Standardized Patients Fulfill a Vital Educational Need

John Lorimer sits in an examination room in the Wichman Clinical Teaching and Assessment Center (CTAC) at the University of Wisconsin School of Medicine and Public Health (SMPH), waiting for the first of the 25 nervous third-year medical students to enter. The students have recently completed their eight-week primary care clerkship, and now they are about to be tested on the clinical skills they have learned.

 

With 10 years' experience as a standardized patient at the school, Lorimer knows how his carefully scripted part of the 10-minute encounter should go. Today he will pretend to have a chronic medical problem and he will ask each of the doctors in training about testing for it. Against a detailed checklist created by the primary care clerkship faculty, Lorimer will assess how well the students address his concerns and utilize their clinical skills.

 

Very few papers and pencils are involved here; unobtrusive cameras will record the interactions and a sophisticated digital capture system will store them for future reference.

 

In another exam room, veteran standardized patient Judy Gunkel role-plays convincingly about her particular pain, very likely speaking from experience. In yet another, Jean Cato presents with an acute illness, saying she needs antibiotics. 

 

They are three of five standardized patients (SPs) the medical students will see as part of the morning's Objective Structured Clinical Exam, or OSCE.

 

Clinical Teaching and Assessment Center director Jane Banning, left, and standardized patient program manager Elizabeth Meister review a checklist that standardized patients will use to assess student performance in an upcoming Objective Structured Clinical Exam.

Standardized patients provide a safe and controlled way to prepare students to see real patients, says Jane Banning, MSSW, director of the teaching and assessment center.

 

"SPs allow students to practice skills such as meeting a patient for the first time, interviewing a patient about some behavioral change, delivering bad news, conducting a routine medical history and performing physical exams," explains Banning.

 

Standardized Patients are an Effective Educational Tool

 

The School of Medicine and Public Health has used standardized patients for student teaching and testing for some 40 years. The roster currently consists of approximately 80 people, and each works from as little as one or two hours a month to as many as 20 or 30.

 

The group is about two-thirds female and one-third male; 60 percent are under age 60 and 40 percent are over. Hoping to mirror the richness of the patient population any student may expect to see in a future practice, the school strives to include people of different ages, ethnicity, race, sexual orientation and socioeconomic backgrounds.

 

"Years ago, medical students usually went directly to the hospital to practice on patients who may have been in pain, on medications or just not feeling well," says Banning. "Those patients might not have been able to provide valuable feedback, or feedback of any kind. What's more, hospitalized patients were not available to large numbers of students in those days."

 

Today the vast majority of the 130 accredited medical schools in the United States use standardized patients. Many created their programs after the National Board of Medical Examiners began requiring students to take clinical skills examinations. In this second step of the licensure exam, students must pass a 10-station OSCE graded by standardized patients.

 

The value of standardized patients is widely recognized. Extensive research has shown that laypeople can do a superior job of assessing clinical skills if they are properly trained to follow a checklist of objectives for each session if the checklist doesn't require a physician's clinical judgment.

 

Standardized patients are particularly effective in helping students with verbal, nonverbal, behavioral and communications skills - or "bedside manner." These skills, which can't be tested on a traditional written exam, are the ones patients increasingly demand of their doctors.

 

Standardized patients provide useful feedback both formally and informally, says Banning. One SP, for example, complimented a student on his friendly style, but gently told him that in his eagerness he was sitting a bit too close to her during the interview. Following that input, the student allowed for more personal space in his clinical interactions.

 

Standardized Patients a Common Resource

 

All medical students at the School of Medicine and Public Health will experience approximately 70 encounters with standardized patients through their first three years. Administrative assistant Angie Bass, herself a former standardized patient, handles most of the scheduling of standardized patients.

 

Students meet their first standardized patients in their second week at medical school, during the Patient, Doctor and Society (PDS) course, and the interactions continue for the duration of that two-year, four-semester course.

 

In their third year, students are tested in OSCEs following their neuroscience, medicine and primary care clerkships. OSCE program manager Bill Schwanke also coordinates and administers the team that organizes a Year End Professional Skills Assessment (YEPSA) at the end of the students' third year. In the YEPSA, in which eight of the 12 stations include standardized patients, students must demonstrate the core clinical competencies needed to graduate. 

 

Banning works with faculty to create the clinical cases for both teaching and assessing, which can be as short as three minutes or as long as 45. She regularly joins Douglas Smith, MD, School of Medicine and Public Health associate professor of family medicine, in monitoring how the primary care clerkship OSCE sessions are going.

 

The two of them do this from computers and a bank of television screens in the control room, which forms the heart of the CTAC, located on the ground floor of the Health Sciences Learning Center.

 

"Two cameras mounted in the ceiling of each of the 24 exam rooms capture the clinical encounters so that instructors can review each case later online," explains technician Mark Johanneck, who manages the control room.

 

Special software links each student-standardized patient video with the checklist, grades the checklist electronically and allows faculty to "write" comments on the video, providing feedback on precise sections of the patient encounter. In cases in which a physician must do the grading, the observing also can be done remotely from the control room, notes Johanneck.

 

Acting Skills Not Required

 

Elizabeth Ortiz Meister, MSSW, the standardized patient program manager, makes sure every standardized patient is prepared for each case. She sends them checklists and other written material describing their roles, meets with each one on one and then gathers a small group of them so they can practice with each other.

 

Individual consistency is crucial, Meister says.

 

"I need to be confident that what an standardized patient does at the beginning of the week - or day - is exactly the same as what he or she does at the end," she says. "We want to be sure every student gets the same experience."

 

Consistency from standardized patient to standardized patient also is essential. Meister will tell all standardized patients, for example, exactly what to say in the opening line of a session set up for discussing a chief concern.

 

What constitutes the ideal standardized patient? Acting skills are not required, say Banning and Meister.

 

"We want people who are genuine and honest, people who are not playing to an audience," says Banning.

 

Standardized patients must take coaching well, offer feedback, be excellent listeners and understand that their sole purpose is to support medical students' learning.

 

"It's not about the individual," says Meister. "Standardized patients have to speak from the place of an everyday person."

 

And although teaching and, particularly, assessment sessions can be stressful for the students, there are many lighthearted moments.

 

"SPs often tell us how poised, humane and sensitive the students are," says Meister.

 

Training Doctors of the Future

 

All of the standardized patients take their jobs extremely seriously and find deep satisfaction in working closely with students and faculty.

 

Lorimer, a former social services manager for the state of Wisconsin, says he likes the educational environment and enjoys the stimulation of being in contact with young people.

 

"I wanted to play an active role in training doctors of the future," says Lorimer, who has helped hundreds of School of Medicine and Public Health students over the years.

 

Adds Meister, "It's heartwarming, and not unusual, when an SP seeks us out to say, 'I love doing this. Please schedule me for more sessions.'"

 

Many standardized patients also take advantage of the health information programs the department has organized for their benefit.

 

Standardized patients aren't helping just medical students either, adds Banning. UW pharmacy, nursing, physical therapy, physician assistant and genetic counseling students also use the service, and the UW veterinary medicine school is now on board.

 

"More and more disciplines are adopting this style of teaching and assessment because it is so effective," Banning says.

 

The future may mean more electronic simulations, she says.

 

"But people who work with patients need the ability to synthesize skills that involve clinical knowledge, clinical reasoning and interpersonal communication. SPs fulfill this vital need."

 

By Dian Land

This article appears in the fall 2009 issue of Quarterly.

Date Published: 11/11/2009