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From Issue #38 March 13, 2014

Playing Sick

Professional patients help doctors become better at diagnosis.

By Carren Jao Twitter icon 

Slender at 110 pounds, 72-year-old Lee Gale Gruen slumps listlessly in a wooden chair as if her aging spine were slowly conceding defeat to gravity. She meets the eyes of the young woman in front of her, waiting with some apprehension for word of her condition. The young woman takes a deep breath and says, “Unfortunately, I’ve got some bad news…” Her voice wavers and wobbles, and the woman breaks down in tears.

“Time out!” comes a call from behind her.

The instructor breaks into the scenario, reminding the young woman and a class of her fellow medical students that they are sitting in a lecture hall in Los Angeles; none of it is real. Yet.

The tension in the air lifts a bit, allowing the young woman to regain her composure. All the while, Gruen’s face is tactfully averted, her body still, as if she were in a movie that was paused. She sits ready to re-animate once the instructor calls “time in.”

Gruen presents the very picture of frailty. She’s five feet five inches tall, with a fluff of white curls framing her delicate features. This has often earned her the role of a terminal patient at the medical school at the University of California, Los Angeles (UCLA).

“I became a standardized patient about seven years ago,” Gruen says crisply. “Back then, there weren’t any online outlets for actors to find work, but there was a newspaper, Backstage West. UCLA advertised a tiny little blurb in this newspaper and I submitted my application, then went for an audition. It was a year and a half before I heard from them.” Since then, Gruen has been poked, prodded, and awkwardly quizzed by young doctor hopefuls learning to be better healers.

Act well your part

Standardized patients — SPs for short — are a cadre of community-theater actors, retired folks with spare time, and drama majors tasked with the heavy duty of faking illness to improve would-be doctors’ communication and examination skills before they’re unleashed on actual sick people. The SPs get paid $15 to $25 an hour. With the help of SPs, med students learn a spectrum of skills, from performing simple physical examinations all the way to dealing with patients who refuse to take Western medicines.

Outside the medical school lecture hall, Gruen is bubbly and vivacious, clearly enjoying her second life as a professional actress after 38 years as a probation officer with the county of Los Angeles1. Since accidentally enrolling herself in an acting class, she’s gone on to appear on VH1, Comedy Central, and even CBS and ABC. She’s played a gamut of roles: sweet grandmother, sexy senior — even gangster-rapping grandma.

If you’re the exercise-at-home type, you may recognize her svelte silhouette backing up Jane Fonda in the 2011 exercise DVD Prime Time Firm & Burn. When not auditioning or giving public lectures on her second act in life, she dons a flimsy hospital gown and emotes in the name of better health care.

Pretending to be sick is serious business. “We can help students learn by doing rather than learn by lecturing, which isn’t nearly as exciting,” says Andrew Nevins, the medical director of the Standardized Patient Program at Stanford University and the chair of the California Consortium for the Assessment of Clinical Competence.2

Faking it

At Stanford’s Immersive Learning Center, 12 clinic rooms are laid out exactly as you would find them in hospitals. Video cameras can record each twitch, wince, and wavering intonation of both patient and med student. Other medical schools also use one-way windows through which teachers watch their students in action.

The recordings have several uses. An instructor might watch a live video feed and take notes of salient moments for a later consultation with the student. Faculty could also review the tape with the student and point out exact moments when the would-be doctor could have expressed more empathy, added more compassion, or simply taken a break from writing notes to establish eye contact with the patient. Though the teaching staff might not always be present during a patient-doctor interaction, Nevins says there is always someone from the school monitoring the situation should there be a need to stop the proceedings.

Re-creating a medical environment is only the beginning. SPs are gussied up with make-up to simulate bruising, and heating pads are placed over body parts, which might signal infection, says Geoff Fiorito, a 49-year-old interior designer, actor, and standardized patient for Stanford. The University of Southern California’s medical school has been known to use yogurt to make coughs more phlegmy, spray beer on clothing to hint at drunkenness, or rub onions on body parts to create an odoriferous patient.

But all of this is worthless without the medical actor’s performance. “Realism is one of the most important things. Students already know they’re not in an actual hospital and they’re seeing an actor, but the SP has to be good enough that they suspend their disbelief. Otherwise, they’re not going to value that experience,” Nevins says.

To pull off this feat of realism, SPs are given scripts that aren’t scripts at all. “Our training is fairly rigorous,” Fiorito says. “We’re sent information associated with the person we’re playing, and you have to memorize it in a very holographic way because the student can come at it from any direction.”

An SP’s script is more than just a full name and occupation. It details symptoms, family history, medical history, drinking habits, diet, and more. The training material even outlines a character’s verbal and non-verbal mannerisms. “Psychological aspects of the patient are written in the case too. There are cases where people are angry because they may be waiting too long to be seen. There are cases where people are too chatty,” says Fiorito. “A student could come in and ask, ‘What brings you here today?’ and I could just ramble on and on and on. It’s up to the students to say, ‘Let’s stick to the problem at hand.’ That’s one of the minefields we lay out for the students.”

A script can be up to 30 pages for crucial exams that determine whether students advance to the next level or graduate. “It is pressure but for a purpose,” says Nevins. More casual learning sessions merit five to 10 pages.

Some of Fiorito’s scripts may have been written by Nevins, whose job includes coming up with these cases and who is one of a few in the profession who actually enjoy this act of creation. “It’s harder than it sounds,” Nevins says. “A script is more than just saying what symptoms there are and how it manifests. It has to be specific. You have to think about all the things a student could do and how an actor should react in response. And you have to put in terms someone not medically trained can understand.”

Right now, Nevins is working on a new script that might make it to California’s statewide exam. He hesitates to give further details, but he says it is meant to test how a student approaches an elderly patient. In it, Nevins includes issues a doctor might encounter not just from the patient himself but from his family.

Dying for laughs

In the last five decades, standardized patients have slowly infiltrated much of the medical-school curriculum. They pop up in laid-back learning sessions where an SP is called to roleplay with a med student in a lecture hall with a classroom of fellow students in attendance. They’re used on medical students learning surgery, pediatrics, even obstetrics and gynecology. (See “The Cervix Industry,” by Alexandra Duncan, about gynecological teaching associates, who guide doctors through cervical and other exams.)

As medical school progresses, so does the difficulty of these encounters. By the end, students are handling bad-news cases, says Fiorito — those traumatic moments when a doctor has to tell a patient the end is nigh.

The standardized patient program was found so invaluable that, as of 2005, would-be doctors have to successfully navigate 12 patient encounters to pass the second part of the three-step exam process for obtaining a medical license in the United States.

The importance now placed on the SP program is a far cry from 1963, the year Howard Barrows, a neurologist at USC, first tested an early version of the program by training an artist’s model to portray a paraplegic multiple sclerosis patient. It worked “extremely well,” wrote Barrows three decades later. “Many more people were coached to be different patients for subsequent rotations.”

Despite positive feedback, the experimental program was criticized as being — in Peggy Wallace’s words in 1997 in the humanities journal Caduceus — “too touchy-feely, too expensive, too ‘Hollywood’” by a more conservative medical community used to teaching students using real patients during hospital rounds. “When I first introduced it, everyone thought it was the craziest thing they’d ever heard of in their lives,” Barrows told the New York Times in 2011. No one was interested in using this method, not even USC. Barrows was frequently invited to give talks on neurology, but was requested to stay off the topic of standardized patients. “He was seen as doing something quite detrimental to medical education, maligning its dignity with ‘actors,’” Wallace wrote.

It took three decades, continued work on this experimental program, and contributions by pediatrician Paula Stillman (who provided a reliable tool that SPs can use to evaluate a student’s performance) and other clinician educators for the program to gain widespread adoption. A 1993 survey by the Association of American Medical Colleges revealed that 111 out of 138 respondent schools used SPs for teaching and evaluation; 39 of those schools used SPs in comprehensive examinations. In the same year, the Medical Council of Canada first used SPs in its licensure examination.

Setting the standard

The value of an SP lies in providing a repeatable experience for medical students across the board. Only a patient with a heart of gold would ever consent to having eight medical students poke and prod them, all the while asking a litany of questions again and again. Imagine the emotional upheaval in a real patient should he undergo a parade of awkward med students telling him he has only a month to live. Barrows writes, “It is far better that students make their mistakes in working with a dying patient, a comatose patient, or a sexually abused patient in a simulated setting rather than in a real setting.”

SPs are physically and mentally prepared for students to blunder, even going so far as to endure pain in an effort to stay in character, in Gruen’s case. During one high-stakes exam, a student scraped the softly pointed metal end of her medical mallet across the bottom of Gruen’s feet in the hopes of seeing some movement in the patient’s supposedly numb extremities. She scraped the soles of Gruen’s feet hard. “I felt like flying off the table!” Gruen says. “But I, as the character, I’m not supposed to feel anything on my foot, so I’ve had to sit there and suck it up. I couldn’t tell her, ‘Oh my god, you’re killing me here!’” The painful episode happened twice, once on each foot.

Not only are SPs trained to perform, but they’re also drilled in proper evaluation techniques. Part of their job is to provide feedback not only on the content of the encounter, but also on how the students approached their patient. Medical actors relate how their characters felt during the scenarios and how a student’s manner would have made the character they were portraying feel. They also fill out the standardized evaluation tool, which asks the actors to rank a student’s performance on various categories using a quantifiable scale. Written comments that may be more revealing are also part of the assessment. SPs have been thoroughly drilled on this too, Nevins says.

While the process might lack Kramer’s panache (no “haunting memories of lost love” equated with the burning sensation of urination here), students get a more valuable lesson: treating patients like a human beings.

Meanwhile, these fake patients find themselves the unexpected beneficiaries of this exercise. They’re able to observe the effects of their acting prowess up close. The thrill of eliciting an immediate, powerful effect is part of why Gruen stays in the program. “I’m helping train doctors, and I also get wonderful acting experience because the roles I’m given are difficult to play,” she says. “It’s almost like I’m getting an acting class myself.”

They also become even more discriminating patients. “Being an SP has given me skill and knowledge to become a better actor, but also confidence in myself as a patient,” says Fiorito. “If I did encounter a doctor who isn’t giving me enough attention, I can say, ‘This isn’t working for me,’ because my health is really important.”

  1. Gruen’s impressive journey from probation officer to professional actress is chronicled in her memoir, Adventures with Dad: A Father and Daughter’s Journey Through a Senior Acting Class

  2. The consortium is a collaboration among California’s eight medical schools and is responsible for creating and conducting the Clinical Practice Exam, a statewide examination medical students take in their fourth year. Without passing the test, students cannot graduate. 

Carren Jao writes about art, architecture and design for the Los Angeles Times, Architectural Record, and KCET, among others. She's fascinated with connections, hidden histories, and how the ordinary becomes remarkable thanks to someone who took time to notice.

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