Healthcare training and standardized patients

Lena H. Sun of The Washington Post, who often reports on health-related topics, has an article in today’s paper about the use in medical training of “standardized patients” — healthy people portraying patients.  (Here’s how Johns Hopkins Medicine describes its standardized patient program.)

Developing the capabilities of doctors, nurses, and other practitioners is a clear example of complex learning.  You have a wide range of skills.  Some are primarily procedural: when you draw blood, do it like this; when you’re checking vital signs, do it like that. Follow this process for obtaining and recording data.

Most of what we think of as medical training, though, involves skill for situations where there’s no single correct approach to a given problem.  So the standardized patient is an individual who’s portraying a particular type of patient–in other words, someone who’s acting as a realistic learning task.

Many [of the standardized patients] are actors, but actors don’t always make the best patients, clinical directors said. Improv is not allowed. People trained to portray a particular type of patient must work from the same facts and deliver responses in the same way to the students examining them.

“They can’t overact,” said Kathy Schaivone, clinical instructor and director [of the Clinical Education and Evaluation Laboratory] at the University of Maryland at Baltimore. “If I can’t guarantee that all five will cry, the ones that I know that can [cry], I have to ask them not to.”

(Here’s an overview of the standardized patient curriculum at U-Maryland Baltimore.)

One challenge for the standardized patients is to provide a structured debriefing: “Did the student palpate the sinuses? Listen to the heart in all four places? Wash hands before and after touching the patient?”

In this setting, I see two interconnected sets of skills:

  • Those needed by the medical practitioners to relate to patients, interact with them, and arrive at a reasonable diagnosis based on limited information.
  • Those needed by the standardized patients in order to believably and consistently portray someone with a particular condition.

Behind both of these, of course, is an intensive effort to design, develop, and implement the training.  Beyond the somewhat obvious (what conditions are both useful to have portrayed and suited to the standardized patient approach?), there’s the multilevel skill required of the patients: how do I portray the condition?  What do I share readily?  What do I tend to withhold?  What am I incorrect about?

In addition, the patients need to debrief the students, both via checklists and via face-to-face feedback. Program directors like Schaivone, meanwhile, need to monitor the performances of both the patients and the students.

To illustrate the complexity of behavior, the online version of Sun’s article has a link to this May 2011 article on how doctors struggle to show compassion, by Manoj Jain, an infectious disease specialist and professor at Emory University.

‘Standardized medicine’ image adapted from the CC-licensed original by Ben Weston (Tek F).