“This can’t be happening,” Sarah said through teary-eyed disbelief. “I’ve been clean for six years. I’ve been doing so good.”
Denise LaMarra, director of the Standardized Patient Program, standing in front of Jared and Sarah
Jared Huber, her doctor, had just told her the she had tested positive for HIV, after some polite conversation about her last appointment and how a new medication is helping with an unrelated issue.
After a few moments of silence, she asked Huber why this was happening. Why, she asked, would God do this to her?
“Doctors aren’t always good at explaining why things happen,” he said, then explaining that he would be there to walk her through the steps that would follow in getting her care for the disease started.
HIV isn’t the death sentence it once was, Huber explained, but they would need to find out what strain of the virus she has in order to prescribe the right type of therapy.
Sarah wiped tears from beneath her glasses and voiced fears that her sister would never let her see her nieces and nephews again once she found out, and recounted how she had watched her friend Jamie die of AIDS alone, just two years ago. Jamie had wasted away, covered in sores, with no one to help, and now Sarah was afraid she faced the same fate, despite all the work she had put in to stay healthy in recent years.
Then, the discussion paused and the real story came out, in front of the several dozen onlookers who had gathered to watch the discussion unfold: Sarah, a professional actor who works as a standardized patient (or SP), stepped out of character to give Huber, a fourth-year medical student in the Perelman School of Medicine at the University of Pennsylvania, feedback on how he had handled the tough conversation. The audience in the room finally exhaled and applauded.
Sarah told Huber—who was playing the role of a less experienced medical student—that he may have rushed a bit after giving her the test results, that she lost a lot of what he said in the drama of the moment, but praised his approach of slowing the discussion down to ask what she was feeling. He gave her time to collect her thoughts and then went through and addressed them, item by item, with her.
Huber and Sarah were demonstrating for a room of attendees at this fall’s annual Parents and Partners Day the type of interactions that their loved ones, now newly minted medical students, would have as they worked their way toward becoming doctors.
The Perelman School of Medicine works with about 150 standardized patients, the majority of which are professional actors, to provide “real-life” training opportunities. The SPs play roles that help medical students learn the ropes of communicating in situations as complicated as the delivery of a serious diagnosis, or for much lighter circumstances. In the first scenario during the Parents and Partners Day demonstration, for instance, Huber had to explain to an irate Sarah that she did not need antibiotics for what was likely a minor viral infection. Another scenario saw Sarah not-so-subtly hitting on her young doctor. All of them are scenarios students may encounter as they begin their careers, and the skills necessary to handle them are tough to impart from a textbook.
PSOM students interact with SPs as early as their first semester here, in their Doctor-Patient Relationship class, and through their third year as they build their clinical skills during rotations throughout Penn Medicine hospitals and outpatient practices. The encounters range from one-on-one exams to interactions in front of large groups of fellow students. SPs are also used in Graduate Medical Education courses throughout the health system, and as part of testing for the medical licensing exams that all new doctors must pass.
Denise LaMarra runs Penn’s Standardized Patient Program. She says SPs provide instructors a great tool, a way to measure a doctor’s approach to patients. Using SPs, LaMarra said, gives students much-needed practice at building rapport.
“In the old days, doctors had a lot of time to talk to patients and practice on patients in the hospital,” LaMarra said. “These days, people aren’t hospitalized as often or for as long.”
For instructors, the interactions with SPs provide a chance to evaluate their students on bedside manner in a controlled environment. They can work with the SPs to establish the case, and to steer the discussion toward what the instructor wants to examine.
Megan, acting in an SP scenario with fourth-year student Arune Gulati
An actor by trade, Megan – SPs are identified to students only by their first names or character names - started working as a standardized patient about five years ago on the recommendation of a friend and fellow actor. The job allowed her to earn some money acting instead of waiting tables. She says giving feedback is the most challenging part of the job.
“You need to have two levels of awareness activated at once. On one level, you need to be thinking about your portrayal and case facts,” she said. “At the same time you need to stay in tune to moments where you have a strong emotional reaction and be able to remember the circumstances that surround that reaction.”An actor by trade, Megan – SPs are identified to students only to students only by their first names or character names -- started working as a standardized patient about five years ago on the recommendation of a friend and fellow actor. The job allowed her to earn some money acting instead of waiting tables. She says giving feedback is the most challenging part of the job.
SPs also give patients from around the country experience with a diverse patient pool. LaMarra said the SP program currently hires from 18 to 80 years old, male and female and some who identify as transgender. They come from all races and backgrounds as well. LaMarra says they aim to have a realistic sample of the many patients students will encounter in their clinical practice.
“We’re fortunate in Philadelphia to have a diverse pool of applicants,” she said. “We don’t have to do too much with recruitment. People come to us.”
But before an SP can be hired, they have to apply and even before they are interviewed, they begin the process by observing an encounter between an SP and a doctor. The applicant is then asked a few questions to make sure they can pick up on the important moments in the conversation. LaMarra said that if they don’t do well with that first step, they are probably not cut out for it.
A lot of the work in the Standardized Patient Program comes from the faculty too. They put together the cases from the physician’s perspective and the SPs immerse themselves in the case and spins it around to the patient’s perspective.
Megan says part of the training includes working with other SPs who will be representing the same case. They share tips and role play amongst themselves to make sure they are all playing the character in the same, standardized way.
“Over the last few years I've done many cases for CHOP residents and fellows as a mother with a significantly ill child. Those are often highly emotional, devastating cases,” Megan said. “I like these cases because it feels so important to give these professionals the chance to have these tough conversations in a non-critical setting.”
LaMarra says SPs are now applying their skills to more and more uses outside of the medical setting as well. Penn Medicine Academy, for instance, runs a performance management course for managers to build the skills and confidence necessary to have difficult conversations with staff.
“So many things would be so much easier if we could have just an honest conversation,” LaMarra said. “The applications for SPs are endless.”