In the medical exam room, Garnetta Mallory gasps, nearly doubled over in pain, her hands clasped to the lower left side of her abdomen.
Behind a closed door across the hall, Peggy Watts complains of an unusual breast discharge.
In the next room, Ranji Singh at first tells the doctor she got her black-and-blue eye and cheekbone from tripping into a door.
And in another exam room, Joy Swofford is a breast-cancer survivor hunched over with severe lower back pain.
Dr. James Harper, 30, an internal medicine resident at the University of Kentucky in Lexington, has eight minutes to interview each patient and get a sense of what tests, treatment or follow-up is warranted.
It looks like a real medical encounter, but the women don’t actually have any of the symptoms they vividly describe.
They are “standardized patients”–real, live teaching tools that have become a medical-school staple. The “patients” are specially trained local actors who help teach and test medical students, physician’s assistants, nurses and other medical practitioners.
The patients follow a script or scenario, faking illnesses and allowing themselves to be poked, prodded and scrutinized by the students to help them learn how to examine patients, proper bedside manner, even how to break devastating news.
The day Harper examined Mallory, Watts, Singh and Swofford, he and a group of other residents were honing their skills during a workshop that focused on women’s health.
After the eight-minute interviews, Harper wrote down possible diagnoses, and the patients gave him two minutes of feedback. The standardized patients had checklists of questions doctors should ask during the encounter; they let Harper know what he had correctly assessed, and which questions he should have asked.
They also commented on his demeanor. The patients this day perceived Harper as “calm and reassuring” and “very personable.”
Harper quickly decided that Singh’s black eye likely was the result of domestic abuse because of her nervousness and body language, but eight minutes wasn’t long enough to draw her story out and fully inform her about her options.
“It’s a time crunch,” Harper said later. “You’re trying to be as efficient as possible, while trying to be as thorough as possible. You try to balance the two, and it gets tough sometimes.”
One of Singh’s scripted questions for the new doctors–“Do you have to tell the police about this?”–also stumped many of them. In Kentucky, doctors are required to inform authorities about domestic violence, but that’s not the case in every state.
“The bottom line is to make better doctors out of students,” said Dr. Steve Haist, medical director of the standardized patient program. “We found that we have very good tests to test medical knowledge, but a written exam is a poor way to test clinical skills, such as taking a patient history or performing a physical exam.”
The University of Kentucky has a roster of nearly 100 standardized patients who range in age from 7 to 83. There are even several families in which three generations are standardized patients.
The faux patients have been used at the university since the mid-1980s to teach patient interviewing skills and for graded examinations since 1991.
No one has been a standardized patient longer than Peggy Watts, 49, of Lexington.
“I’ve played appendicitis, I’ve played kidney stones,” said Watts, a local actress who has portrayed faux illnesses for about 14 years. “I’ve done patients who won’t talk at all, or who are out in left field. I’ve been an angry patient, where I verbally attack the student. I’ve been a diabetic, or had a heart condition, and had to cry on bad news. By now, just about every part of my body has had something wrong with it.”
The evening before Watts portrayed the woman with breast discharge for the women’s health workshop, she spent two hours getting 12 pelvic examinations from a group of student physician-assistants. Watts also has had more breast exams than she can count. “You kind of lose your shyness,” she said.
Some people may find her willingness to be examined unusual, but Watts is clear about the benefits.
“We’re the first patients they come in contact with,” she said. “I get to teach these students. Their attitude is just as important as knowing technically how to do something. And winning the trust of the patient is just as important.”
Standardized patients at the university are paid $12 to $14 per hour when they’re used to teach or test students. They earn more for intimate exams: $20 per hour for breast exams, $35 per hour for pelvic exams.
The standardized patients get about 14 hours of training and then are tested to make sure their observations and record-keeping are reliable. And their acting must be realistic.
