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Standardized History, Unusual Life

You knock on the door. “Come in.” When you enter the room, a gowned patient sits calmly atop the examination table. For the next 15 to 20 minutes, you spend your time in the small, cramped and surveillanced room with this individual to tease out the mystery of their chief complaint.

This scenario shouldn’t be foreign to the modern medical student. In 1963, the first standardized patients were trained to provide both students and patients with a safe opportunity to learn and practice their clinical skills. Soon, medical schools across United States started incorporating these unique actors into their medical curriculum. These transiently “ill” patients are trained to present specific patient profiles in order simulate realistic scenarios for students to not only practice their differential reasoning and examination skills, but also to flex their clinical interviewing muscles. Cases of varying intellectual or emotional difficulty are taught to these standardized patients, and they are trained to provide feedback for further improvement. When needed, they break character to provide necessary support to frustrated or struggling students.

In the eyes of a medical student, the perception of our standardized patients is no doubt calm and knowledgeable in the face of our nervous, scrambling minds. However, after having the honor of interviewing three volunteer standardized patients, I have realized the uncanny parallel between both patient and student in the frantic scramble and last-minute preparation before the show starts.

As I sit down with these three standardized patients after their day of training workshop, I am met with warm and familiar smiles. Most standardized patients at our institute happen to be actors, but I was fortunate enough to have the anomalies as my interviewing audience. One a librarian, one a playwright, and another a governmental office worker. Upon reaching retirement and needing an occupying hobby, each of these individuals responded to the advertisement looking for standardized patients. The training process is ever-changing, and they attend many workshops before and after each clinical encounter day to prepare and tackle potential problems as well as discuss points of improvement next time. They train through different scenarios of difficulty through time, much like the way we start with the most basic of clinical scenarios.

Listening to them recount their experiences, I can’t help but draw similarities in the continual learning process that both standardized patients and students return to. Behind the calm façade that they exude, I hear the frantic last-minute checking (leaping off the bed to check their “one liner” introduction with seconds to spare ere that fateful knock) and obsessive repeating of information right before the encounter — not too different from our own last-minute checks before shoving our annotated notes away. They chuckle at their frustrations and fumbles during these standardized encounters, internally worrying whether they provided us with the correct social history or appropriate denials to certain questions. The multiple profiles they must memorize and inhabit result in the inevitable intermingling of memorized tidbits. This sets the stage of an internal disastrous turmoil. Just as our nervousness of hitting all the right points and scrambling to whittle our differential down to two plausible ones, both sides struggle to balance the internal chaos and external professionalism. The camaraderie I see as the standardized patients bond as a family through their collective experiences, exchanging helpful hints for cues, discussing odd questions brought up by the students and swapping funny encounters, is not so different from the way we as medical students have bonded through our learning experiences.

As the interview continues, I ask them of the most common mistake that medical students make, and they laugh with twinkles in their eyes.

“Definitely using the otoscope for the fundoscopic exam,” C replies demurely.

They nodded in agreement. Their laughter wasn’t derisive or condescending; rather, the amusement they presented was akin to the way parents smile at the stumbling steps of their child finding their way and grasping the ropes. C laughed when I probed for horror stories. He recounted a student failing to pull out the table extender when asking him to lay down. He raises his brows as he chuckled that the student had pulled out the stirrups instead when he had gently prompted the student to pull out the table. The others shake their heads and share entertaining stories. They laugh at the chaos right before each encounter and the funny interactions that can be viewed from the control room.

But it’s not all giggles and internalized panic. There was a heartwarming moment when A had an old student walk in as the medical student. She had taught at a local school prior to this new occupation, and the student had struck her with familiarity. After the encounter, A had finally asked the question and the student had recognized her. It was a sense of amazement to the odds of the universe and another sense of pride that A expressed; to her, being a standardized patient has opened her many doors of novel experiences and opportunities. Perhaps most heartwarming to me was B’s astonishment of having one of his medical students as his resident physician for his recent surgery.

From their perspective, the most gratifying part of being standardized patients is being a part of our growth as medical students through our four years of clinical skills training. To us, each encounter feels bumbling and flustered — clumsy and unnatural. However, at the other end of the kaleidoscope, they have the unique position to work with us at every stage of our process. From the nervous recitation of mandatory questions to a fully fledged physical examination, to finally a smoothly transitioned clinical interview along with astute differentials. We mature at each step of the way without knowing it. To be able watch us grow and help us improve with their constructive feedback — isn’t that the mission of all mentors? It became clear to me that although each standardized patient came from very unique walks of life, they all share the quality of mentorship. Their ability to provide us with constructive feedback and contribute to a part of our rigorous training process, is the most meaningful motivation for them to continue their job. Within each standardized patient, I see the teacher and parent that wishes for their children to thrive and grow.

When asked about the impact of being a standardized patient on their personal lives, their experiences have definitely been enriching. Most significantly, they have become advocates for themselves and are able to become active participants in their own medical care. Not only have they become more astute and well versed in the process and lingo of medicine, but they have also become more perceptive of the physician’s interactions and intent. They have also been able to become patient advocates for their loved ones and found this new skill to be an empowering one. It’s fascinating as B mentions that his physician groaned when he announced his new job as a standardized patient, claiming that he would now become more of a hassle. Even funnier is the fact that C’s physician had stopped to ask “So, how did I do?” after an appointment, meaning to double-check on his clinical skills. It seems that the lives of standardized patients may have a standardized and seemingly unshakeable history, but they definitely lead some unusual and vibrant lives.

Author’s note: I would like to thank Heather Frenz, the Albany Medical College Patient Safety and Clinical Competency Center and its staff, and the standardized patients to allow for this wonderful experience to happen.

Nita Chen, MD Nita Chen, MD (39 Posts)

Medical Student Editor and in-Training Staff Member Emeritus

University of Florida Fixel Movement and Neurorestoration Institute

Nita Chen is a current movement disorders fellow at University of Florida Movement and Neurorestoration program. She is Class of 2017 medical student at Albany Medical College. To become cultural, she spent her early educational years in Taiwan and thoroughly enjoyed wonderful Taiwanese food and milk tea, thus ruining her appetite for the rest of her life in the United States. Aside from her neuroscience and cognitive science majors during her undergraduate career, she holed herself up in her room writing silly fictional stories, doodling, and playing the piano. Or she could be found spazzing out like a gigantic science nerd in various laboratories. Now she just holes up in her room to study most of the time.