students can practice new skills. “To try things out and to stop and do it over, get consultation, or to try new things and find out if it works,” he said. “Then, they find out from the patient how the experience was.”

In the class, students role-play interviews with SPs. They have the opportunity to “time out” and ask for suggestions from other students if they find themselves at a loss for how to proceed. During the timeouts, the SP becomes “inactive” — staying in character, but sitting quietly and looking at the floor while listening for clues that will help him or her adjust to a new direction when the class “times in” and the student continues with the interview. At the end of the encounter, the facilitator asks the student what feedback he or she would like from the SP, who is trained to respond in character both honestly and compassionately by relating how what the student did made him or her feel.

Cohen acknowledged the medical interviewing course can be difficult for faculty who are accustomed to other methods of teaching. “You don’t demonstrate, you don’t lecture or tell how to do it. You set up a learning environment in which the student discovers what to do. The emphasis is on guiding students to a successful landing,” he said. “When it works, it’s magic.”

Each session has an objective — perhaps introductions, getting a patient’s story, empathy or dealing with tough situations — and SPs are trained to “reward” students when they demonstrate skills related to the day’s objective by opening up with additional information.

“Watch for student behavior you can reward with more information,” Fulmer urged SPs in a recent training session. “Even if they attempt it, our job is to give them a little bit more.” When a student is stuck, SPs can offer a verbal “window” that students could seize upon to get back on track.

“Be subtle but obvious,” Fulmer coached.

Training time is spent teaching the SPs to weigh their words carefully — the magic “however” and the magic “and” are invaluable in offering feedback, Fulmer noted, as opposed to the word “but,” which tends to negate everything that preceded it.

“Err on the side of compassion,” she urged the training session of about 30 SPs that was roughly evenly divided between newcomers and experienced SPs.

“We want to be mirrors for the medical students,” Fulmer said outside the class. “We try to emulate what we hope they’ll do in the future with their patients” in communicating respectfully. Negative experiences for students in the first year can impact them for years to come, Fulmer said. Some students are book learners and are not accustomed to role-playing. “If they feel judged, it can affect them,” she said.

Difficult patients (or as Cohen prefers, “patients in difficult situations”) aren’t presented to patients until later in their training. “Early on we just want them to learn to talk with people. We don’t want to be rough,” Fulmer said.

Fabiana Cheistwer, an SP with five years’ experience, said the training has helped her become a better parent to her three children, noting that the respectful communication skills it emphasizes can be extrapolated to any relationship. “Honesty and compassion, isn’t that what life is all about?” she said.

Cheistwer, who also is a health and wellness consultant, said she enjoys the SP cases that show the most emotion and likes helping students recognize emotion.

She prefers working with the newest med students rather than residents, whom she finds less challenging because they are more skilled. “I can make a big impact,” she said.

“To see the students’ skill level grow and blossom is so cool,” she said. Although she typically will not see the same students from week to week as she portrays patients in the basic interviewing class, she can see their abilities improve as a group as the weeks progress. “I like to see the novice grow into a skilled interviewer,” she said.

“This is my favorite job,” she added, noting that when she completes an SP encounter, she leaves with a sense of accomplishment, pride and elation.

Another role SPs play is in assessing students’ examination skills and coaching them in how to improve those skills.

Hollis Day, medical director of the SP program, noted that the program also helps assess students’ true performance. “You can assess knowledge, but it’s harder to assess how someone does something. From a faculty standpoint, that’s very beneficial.” While the program has grown in the past year or two, “more” is what the faculty want, she said. “It’s seen as a valuable tool,” she said.

For example, a second-year final exam requires the student to get the SP’s history and reason for coming into the office, then conduct a basic physical examination within a 50-minute time limit. In addition to portraying the patient, the SP also completes a checklist of what the student did or did not do correctly.

To prepare them to assess students’ performance, the SPs get the same training on the basic physical examination as the medical students receive.

Crawford said the SPs initially serve as coaches in preparing the students to take the exams. “We have to help them remember all the things they need to do in the exam,” he said. It may be simple details such as reminding them that they need to place their stethoscope on the patient’s bare skin, not the gown, or helping them with tips on where they could move faster if they have trouble completing the exam within the allotted time.

“My knowledge is very precise — but limited,” Crawford said.

Crawford is among a smaller subset of SPs who also allow students to practice more invasive examinations.

Some things can be taught on a model, but real people are needed for the inguinal hernia test, for example, Crawford said. “There’s no model for that,” so he must know what the proper technique is in order to help students learn to do it right.

Urological examinations aren’t anyone’s idea of a good time, “but it’s an opportunity [the students] need to have,” he said.

On a lighter note, he added that compensation for such roles is higher than ordinary SP roles. “You can pay the rent and electric bill and a couple of trips to the Giant Eagle with those,” he joked.

The desire to contribute to students’ experiences is a common theme for participants in the SP program.

A role-playing exercise in this month’s training placed Preciado in the role of the student and Crawford as the patient. When she asked for his feedback on how he felt when she introduced herself as a first-year student and asked if she could ask him some questions while he waited for the doctor, his reply was, “I felt needed.”

That response struck a chord with other trainees.

“We do feel we play a role that’s important,” Crawford said. “Medicine’s not all about drugs and tests and surgery. It’s a lot about having interactions, making people feel better by listening to what they have to say.”

—Kimberly K. Barlow

Filed under: Feature,Volume 41 Issue 1

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