Bioethics Discussion Blog: Standardized Patients, Actors, Acting in Medical School Teaching and Empathy

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Monday, March 07, 2005

Standardized Patients, Actors, Acting in Medical School Teaching and Empathy

As a follow-up on the issue of teaching medical students empathy through method-acting, I would like to point out that acting out clinical encounters is going on all the time in medical school teaching. If you don’t already know of the role of “standardized patients” as used for this teaching, read on.

For a number of years, more and more medical schools have incorporated professional actors in their teaching programs related to the first and second year students learning how to take a history and how to perform a physical examination. These actors are trained to provide the students with a simulation of a real patient, a clinical case, but with teaching advantages included. Those advantages include interviewing and examining in a non-threatening environment, with the support of a group of fellow students and the instructor-facilitator. This is in contrast to the experience “on the hospital wards” where the students are often alone with a patient and have to struggle with their own uncertainties and inexperience with no immediate assistance.

With the standardized patient, the student who is doing the interviewing can, when their own ability to know what to say or what to do next fails, can call a “time out”. The interview may abruptly stop, with the standardized patient ignoring what follows and the student can then communicate with his or her colleagues and the facilitator for help. When “time in” is called the interview proceeds as though there was no break. Another advantage for the students is the feedback that the standardized patient actor, who is again trained for this function, can deliver to the students. The actor can express how he or she, in the role they played, reacted to the questions and behavior of the student and provide valuable constructive criticism or encouragement to the student. This kind of feedback is not uniformly available from the real patients the student examines. Standardized patients can also provide a more comfortable environment for the student to practice physical examination. Though often pathologic findings may be absent, nevertheless on occasion a standardized patient with an abnormal physical finding may be discovered this becomes a valuable asset.

My experience with teaching first and second year medical students, even when they are role-playing the doctor and patient, is that we never encourage their “acting” out a certain behavior toward the patient except to keep in mind the requirement to be professional in their relationship with their patient with the goal of caring, being empathetic, therapeutic and beneficent.

Teaching “light empathy” as described in the literature, is essentially acting to maintain an emotional posture which is acceptable by the patient even though the student is upset with the patient or has moral differences of opinion but with no real understanding of the patient’s motivations and no intent to change the student’s own attitude or emotions, This may be effective and financially rewarding if the student was going into a non-medical care business but I think is unacceptable in medicine.

If anything, “deep empathy” is worthy of teaching where there is no acting in a theatrical sense. With “deep empathy”, the student is encouraged to pay attention to and try to understand what the patient is going through and try to understand his or her own emotions based on a previous similar personal experience. For example, for a patient complaining of pain, the student might remember some injury long ago which caused pain but the student didn’t know the severity of the injury or how long it would last or whether there would be residuals. Would there be some similarity of how the student felt with that the patient is feeling currently? With this contemplation, the student may be able change his or her own feelings about the patient and the patient’s perhaps disturbing reaction to pain.

So this is what I can tell you about “acting” as a part of the teaching clinical medicine in medical school. I hope it has given those visitors who have not been involved in such teaching an idea of what is going on these days. ..Maurice.

9 Comments:

At Tuesday, March 08, 2005 12:07:00 AM, Blogger Geekbird said...

bioethics are my life...

geekbird.blogspot.com

 
At Tuesday, March 08, 2005 6:15:00 AM, Blogger Bioethics Dude said...

As a part of my job, I "teach" researchers (undergraduates, graduate students, faculty, etc.) regarding human subjects protections regulations, and the underlying ethics that drive those regs. I hate to be a cynic here, but in my experience there are always a small portion of the audience that could care less about what’s being taught. They pay attention enough to “pass” whatever exam or quiz is at the end, but I wonder how much they will carry into their conduct. Now most of the research I oversee is extremely benign and so I’m not as worried about this, especially because the greater than minimal risk stuff gets due attention, but I wonder 1) how much of this carries over to med school; and 2) what teachers do about this (e.g., somehow make the nonchalant student aware of the ethically critical issues by putting them in the thick of things).

 
At Tuesday, March 08, 2005 9:05:00 AM, Blogger Maurice Bernstein, M.D. said...

To Geekbird: Bioethics should be everyone's life since we are all at one time or another affected by the consequences of the bioethical issues.

To Bioethics Dude: It is a well documented observation that almost all medical students on entering medical school have an idealistic almost altruistic attitude towards medicine. Unfortunately, this attitude turns to degrees of cynicism in their later years of medical training. The actual practice of medicine, not just the learning of the facts, is so tough, time consuming and emotionally challenging that "being in the thick of things" while also being subjected to the ways their superiors behave, leads to their cysnicism and perhaps, with some,overlooking the ethics. ..Maurice.

 
At Tuesday, March 08, 2005 5:37:00 PM, Blogger Bioethics Dude said...

Maurice said: actual practice of medicine, not just the learning of the facts, is so tough, time consuming and emotionally challenging that "being in the thick of things" while also being subjected to the ways their superiors behave, leads to their cysnicism and perhaps, with some,overlooking the ethics. Now I see the similarities to law;-)

 
At Saturday, March 12, 2005 7:35:00 PM, Blogger Dipesh said...

The use of "standardized patients" in medical education is a good thing, but only if the actors are actually well-trained. In our history and physical diagnosis class we had "standardized patients" who were well-meaning lay people that were excellent in some instances, but in many cases either bad actors or had an agenda to promote. I was 'blessed' with a woman who was allegedly depressed but laughed and smiled. The dissonance set off my "something's wrong" sensors from my years of being a PA, and I had to keep reminding myself this was because of bad acting, not some hidden agenda. To top it off, they had been told to fill in past history from their own lives if it wasn't relevant, and she took this opportunity to go through a long list of herbal medications. She later told me this was part of her effort to help educate medical students about being sensitive about alternative medicine. That was all well and good (and I could certainly handle it), but my classmates who were in a patient interview situation for the first time ever left even more confused than ever. *sigh*

We later on had an exercise in which students from the theater school here acted as "difficult patients". They were frighteningly realistic, I must say...too bad we couldn't get them for the earlier exercises.

 
At Saturday, March 12, 2005 9:01:00 PM, Blogger Maurice Bernstein, M.D. said...

My experience with the standardized patients at the Univ. of So. Calif. where I teach is that they are all professional or almost professional actors. In addition, they spend much time learning their scripts and coaching by members of a special department for standardized patients in the School of Medicine. The scrips are updated based on feedback from the students. Their work is very theatrical including anger (frightening for the students) and weeping (with tears) and to make things even harder for the actors, they have the ability to go back to an earlier part of their communication with the student ( a rewind) so that the student can see what taking a different approach to the patient might result. One lady actor, I remember, who on a rewind would have to start crying again said she can only perform the rewind only a few times since doing it more would be too emotionally exhausting for her!

I can see how having a standardized patient who is really neither a professional actor nor a real patient can appear to be some strange anomalous creature to the student and not to helpful to practice upon..Maurice.

 
At Wednesday, March 23, 2005 2:29:00 PM, Anonymous Anonymous said...

Having been a SP for a few years covering a number of scenarios, I would agree that it is a mixed bag in terms of skill. I also have to say that some students are more interested in maintaining the practice role they are in which also impacts the success of the interaction.
I am neither a professional actor nor a person with an agenda other than wanting to contribute to the newest generation of MDs. I don't think I have room to offer critique if I don't have time or take an interest in helping to impact their education.

I do my best to stay in character and present as realistically as possible.

 
At Saturday, December 23, 2006 9:48:00 PM, Anonymous Anonymous said...

As a medical student, I initially loved and appreciated the idea of a standardized patient--a chance to get feedback on my history-taking and physical exam skills, without subjecting a "real" patient to my lack of experience--a chance to have someone be honest with me about mannerisms that are helpful or hurtful that I might not otherwise have ever recognized in myself. But then, like so many good ideas, once you try to implement SPs into the curriculum, the concept takes on a life of its own. It just doesn't work to teach what it should.

For one thing, the encounter (and video cameras, and time-out feedback...) becomes all about ME as the clinician. And yet, my best interactions with "real" patients in true clinical settings have been (I'm certain) when I managed to stop being self-conscious and self-focused and to become focused instead on the other person. The whole standardized patient interview turns that concept backwards and inside out, once again. The inner monologue in my head when talking with a patient should be things like "what's happening here, right now? How is this person doing? where is this pain coming from? what else do I need to know? What else needs to be considered before we take this to the next level of care?" but instead it's "did I say that right? did I sound concerned enough?" --sounding concerned and truly wanting to help are not a problem, in the real setting! But I cannot achieve the same level of sincerity and genuine concern and empathy with someone who really isn't experiencing their symptoms. It just feels weird. No reflection on them, but the situation IS fake, it is a ruse, it's not true that the patient is feeling 9/10 pain or hasn't used their hand in a month or what have you. Maybe others benefit from this, but I don't.

However, since standardized patient encounters are now a requirement for graduation, I'm glad that my medical school does some training and practice with them. I'm also sure that some other medical students (though not necessarily the majority) feel differently from me, and have truly found SP encounters helpful in their curriculum. I will say that it's important, in the same way that taking practice tests for SATs or MCATs or USMLE is important--whether or not these skills actually help you in the real world (debatable)--the SP practice simulations along the way are great training for the SP simulation that really counts, at the end of the year. But I've come to believe that at least for me, SP encounters as a whole entity are just more hoops to jump through as a medical student--kind of a waste of time--I learn so much more from interactions with the many, many, extremely generous REAL patients who allow medical students to participate in their REAL care.

 
At Tuesday, December 26, 2006 12:14:00 AM, Blogger Maurice Bernstein, M.D. said...

As a facilitator for medical students learning, I would suggest students look at the SP experience simply as a teaching tool and in no way a definite simulation of a true clinical experience with a patient. Face it, standardized patients are not real patients, they are simply actors and teachers. What SPs can do is present an example through acting of a specific teaching issue such as "the adolescent patient", "the difficult (or angry) patient", "taking a sexual history", "the dying patient" and so forth and then through "time-outs" and later feedback to have the hour experience as a testing and directed learning experience for the student. Yes, the exercise should be student oriented and the issue is not what is happening to this particular "patient" but what is happening to the student and how can the student be helped in formulating an approach to deal with a real patient. The details of the history, the details of the physical exam on the SP is not the essential part of the experience--it is the process itself that is important and is what should be properly developed. If you think about it, as a student interviews and examines a patient on the ward or in clinic, there are no "times outs" and no constructive feedback instead the student is faced with making his or her own interpretations of what he or she did right or wrong. (To have a formal teaching session with your instructor in the presence of a real and ill patient being examined is awkward and not in the best interest of the patient.)This self-challenge in the real clinical experience is nothing which should be avoided but it is the time spent with the standardized patient that can provide a more objective evaluation of the student's decisions and actions and provide a more substantial foundation of the difficult process of how to effectively take a history and perform a physical examination. I hope these words have conveyed how I think a student should look at the SP session. ..Maurice.

 

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