Acting the Part

Dianne Bye is not a patient, but she plays one at medical school.

Clad in an examination gown and calling herself Joan Brown, she tells a third-year medical student at UC Irvine she has suffered severe abdominal pain for three days, always after a meal.

She lies down on the table in what looks to be a doctor’s examination room, pulls up her gown and allows her belly to be poked repeatedly.

“Ow!” she blurts out when the student tells her to inhale while he presses her abdomen. “It hurts more when I breathe in,” she says--a telling response for someone with gall bladder problems.

In the exam room next door, another woman complains that she can’t sleep.

Down the hall, a man is panicked about recurrent bouts of chest pain.

A young woman in another room seeks a new method of birth control.

But none of these people is really in need of medical attention.

No hypochondriacs, these recipients of sometimes unpleasant procedures and probing questions are being paid to act sick. They are known in medical schools as “standardized patients,” living, breathing versions of real patient case files on whom future doctors practice and perform tests.

As if enrolled in “Bedside Manner 101,” medical students practice how to express empathy, how to gain a patient’s cooperation, how to win a patient’s trust.

The students learn how to respect a person’s modesty and comfort level while performing a physical exam. They practice how to ask the right questions to draw out a patient’s complete medical history or to hone in on symptoms to make an accurate diagnosis. Other exercises might involve aiding a patient in stopping smoking or telling a patient he has cancer or AIDS and advising a course of treatment.

Standardized patients “are another type of teaching material. But these are live bodies instead of paper cases,” said Elizabeth O’Gara, standardized patient coordinator for UCLA’s School of Medicine.

“We are interested in more than what a student knows. We are interested in the application of that knowledge,” said Dr. Alberto Manetta, senior associate dean of educational affairs at UC Irvine’s medical school. “There are students who can recite all the different kinds of ovarian cancer. But that doesn’t mean that, when they are presented with a patient, they can establish a path that leads to the right diagnosis.”

All five of Southern California’s medical schools employ these standardized patients, often drawing on the area’s ample supply of actors to fill their simulated examination rooms. Most U.S. medical schools also use standardized patients.

Once scoffed at, they are so widely accepted now that by 2001, the national exam for licensing doctors is expected to test physician candidates, in part, with standardized patients instead of solely paper and pencil.

And perhaps the clearest sign that standardized patients have made it, they were lampooned on “Seinfeld,” embodied by the character Kramer, who wins an acting job to portray a patient with gonorrhea.

Disappointed he does not get the plum role of a patient with cirrhosis of the liver, Kramer makes the most of his assignment by dramatically recalling an imagined romantic interlude that led to his disease, all to the applause of the medical students.

The episode was funny, but not at all like the scenes that took place recently at UC Irvine’s medical school’s Student Training Center, where eight rooms are furnished like doctors’ examining rooms.

Jennifer Campbell is slumped in a chair in one room, a jangle of nerves with her knees bouncing nonstop and hands pushing back her unkempt hair. She just wanted medication to sleep, she told the medical student, as she tried to dodge questions about how much she drank and her troubled relationship with her live-in boyfriend.

After the exchange, a professor in the room advised the student to follow up the patient’s answers more thoroughly. When insomnia has organic causes, it is only a symptom, he reminded the student. The standardized patient, as it turned out, needed treatment for alcoholism.

In another room, James Goss portrayed a bank vice president troubled by recurrent chest pains that mysteriously went away after a few minutes. Down the hall, a middle-aged woman posed as a seemingly healthy patient getting an annual physical exam, but she would not mention her menopausal problems unless the student asked.

Silently, video cameras perched high in the rooms captured the exchanges and piped in images to a screening area full of television monitors and VCRs, so that professors could view the tapes later. This battery of exams would make up 15% of the students’ grade in their family medicine course.

“I’m having a great time doing this,” said Doug Evans, a scuba instructor who was impersonating a patient with a skiing injury. “It gives you an insight into the learning process. You can pick out who will be the good doctors of the future.”

“When I started doing this at first, I thought I was the star,” said Gary Halbert of Laguna Niguel, a part-time actor. “Then I realized that instead I’m just a prop for the student.”

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UCI’s and other medical schools recruit their standardized patients through ads in drama and local publications, visits to community theater auditions, and word of mouth. Standardized patient coordinators say they are always on the lookout for new participants. People of all ages, ethnicities, language ability and medical backgrounds are needed to represent the diversity of patients, they said.

The work is not steady but the pay is decent, varying according to the particulars and duration of each assignment. It can range from about $75, for a quick, uncomplicated encounter, to $400 to $1,200, for intensive, repeated testing situations, said Ellen Lewis, director of UCI’s student training center.

The bureaucratic-sounding moniker of “standardized patient”--sometimes abbreviated as SP--indicates how seriously medical schools regard this play-acting. The term means that the patients portrayed by the actors are the same--standardized--so that all medical students being tested or trained are exposed to near-identical experiences.

“We know medical students are smart, but can they transfer that knowledge into interaction?” asked Peggy Wallace, who led the standardized patient program at USC before taking a similar post at UC San Diego’s medical school two years ago.

Educators can assess students’ skills by using simulated patients, she said, “to consistently portray a given type of patient with given symptoms and a given history. And we need them to do it over and over and over to student after student after student.”

Medical schools no longer can depend on their teaching hospitals to supply students with sufficient hands-on learning experiences, officials said. Managed care has changed that.

“It used to be that doctors put patients in the hospital to try to figure out what was wrong,” said UCI’s Manetta. But with insurance companies’ heightened requirements for hospitalization, “a patient can’t be admitted now without a diagnosis,” and hospital stays are too short to allow much student interaction, he said.

Even in outpatient settings, managed care has impacted how medicine is practiced--and taught.

“If managed care takes over everywhere as it is supposed to be doing, where a physician has only seven to eight minutes with each patient, your clinical skills will have to be sharper than ever before,” said Dr. Mark Swartz, director of the Mount Sinai School of Medicine’s Morchand Center in New York, which runs the nation’s largest standardized patient program. “It’s one more reason why it’s so important to train doctors how to communicate effectively.”

But physicians were not always so keen on standardized patients.

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The first SP on record entered a medical school classroom in 1963 at USC. She was called Patty Dugger, a paraplegic with multiple sclerosis, and was portrayed by an able-bodied artists’ model, Rose McWilliams. The case was created by Dr. Howard S. Barrows, who wanted a better method of assessing the techniques and skills of his third-year neurology students, according to a history of standardized patients written by UC San Diego’s Wallace.

The technique of using simulated patients was initially ridiculed but slowly began to catch on.

Southern California’s five medical schools--UCI, UCLA, USC, UC San Diego and Loma Linda--formed a consortium in 1991 to capture a grant from the Josiah Macy Jr. Foundation. The foundation offered funds to consortia nationwide to develop standardized patient programs for the Clinical Practice Examination (CPX), medical schools’ version of a final exam, given at the end of the third year so that problems can be remedied in the last year.

Usually, all five Southern California medical schools give the exact same CPXs each year, using identical patient cases, although employing different actors at each campus. This year, however, UCI’s is different from the other four because UCI is helping the National Board of Medical Examiners, the agency that tests all medical school graduates for licensure, to develop standardized patient cases for future use in the national exam.

The impending use of SPs in the national exam is spurring the few medical schools without such programs to get one started, several educators said.

At UCI, standardized patients are used throughout medical students’ first three years.

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Teaching future doctors how to be empathetic can have legal rewards, said Mount Sinai’s Swartz. He said that 85% of malpractice lawsuits stem from miscommunication between doctor and patient. Patients who believe they have a good relationship with their doctors are less likely to sue, a study has shown.

But Manetta said UCI’s use of standardized patients has “zero connection” to malpractice liability. He said patients are more cooperative about improving their health when there is good communication with their doctors.

“That communication may make a difference for a patient with high blood pressure, whether he takes his medication or not,” Manetta said. “And that could be the difference between life and death.”

Being a standardized patient helps actors in their profession, too, according to the hired help. Play-acting at medical school requires the actor to become immersed in the patient’s case and improves improvisation skills, they say, for there is no script and the standardized patient must always stay in character, no matter what the medical student asks or does.

“You get involved in the truth of the moment,” said actress Dianne Bye, who in addition to portraying a housekeeper with gallstones, has had medical students practice basic physical exam procedures on her.

And while standardized patient coordinators were amused by the “Seinfeld” episode and pleased for the attention it drew to their specialty, they also stressed that Kramer’s free-wheeling portrayal of a gonorrhea patient would never be allowed in their simulated exam rooms.

“We want people to know about this program,” said USC’s coordinator, Linda Perkowski. “But anyone who did what Kramer did would never work as a standardized patient again.”