Coming in Sick to Work - Being a Standardized Patient

[ Just so everybody's clear that "American Currents" is still my general blog and not an "All Occupy/All the Time" station, here's a commentary on a different aspect of my recent activities. There will be more to come, on other topics, as well. Stay tuned. . . ]

Yesterday I had pneumonia, complicated by my asthma, high blood pressure, and one-pack-a-day smoking habit. On Wednesday I was blind as a complication from my diabetes.

Last year, I had heart disease, lower back pain, asthma, and a drinking problem I was not inclined to be readily honest about. I look forward someday to receiving a cancer diagnosis, thyroid condition, and a sexually transmitted disease . . . but probably not a positive Pap smear.

If you’re wondering what I’ve been doing in the hospital, I work now and then as a Standardized Patient (or “SP”). This means I pretend to be a patient in medical exams conducted by first-year, second-year, and third-year medical students, nurse practitioners, and naturopaths at several medical teaching institutions in the city.

As noted above, I could have any kind of complaint: When they walk in the room and I’m sitting there waiting for them, they have to examine me, verbally and sometimes physically, to find out what it is. Then they decide on a suitable course of treatment.

Some conditions require a quick and targeted response; others tend to involve a detailed medical history, such as a description of where I work, what I do (for environmental factors like lots of heavy lifting or standing in place -- or dust and hazardous materials), family situation (potential source of support or stress), family medical history (for predisposition to heart conditions, diabetes, or hypertension), or sexual practices.

Although I can easily make myself look exhausted, and I made myself lightheaded by acting out a mild asthma attack ALL DAY for a series of students, obviously there are some symptoms I can’t fake. When I had pneumonia yesterday, for example, once the student properly had listened to my lungs with a stethoscope, I’d hand over a slip of paper that included critical information about “crackling” the student “heard” in my lungs and precisely where.

We’re given a script with much of the patient’s medical history, background, and current medications, but often we have to make up details on the spot, depending on where the questioner chooses to go: names of children, where we were born or lived before coming to town, what exactly do we do on the job, what was our temperature this morning, whether we’ve noticed a recent change in our weight or bowel movements.

So it’s improvisatory acting . . . except that we also get to evaluate the “audience.” After the student finishes, I get to talk to him or her about the strengths and weaknesses of the exam. This can range from critical medical information the student neglected to elicit, to comments on his or her bedside manner, overuse of technical jargon unfamiliar to the average patient, and unconscious habits that might be alienating -- such as a lot of brow-knitting or standing too close and looking down at the patient.

The school also throws unfamiliar situations at them, such as how to treat a blind patient who can’t see when you’re trying to shake hands or want to conduct a physical examination, or an angry patient who comes in still steaming over an unrelated matter. Students are also challenged by having to deliver bad news about a positive cancer test or take a detailed sexual history from a person who has just received a positive test for an STD.

Nerves, insufficient training, or youthful inexperience can make a flustered medical student do inconsiderate or counterproductive things . . . but that’s what the exercise is for: to iron out those kinks before they become doctors and nurses and treat real people. They’re less likely to walk into a room with unpleasant news and make a casually humorous remark that comes across as callous, or overlook a tiny but crucial clue for an accurate diagnosis.

It’s a different kind of acting for me, because instead of having to be “on” and utterly compelling for an audience or camera every second, I have an excuse to act passive, sleepy, wary, even stupid. I can be slow, think hard about an answer, or dither a bit -- as long as I’m careful not to provide misleading information about the case. One of the challenges is to avoid the temptation to help the student out; I must resist the impulse to volunteer too much useful information when it hasn’t been honestly elicited.

Deciding whether the “doctor” has pressed enough, or asked the right kind of question, can feel like playing cards. I sit behind a mask of exhaustion or discomfort and try to gauge whether the student pushed hard enough to hit paydirt. “Okay,” I think to myself, “he played a seven . . . should I toss out another four or HIT ’IM WITH THE QUEEN?!”

There are amusing moments, too. When I was a heart patient, students not only had to listen to my heart and lungs through a stethoscope, but press their hands on various parts of my chest to search for pulsing in unfamiliar locations. If they do sense a throb in a place where there normally shouldn’t be one, that’s known in the trade as a “thrill.” So there I was, with a series of pretty young med students touching my bare chest and saying, half to themselves, “I’m not getting any thrills,” and I said to myself, “Works for me, honey!”

Medical schools only started doing this sort of thing in recent decades: practicing on medical dummies or fellow students just isn’t the same. A trained SP who also does professional acting on stage or film can inform the kids of their unconscious habits, such as asking multiple questions at one time (which will usually get you only one answer -- to the last question), or absentmindedly touching their hair and neutralizing the trouble they took to wash and disinfect their hands when they entered the room.

We’re training the doctors of tomorrow, and it’s an exciting thing to encounter a student who strikes that perfect balance between covering all the diagnostic bases and expressing genuine interest in the patient as a person and compassion for his or her condition.

For the rest, we reinforce their strengths and let them know where they can improve. We teach them to treat whole human beings, not checklists of symptoms.