Patients Who Help Train Doctors

October 10, 2000

Heather Heilman

The patient had fresh scars on her wrist and a past diagnosis of depression. But the doctor didn't feel comfortable asking about the scars, and didn't mention them. Luckily, the doctor was still in medical school, the patient was only acting and the scars were fake.

It's Delia Anderson's job to make sure that Tulane medical students graduate with good clinical skills. They need to know how to conduct an exam, of course, and what to look for. But it's equally important that they know how to listen to patients, how to communicate with them and how to make them comfortable during the exam.

"We want them to ask open-ended questions," Anderson explained. "They should let the patient talk without interrupting. They should be courteous and respectful, never judgmental."

Anderson is the executive director of the program for the teaching and assessment of clinical skills at the medical school. She and medical director Harold Szerlip direct, develop and coordinate the use of standardized patients at Tulane. Standardized patients are actors, in a sense. They are people who have been trained to act like patients and to teach and evaluate the students who examine them.

Tulane has been ahead of the curve in the use of standardized patients and is one of nine medical schools working with the National Board of Medical Examiners to develop the standardized patient exams that will soon be part of the United States Medical Licensing Exam.

"It's amazing that it took so long to realize they didn't have to use real patients for everything," said Martha Stanton, senior program coordinator, of the use of standardized patients, which has only become common in medical schools in the last decade. The precursors of standardized patients are the gynecological teaching associates (GTAs) and their male equivalents, who have had a place in medical school curricula for several decades.

These teachers guide students through the most invasive of the physical exams, giving direction and feedback that doctors can't get from real patients. In fact, Anderson first got involved in the field by working as a GTA. She was studying for a master's degree in urban and regional planning at the University of New Orleans when she heard that Tulane Medical School needed women to demonstrate gynecological exams, and the pay was generous.

Most of these teaching associates are first attracted by the pay, which can be in the neighborhood of $40 an hour or more, but also fear the experience may be uncomfortable or embarrassing. In practice, it usually turns out to be powerfully positive for both the teacher and the students.

"A lot of GTAs say it's the most empowering thing they've ever done," Anderson said. It's the opposite of the helplessness many of us feel on the exam table. The students are grateful for the experience and the teacher knows she's helped increase the knowledge and sensitivity of the next generation of doctors. In the last decade the use of standardized patients has expanded dramatically.

Tulane students encounter standardized patients in two guises. In some cases, they act as both instructors and patients, guiding students through a complete exam. At other times they are actors, playing the role of a patient with a specific set of symptoms and a specific medical history. "It's very labor intensive," Stanton said of producing the standardized patient exams.

"It's like producing 10 little one-act plays and then running all 10 simultaneously for 15 days." Students "treat" standardized patients in every year of their medical education. They have to pass two high-stakes exams-one at the end of the second year and one at the beginning of the fourth year-that use standardized patients to evaluate clinical skills. Standardized patients play a part in half of the third-year clerkships. The exams are staged like those that might take place at a clinic or private doctor's office.

Standardized patients can present a wider range of symptoms, complaints and patient types than students typically encounter at area hospitals. Based on faculty-designed cases, their presentations are used as evaluative tools of the student's clinical ability. Standardized patients are coached on what to say and how to behave. They have to learn not to withhold information but not to give up too much too easily.

The exams take place in one of 10 spartan but realistic exam rooms. After the exam, the student makes notes and writes his or her chart on the patient. At the same time, the patient fills out an evaluation form on the student, indicating whether or not the student asked everything he or she should have and followed up appropriately, as well as making notes on the student's communication and examination skills.

The results are used not just to evaluate students but the curriculum as a whole. Professors might notice, for example, that few students know to ask about a particular symptom, and adjust their teaching accordingly. The standardized patient program also is involved in several research projects. One sends standardized patients into real medical practices to evaluate the system and practice standards.

Another aims to demonstrate to potential preceptors that students really can be helpful and effective in the clinic, rather than a potential burden. And then there is the ongoing development of the U.S. Medical Licensing Exam. Standardized patients will be part of the board exams as early as 2002, something for which Tulane students should be well prepared.

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