Simulation, or: Mr. DeMille, I’m ready for my close up!

Photo by Avel Chuklanov on Unsplash

I can trace my time spent in the wings of high school musicals to this moment.

I learned long ago that my time in a classroom equated to time on a stage. Playing a standardized patient would add a notch to my acting belt…I hadn’t been this excited since I joined ACTRA briefly years ago at work while recording audio for a listening test.

I have taken a blogging pause in my write-up about Springfield and standardized patient (SP) training because I knew I would soon have an opportunity to play an SP in three Observed Standardized Clinical Exams (OSCEs). The experiences in training and high stakes were the same, but not the same-same. I’ve combined both in one post.

SP-in-Training

On Day 2 at the SIU School of Medicine, we prepared our performances for second and fourth year students.

“I’m really having a problem with all of these headaches.”

I can still remember Shakespearean sonnets I memorized in high school, but this standard opening line was difficult for many of us to remember. We repeated it randomly to each other on the bus and over dinner.

This seemingly benign line is the trigger for a directed line of questioning in an encounter. The line must be delivered correctly in order that all students have the same opportunity to make a diagnosis and offer a differential. Certain lines must be delivered by the SP at critical moments of the examination (the doorknob question) or are triggered by certain words (“A psychiatrist? Why do you want me to visit a shrink?”)

The method used at SIU for training SPs is one that Dr. Harold S. Barrows developed. Barrows, a medical educator and a neurologist, established the idea of using a simulated patient, based on a real case, at the University of Southern California in his clerkship. You can read about the history of using simulated/standardized patients and Dr. Barrows here (CanCon alert – he also worked at McMaster University in Hamilton – it’s the first medical school that used a problem-based curriculum). How the trainer shares details of the case depends on the case’s complexity – focusing on important details may come up a few times during the case (i.e. drugs and doses; days on medication, onset of symptoms). The case developers should try to make these numbers easy to remember and draw attention to them when training the SP. For example, when I played the headache patient there were many “2s” in the case – 2 months ago, 2 weeks ago, 2 tablets/day, 2 siblings, etc.

The SP is also told how to play the role – despondent, agitated, concerned, angry. The SPs take notes, ask questions, and are given the role to practice. Depending on the level of detail (how much personal life details should be provided vs improvised?), there may also be some research to do, like watching a YouTube video of a certain physical condition. This is important, such as when the medical student has to check reflexes – with practice, it is possible for an SP to mimic a condition that does not normally present in an adult, such as the Babinski reflex. The shuffling gait of a patient with Parkinson’s, as well as the Parkinson’s mask, can also be mimicked convincingly for a medical student.

All the training is done to ensure each student receives a similar experience, and to prevent an SP from going “rogue”.

I was ready – my headache was going to be the best headache anyone had ever had in the history of SPs. Ego is a problem in the theatre, but mine was in check.

Many of us found it difficult to deliver details while reacting to the medical student. The first rule of simulation – never break simulation. One of us giggled when a student inadvertently checked our heartbeat by placing the stethoscope on our abdomen. Another rule is to deliver consistently and accurately. Memory is a funny thing: I watched my partner deliver her performance through a two-way mirror, and she swore afterwards she said she had had her headaches for two months, but neither the trainer (watching remotely via camera) nor I heard her. The medical student did not include it in the SOAP note. It was an important detail for one of the differentials. Some SPs have been known to write things on their palms to remember – not the best thing for a medical student to discover as they conduct a physical examination. Better to use mnemonic devices, such as acronyms for the things one needs to remember, or turning a watch around, and twisting it back once it’s done.

My takeaway in Springfield – I understood why one of the veteran SPs said it is a privilege to play a small role in furthering medical education. It is humbling to see how much knowledge these students already have in their first years of medical education. It is also frustrating as an SP not to be seen as a “real” patient. My internal voice screamed “Can’t you see how hard I’m working to make this real for you?”

High Stakes – OSCEs

Being an SP is fun. It is fun when you only perform once, and it is fun when you play the same role thirty times in the span of three hours. I monitored my responses to the students and checked in with the marker to ensure I delivered a consistent performance. My initial guilt at making the first student experience a traumatic encounter (I was the “Cheating Husband – Communication Station” SP) disappeared when I thought how lucky the students are to make mistakes on an exam, and not on a real patient. Even though these were five-minute encounters, the intensity and maintenance of emotions became real – I shed tears with one student when I started my story. My method approach threw a few students off – I had the marker’s phone number programmed into my mobile, and passed my phone to the student when I called my “sister,” saying I couldn’t bring myself to talk. Maybe I enjoyed the look on their faces too much as they realized I had made a real call and they might have to talk to someone. The marker could direct the call to voicemail from her watch. This time, I was not overcome by my ego – I got a few taps on my shoulder from students with a “wow, you were intense – thank you” comments. No time for basking in the glory, however – there were 10 interactions in 60 minutes. To stay on schedule, we used a hidden hand system for the SP grade. Grading the SP experience is different than marking the station with a rubric – I want to be acknowledged as a patient, I want my questions answered, I want my needs addressed. At this station, the marker is looking for empathy, scope of practice, professionalism, communication.

I would love to share more details about what happened in these encounters, but these were students and they were graded on these experiences. Some were touchingly compassionate. Other encounters reinforced my belief as a curriculum designer that this kind of station is essential to help shape and improve students’ abilities to communicate with patients.

I also played a patient with lower back pain. That was a history station, and it was not as interesting, but just as important. I played that patient 60 times in one day. It wouldn’t be fair to student 60 that I had heard the same questions all day and could anticipate them – I had to remember to ask students what they meant when they asked “Can you characterize your pain?” because it isn’t patient talk, it is doctor talk. Regular people never ask that question – they ask “What does it feel like?” I also monitored my own speech over the course of the day, and had to prevent myself from parroting medical talk: “Yes, the pain is constant” and instead saying: “It’s all the time. I feel it all the time.” Determined to provide a real encounter, I drew on my memories of doctor office visits when I was pregnant – I remember how each doctor couldn’t wait to get out of the examination room, but I had a doorknob question, jotted on a piece of paper so that the intimidation of being in a doctor’s office wouldn’t allow me to forget. I was aware how much power a medical professional wields in their practice – an SP can be compelled to answer a question they are not supposed to answer in a simulation, because “I felt that I had to answer.”

In the “Cheating Husband” scenario, I drew on my 2-year-old-daughter’s tantrum when she couldn’t get her tights over her legs, but refused offers of help because she wanted to do it by herself. The vivid memory of her staccato catches of breath between words informed my speech pattern, and I hoped the student felt the same sense of helplessness I had years ago, watching her struggle, sitting through an emotional outburst. If a student did not acknowledge me when leaving the station, it felt personal, because I opened the door to vulnerability, and it didn’t receive acknowledgement. This frustration helped fuel the next encounter, injecting fresh trauma into this embodiment of anguish.

OSCE takeaway: no one wants gonorrhea, but it’s what you do with it that counts.

Final blog post on standardized patients to come: stars and wishes, as well as bringing it back to language teaching – why this method won’t happen in language teacher education programs, but why it should.

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