University of Vermont

A Teaching Role

When standardized patients portray illness, they mold the performance of future physicians

By Jeffery Lindholm Article published April 27, 2005

Jim Court’s bare legs dangle off the side of the exam table. He adjusts the hospital gown, trying to cover his backside. Still, unlike most people in such a setting, he’s at ease. In fact, he’s at work.

Court, a part-time university employee, is preparing for his exam at the College of Medicine’s Professional Learning and Assessment Center in the Given Building, a collection of a dozen exam rooms, a life-sized patient simulation robot, a bank of video monitors and a patient waiting area. He is one of a group of about 70 “standardized patients” who have been trained to teach medical students what can’t be learned from a textbook — physical exam and communication skills — or to portray a variety of patient roles targeted to curricular objectives.

A group of medical students and an instructor gather around, and the “exam” begins, with Court showing a student how to locate a brachial artery, helping her get the cuff adjusted and wincing when she pumps it too tight. When she’s looking into his ear, he shows her how to pull a lobe back to get a straight-on view to the eardrum.

“I like to see lights go on for the students,” says Cate Nicholas, director of the medical college’s standardized patient program. “It’s great when they see the ear canal and the eardrum through an otoscope for the first time, and the standardized patient’s feedback lets them know that they know how to do it.”

A patient family
Jim Court first learned about the program from his wife, Angele, who picked it up from a friend. When the program needed a mother-daughter team for a continuing education session in psychiatric medicine for doctors, Angele recruited her high-school-age daughter, Hannah, for a scenario portraying a pushy mother who was stressing out her daughter in a quest for excellence.

In other sessions, Angele has played an alcoholic patient as well as an abused woman. In the latter case, her character comes in with a headache, which she has because “my husband winds me around the house a lot,” Angele explains. “I’ve had broken bones and there are clues there, but if the students don’t ask the right questions, they’re not going to get it.”

Being a standardized patient involves much more than acting, however: considerable study is also required. Nicholas and other faculty members work with them to help them learn both the exam skills in which they will train students and the background that will let them convincingly portray various patients and their illnesses.

“I’m an adult learner,” says Angele Court. “Having to study the textbook and know certain systems is really energizing. Sometimes I think the last thing I need after a long day is to read 100 pages of text, but you know, it is great to learn new things. It keeps your mind going and sharp.”

For portrayals, standardized patients get a written “script” that includes background on their roles and what symptoms they’ll be presenting with. They also get readings about the conditions. Before they see students, they rehearse their roles with relevant faculty. Once they’ve got it down, they meet students in the assessment center for a dry run before their debut. The preparation is necessary so that the sessions yield useful data for medical instructors. For evaluation purposes, each student needs to see the same patient problem presented in the same format (that is, “standardized”). This guarantees fair assessment and also allows students and faculty to compare and contrast student competence. As an added benefit, all along the way their acting is honed.

“The SPs do an incredible job of acting out the situations,” says second-year student Justin Sanders. “They’ll get to the end and everyone’s thinking, ‘Wow, that was really an excellent performance.’ It’s an important part of our learning for them to get it right.”

To help the actors get it right, after every session they fill out detailed evaluation checklists developed by medical faculty and give students verbal feedback. Every student and standardized patient uses the same checklist, and the lists receive regular statistical scrutiny to detect and then correct patterns: a group of students missing a particular skill, a particular standardized patient not presenting a condition adequately.

Putting it together
While the College of Medicine has been using standardized patients since the 1990’s, the 2003 implementation of the Vermont Integrated Curriculum, which involves continuous assessment and tight integration of scientific and clinical skills, increased the emphasis on the technique and made encounters with standardized patients part of all four years of medical school. The patients are catching on nationally as well; the National Board of Medical Examiners recently required students to undergo a national exam which uses standardized patients as part of the process of receiving state licensure.

“Our standardized patients turn the theory into practice,” says Dr. Lewis First, senior associate dean for educational and curricular affairs and leader of an advisory committee that helped national board design, implement and evaluate the national SP licensing exam. “You can read about baseball, but you need to pick up a bat and ball to really understand how the game is played. This is a good analogy as to why we are using SPs so frequently in our new curriculum. The SPs allow the students themselves to actively step up to bat and practice the clinical skills and knowledge they’ve learned in the classroom and then be given direct feedback through observation by SPs and faculty that they’ve successfully mastered these learning objectives.”