Feigning Illness

In these encounters, neither patients nor doctors are quite what they seem-yet medical students still learn important lessons.

By Ann T. Lemon

On a small TV screen in a discreet corner room lined with tables, televisions, and VCRs, a middle-aged patient lying calmly in his hospital bed is visible. A door opens, and a young woman wearing a white coat enters. The woman, appearing both concerned and nervous, approaches the patient's bedside, smiles, shakes his hand, and asks the reason for his hospitalization. Rubbing his side, the patient talks about his recent stomach pain and answers his examiner's questions.

Then, the woman in the white coat shakes the patient's hand goodbye and walks towards the door. Now half-visible on the screen, she looks back. "Don't take what I said too seriously," she says good-naturedly, "I'm just a medical student." And with that, the woman is gone, leaving her patient-really an actor playing a patient-chuckling softly.

This scene is one episode of a third-year medical student's internal medicine exam-a simulation mimicking a real patient encounter, the only hint to the interview's true nature being the student's parting remarks. Viewed from the monitor room in UTMB's Standardized Patient Center, located on the third floor of the Marvin Graves Building, just a few yards from the site of the encounter, it is easy to see how realistic-and nerve-racking-an interview with one of these well-trained actors, known as standardized patients, can be. This is yet another tool employed by UTMB to better prepare students for the world they will soon face, brimming with interviews of real patients with similar stories.

The term "standardized patient," introduced in 1963, reflects the hired actors' goals to appear the same for each student encountered. Already familiar to students at medical schools throughout the United States (80 percent use standardized patients in testing), the use of standardized patients will soon be further institutionalized. For medical students graduating in 2005, the National Board of Medical Examiners is instituting a national standardized patient exam; a passing score will be required for licensure.

Formally established in 1976, UTMB's Standardized Patient Program is integrated into all four years of medical school. Students begin interviewing and examining standardized patients in their first term, when they must gather these patients' data from head to toe. Second-year students undertake more difficult interviews, including imparting bad news and performing pelvic or genital and rectal exams on standardized patients (who walk them through the process). After the second year, the program becomes less a means of instruction and more a method of testing students' performance. Third-year students encounter cases relevant to a particular area of medicine, while fourth-year students, who must pass a standardized patient exam before they can graduate, may encounter virtually any illness behind the standardized patient's door.

Both on screen and in the examining room, the apparent authenticity of the fictionalized patient-physician encounter is striking. Rooms are identical to those of hospitalized patients, actors are hooked up to seemingly genuine IV lines, and make-up substitutes for bruises. Fictionalized patients dutifully memorize their assumed personas and histories, including lifestyle habits such as caffeine and alcohol intake, medical history, and family history, complete with parents' ages and, when appropriate, causes of death. Physical attributes that are impossible to reproduce are captured through technology: on this day, lying on a table next to a standardized patient is equipment designed to let students listen to what a sick patient's water-filled lungs sound like.

For students, the Standardized Patient Program inspires conflicting emotions. While they are glad that no one will be harmed by a possible misdiagnosis, many students, particularly those in their third and fourth years, seem wary about being tested. Enter the pre-exam waiting area and you can see the unease in students' somber expressions.

Yet students do seem to benefit from the program. Because UTMB's medical school integrates the standardized patient program into all four years, with each student encountering between 47 and 60 standardized patients during that time, students like Susan Allen, from Garland, Texas, see how their practical skills and knowledge grow from term to term. Associate Dean for Educational Affairs Steve Lieberman recalled asking a student to counsel a genuine patient on end-of-life issues. Although it was her first time doing so and she was unsure of herself, Lieberman observed that she did a great job. Afterwards, Lieberman said, the student acknowledged that "if she hadn't practiced on a standardized patient, she wouldn't have been able to do this."

However, it is not only students who learn by participating in the Standardized Patient Program. For actors-who are happy to earn extra cash while giving students the opportunity to test skills in a safe but realistic environment-the program offers a chance to learn about different medical conditions. Judy Thornton, director of the Standardized Patient Program, noted that standardized patients have been known to give up decades of tobacco use after they are assigned to play a patient with lung cancer or chronic obstructive pulmonary disease and are provided with a slew of information on how dangerous using tobacco can be.

Faculty, too, find themselves learning a few things from their involvement in the program. Take, for example, Dr. Karen Szauter, medical director of UTMB's Standardized Patient Program and herself a former actor and standardized patient.

Szauter, who helps to create fictionalized patient roles, once faced a real-life case similar to one she had created a year earlier. While serving as attending physician on a ward, Szauter encountered a patient fighting his physicians' recommendation of an emergency surgery. Wondering how to help, Szauter recalled a checklist given to students before they interview difficult standardized patients. One recommendation was to explore spiritual beliefs-something she had not done. With the help of a chaplain, Szauter was able to convince the patient to have the operation. If not for surgery, the patient "most likely would not have survived," she said.

Former assistant editor Ann T. Lemon is a law student at the University of Texas at Austin.