Acting and Educating

Standardized patient actors play a role, literally, in the education of UNC medical students. They’ve begun playing new parts to enhance resident training.

by Zach Read - zread@unch.unc.edu

At the UNC School of Medicine, standardized patients, referred to simply as SPs, play a critical role in the educational development of medical students. From year one to year four, students interact with SPs in assessment exams in which they diagnose the medical condition portrayed by each SP, take the SP’s history, and work on bedside manner, all to prepare them for the clinical setting.

“The standardized patients are such a huge help,” says fourth-year medical student Anna Rodenbough, who completed her CPX exam over the summer and plans to go into pediatrics. “The SPs do an excellent job recreating the real-life clinical experience. They respond honestly, as a patient would, and because of their professionalism and their experience playing the role of the patient, they make you feel like a real doctor seeing an actual patient.”

Trained at the School of Medicine’s Clinical Skills and Patient Simulation Center, SPs come from a variety of backgrounds. Some are local retirees, others are graduate students. According to Julie Messina, director of assessment at the Center, SPs are an invaluable resource and serve as reliable partners in medical student training.

“Standardized patients are the lifeblood of what we do at the Center,” Messina says. “Without our SPs showing up prepared to portray the cases they’ve been given, our medical students would miss significant learning opportunities.”

Messina points out that the enhanced educational experience does not go unnoticed by students. The Center recently received an email from a student who said that one particular SP he worked with during his Observed Structured Clinical Exams (OSCE) and CPX exam provided feedback that was valuable in his trajectory toward becoming a resident. He even wanted to meet the SP to express his gratitude.

“Even though the SPs play different patients with different conditions, the students begin to recognize them and the important, formative contribution they’re making in their development,” Messina says.

For nearly a decade, Katherine Fairchild and her husband, Steven, have served as standardized patients.

“Now that I’ve done a few of the cases over and over again,” Katherine says, “far less preparation for them is required.”

The Fairchilds have become so seasoned in their capacities as SPs that they welcome new challenges.

“If we get a new case, we spend several hours outside of the Center reviewing it,” Katherine continues. “Steven and I quiz each other, helping each other memorize parts of the role, including the medications we’ve taken and the health histories.”

Although the Center recruits SPs from the local community and even partners with the university to incorporate undergraduate student interns known as “patient facilitators,” a select few SPs, including the Fairchilds, make medical student clinical assessments such as CPX and OSCEs highly successful.

“We have a broad range of people that we’ve worked with, but there’s an exceptional group of SPs that we bring in for the higher-stakes exams,” says Messina.

As part of that exclusive group, the Fairchilds take their roles seriously.

“We study our scripts, we role play, and we practice until we have it down,” Katherine says.

Why do individuals like Katherine and Steven Fairchild and the rest of the SPs spend their time learning these roles? What value do they find in participating in the development of young physicians?

“The thing that’s most rewarding is watching how students evolve from their first year to their fourth year,” Steven says. “We don’t give them any help. We’re trained to be non-communicative. But as they develop, they become so much more proficient in taking oral histories and focusing on what they need to do to complete the exam.”

Over the years, the Center’s SPs have built a bond that keeps them excited about the work they’re doing and ensures that they’re prepared to step in for a fellow SP if an outside conflict arises.  

“We’re very good friends,” says Katherine. “And we often know each other’s cases so that when one of us is actually ill or can’t make it to an exam, another can fill in and help.”

SPs take on new roles as “embedded persons”

In summer 2013, the Consortium for Anesthesia Patient Safety and Experiential Learning (CAPSEL) at UNC developed an innovative use of SPs by creating a truly immersive, high-fidelity operating room environment that can't be simulated with a computer patient alone.

Serving as so-called “embedded persons,” or EPs, SPs enter the OR to play the role of surgeon, nurse, or other team member during simulated emergency situations that demand immediate response from anesthesiology residents. Situations may include anaphylaxis, cardiac arrest, severe blood loss, or transfusion reaction, among others.

The resident, surgeon-EP, and nurse-EP care for a computerized mannequin “patient” in the simulated OR while several resident colleagues monitor the scene from a nearby observation deck. CAPSEL faculty members direct the scenario from a control deck, with the help of a simulation tech specialist. They may provide the EPs with verbal cues via microphone headsets to enhance or clarify the emergency medical conditions for the resident.

Changes to medical condition require the resident to apply crisis management skills and develop critical thinking in response to crises. And, this type of simulation offers practice for rare but serious conditions in an on-demand way that residency itself doesn't offer. But that’s not all they learn.

“Our residents practice leadership and teamwork skills as they manage simulated critical events, and the ‘surgeon’ and ‘nurse’ are integral parts of that experiential learning process,” says Marjorie Stiegler, MD, assistant professor of anesthesiology and director of CAPSEL. “In the future, we plan to include real nurses and surgeons for multidisciplinary scenarios, but we would still need EPs to ‘drive’ the direction of the case.” 

The CAPSEL has a library of approximately 20 emergencies that they simulate, and the number continues to grow. The success of the simulations depends heavily on the capabilities of the EPs to enhance situations physically and verbally.

“We can’t make the mannequin develop a rash during the scenario,” says Dr. Stiegler, “but a rash might be an important clue in anaphylaxis.  Rather than have a facilitator interrupt the case to say, ‘Pretend the patient has a rash,’ we can instead have the nurse EP say, ‘I see some redness developing on the chest.’ This method is an organic way to allow the learner to incorporate the possibility of a rash into their decision-making and to proceed with that in mind….I would say that the addition of the SPs makes our options extremely broad.”

Anthony Khoo, an SP for medical student exams conducted at the Clinical Skills and Patient Simulation Center, also serves as a nurse-EP during OR emergency anesthesiology simulations. A surgical nurse by profession, Khoo understands the pressure that residents face during emergency simulations.

“When things aren’t going right, it is quite intense for them,” Khoo says.

Having recently moved from Australia, Khoo is working on receiving his RN license in the U.S. Even with extensive professional experience, he learns from the residents and the situations in which he acts.

“It keeps my knowledge fresh,” Khoo says, “and I feel like I’m participating in the education of residents.”

Steven Fairchild works alongside Khoo as the simulation’s ‘surgeon,’ a much different experience than portraying medical conditions as an SP.

“This is a whole new world for me,” says Fairchild. “The learning curve is a lot steeper in here versus the medical student exams because of the medical terms they use. You learn so much doing this, and that’s one of the most enjoyable aspects of taking on this role.”

As ‘surgeon,’ Fairchild usually pushes the resident by becoming impatient. Presenting a sense of urgency to rush the resident along simulates what the resident is likely to find in the OR. CAPSEL faculty members use this kind of EP pressure for two purposes. First, it provides an opportunity for the residents to practice articulating their concerns in a way that is compelling to OR team members, because patient safety should take priority over production pressure, which is often intense in real life. Secondly, it encourages the residents to communicate verbally, enhancing data capture of their thinking processes, which is explored further during the debriefing session that follows the simulation itself.

Since these hybrid simulations involving both actors and computerized patients began over the summer, residents have found them critical components of their training.

In the OR, vital sign changes are associated with clinical context – like bleeding – and physical exam findings. EPs clarify this context physically and verbally. “The EPs help simulate scenarios and interactions where before we wouldn’t necessarily know what was going on with the mannequin,” says anesthesiology Chief Resident Jessica Stevens, MD. “They can help facilitate the environment of the situation or the medical condition, so I think it aids significantly to the fluidity of the whole training process.”

Resident Eva Waller, MD, agrees. “The stress and pressure you feel under the situations have been enhanced by the SPs playing the roles of surgeon and nurse,” Waller says. “Formerly another resident acted as that person, and residents typically are nice to you. The surgeon-actor does not factor in his relationship with you – he doesn’t have one with you. He’s going to want things done quickly, and that’s more realistic.”   

The use of standardized patients in the training of medical students and residents continues to evolve. Today SPs play the role of parents and spouses of patients who have either died or are undergoing emergency treatment for traumatic events. During these simulations, the medical learner relays bad news to a loved one, effectively removes distraught loved ones from emergency settings while obtaining information critical to the patient’s treatment, and works through language barriers to get information from families of Spanish-speaking patients.

And so long as students and residents continue enhancing their skills and knowledge by working with SPs in clinical assessment exams and emergency scenarios such as the OR in the CAPSEL, identifying new and creative ways of using SPs will remain a priority.  

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