A doctor walks into the consultation room and greets her patient, a homeless man named Jim who sits on an exam table.
“What brings you here?” she asks Jim.
He looks at her and says, “I’ve been having some chest pain, which is worrying me…”
Thus began a recent dialog, not in a doctor’s office, but rather in a small room in the basement at the Keith Administration Building. The doctor was not really a doctor, either–at least not yet. She was a Keck School of Medicine student learning how to interact with patients. And the homeless man? No, he was not really a patient, but instead an actor carefully coached to play the part.
“It is part of the standardized patient program, a component of the medical school’s educational experience,” explained Win May, associate professor in the division of medical education, who directs the effort.
Who are standardized patients? They are actors who have been trained to portray all the characteristics of real patients with a specific illness or problem, May said. When students work with a standardized patient in a clinical setting, it gives them a chance to learn and practice interviewing and physical examination skills, and allows faculty to evaluate them more objectively.
Although perhaps first brought to popular awareness in several television series, most recently a 1998 episode of the TV sitcom “Seinfeld” (in which lanky sidekick Kramer served as a standardized patient with a sexually transmitted disease), the idea is not new.
The use of actors to play the part of patients for medical students started when former professor of neurology Howard S. Barrows developed it at USC in 1963. Stephen Abrahamson, emeritus faculty member and former chair of medical education, spearheaded the effort at USC.
Since then, the practice has spread not only throughout California but also nationally and internationally, May said.
Each patient portrayal is based on a real case. In Jim’s situation, he was a street person who came to see physicians at USC for chest pain and a cough. And now, his case serves as an example for third-year students refining their physical examination, history-taking and personal skills.
“The diagnosis for Jim was pneumonia,” May explained.
The same day, each student individually also had the opportunity to interview a patient named Carla, who also had chest pain–and students had to determine that a heart problem was the reason for her discomfort.
Having standardized patients for students to work with brings numerous benefits, May explained.
Unlike real patients, who probably cannot tolerate having repeated examinations by students, the standardized patients can reproduce the same history, behavior and symptoms over and over again. That means that faculty members can more objectively measure how well a student interacted with the patient.
The standardized patients also allow all students to see the same specific cases, which faculty members feel are essential for their learning experience.
Standardized patients also enable students to scrutinize their own communication and interpersonal skills. For example, a student who furrows her brow in thought while interviewing a patient might not realize that her expression is concerning the patient. But after the interview, the standardized patient gives feedback to the student about how well the office visit went, from the patient’s perspective.
The technique has proven to be so effective that more medical schools are using this method. “Next year,” May said, “all eight of the state’s medical schools will use the same patient cases for their clinical performance examinations, or CPX, which are given at the beginning of their fourth year.”
At USC, students have been required since 1995 to pass the CPX as a requirement for graduation.
The National Board of Examiners, or NBME, will soon require some form of standardized patient clinical assessment for evaluation of clinical expertise as part of their licensure, May said. “Thus, the use of standardized patients in medical education, all of which started at USC some 37, years ago, has become an established method for the teaching and assessment of clinical skills, worldwide.”