“How are you doing today?” the doctor asks cheerfully as she shakes hands with a new patient, a 55-year-old woman named Karen who smiles broadly. “Well, I’m OK right now,” says Karen, seated next to an exam table.
“So what brings you in?” the doctor asks, glancing at a chart.
“I’ve been having this awful pain in the side of my stomach,” Karen says.
And so begins another routine medical exam in a routine setting.
Except it isn’t. The “doctor” is actually a second-year medical student in the Joe R. and Teresa Lozano Long School of Medicine, and the patient is a carefully trained actor playing a part.
The encounter in the H-E-B Clinical Skills Center is part of the standardized patient program. The center’s director, Diane Ferguson, B.S.N., RN, explained that the standardized patient-student encounter is a creative teaching approach and an important component in medical education.
“We train and assess health care students on clinical skills primarily by using human simulation,” Ferguson said. “So we give [the standardized patients, called SPs] a script, a clinical case.”
Ferguson, who developed the standardized patient program at UT Health San Antonio in 1995 and has directed the Clinical Skills Center since 2005, said the encounters help students learn physical exam techniques, how to interview a patient and take a medical history and, importantly, how to communicate effectively, including when delivering bad news.
Employing SPs, she said, especially benefits students. A real patient couldn’t or wouldn’t tolerate repeated encounters with students. And using SPs, who all exhibit the same symptoms, have the same history and answer the questions the same way, allows for a better skills assessment.
At a recent training session, standardized patient educator Kenton H. Coker Jr. hands out a case summary and script to some 20, mostly middle-aged, SPs in preparation for encounters with medical students. All the SPs will assume the identity of a patient experiencing abdominal pain. They will all memorize identical answers to anticipated history questions such as onset of the pain, duration, location, severity and associated symptoms. Additionally, the SPs are trained to recognize the correct techniques of the expected physical examination for that case.
“Every case has a demographic that we try to match if we can,” he said. “So if it needs to be a 55- to 65-year-old male, then we’ll only send out a request to that group of SPs. And each case has a specific training.”
Coker explains the objectives to the SPs, reviews the symptoms and patient history, and describes what the physical exam will entail. He reminds the SPs of the importance placed on the students’ communication skills and answers questions on how to evaluate the students based on a checklist.
There are around 75 SPs, all of whom are hourly employees of UT Health San Antonio.
One of them, Janie, has been an SP for over a decade and finds the experience rewarding.
“I really enjoy helping them become doctors,” she said. “And they find it beneficial to get the patient’s point of view. They’re grateful for what we do. Patient interaction is very important. The interpersonal skills are key. I always tell them that the better the communication is, the better their practice will be. It’s about using the right language so the patient understands and establishes trust. It’s not just about the exam.”
The encounters are serious, but there can be light moments.
“Once a student was auscultating [listening through a stethoscope] to my carotids,” Janie recalled. “He forgot to tell me that I could breathe normally again. And as a patient, sometimes you don’t know you can breathe again if the doctor doesn’t say so. So I was holding my breath until he finally noticed and said, ‘Oh I’m sorry! You can breathe again!’”
A typical encounter between an SP and medical student lasts 13 to 15 minutes, which includes the interview and physical exam. The SP then completes the checklist followed by a dialogue with the student about what went well, what the student may have failed to ask and ways to improve.
“I thought you were very thorough on your history,” Janie tells a student after their encounter. “And you had good eye contact and you smiled. That relaxes the patient.”
Time management is emphasized, which forces the students to focus on the symptoms and on interview techniques that will elicit the most information.
Medical student Alia Hemeida said the encounters are valuable.
“It’s a real application of what we’re learning so that by the time we get to a hospital setting in the third year [of medical school], we’re comfortable with patient interactions and conducting these interviews and physical exams with real patients,” she said. “It’s a safe setting for us to incorporate what we’ve learned in the classroom and start critical thinking in preparation for third year.”
Hemeida said the SP encounters are especially useful for learning how to discuss sensitive personal health issues—incontinence or sexual history, for example—with patients.
Ferguson, the skills center director, said the standardized patient program serves medical students in all four years and medical residents, as well as students from the health professions, dentistry and nursing, and pharmacy students from the University of the Incarnate Word.
She described the program as “a bridge between health care education and patient care where learning occurs in a safe environment, which allows for honest feedback that students cannot obtain elsewhere. Who better to give future providers pointers on establishing patient connections than human patients?”