We're sitting in a room that's maybe 9 feet wide by 20 feet long, lined with countertops that hold 12 TV monitors. The screens let us spy upon what's normally one of the most private of encounters: the interaction between doctor and patient, taking place in a dozen nearby examining rooms. In three of the rooms, the patient is talking about a worrisome bout of diarrhea. Patients in another three rooms are complaining about their chronic insomnia. Three more are seeking medical advice about shortness of breath, while the final trio (all young women) have been coughing up blood. The white-coated figures in the exam rooms are asking questions. Some take notes. Almost all pull out stethoscopes and listen to hearts and lungs and stomach gurgles. But none of the White Coats is licensed to practice medicine. They're third-year medical students being tested on how well they deal with patients. And none of the "patients" is actually ailing. They're actors who've been trained to serve as both the students' test and their grader.
Almost unheard of 25 years ago, such actors are now a fixture at every medical school in the United States, according to Peggy Wallace. She heads the program that hires "standardized patients" (as the actors are known) on the UCSD campus. Wallace says med schools have embraced this approach in part because two years ago the board that licenses U.S. doctors began requiring candidates to pass a day-long evaluation of their clinical skills. In that grueling marathon, the aspiring doctor sees a dozen standardized patients who might complain of anything from dizziness to depression.
The licensing board's insistence that would-be MDs demonstrate interpersonal savvy with patients reflects a sea change. Wallace says doctors once thought that a good bedside manner was something one was born with. "They thought you either had it or you didn't." But research over the past two decades has shown that winning patients' trust is "a teachable skill," she asserts. It's not one most people learn in the course of their normal social interactions because "the interaction of a doctor with a patient is not a normal social interaction," Wallace points out. In a normal social setting, you don't let anyone examine your body. You'd be startled and affronted if another person asked about the color of your feces or how many people you were having sex with. But doctors do. Practicing on simulated patients can help them learn to appear both professional and caring, according to the current thinking.
The UCSD School of Medicine's use of standardized patients seems designed to squeeze every iota of insight from the contrived encounters. Consider the third-year students' midterm exam that I observed from the room with the TV screens. Each of the 12 students that afternoon saw one patient who was short-winded, one with diarrhea, one who was sleepless, and one coughing up blood. Although three different actors played each type of patient, each of the three was depicting the same person (based on a real case), and he or she had learned that patient's personal and medical history in detail.A number of different problems and/or diseases might be causing each symptom, the student doctors knew. But their grades for the midterm would not depend on whether they came up with the right diagnoses. The point instead, Wallace explained, was to assess their clinical skills -- the tools they would need to arrive at correct diagnoses time after time. They would have to examine the relevant parts of each patient's body. To know what those were, they would need to interview the patients about their current complaints as well as their medical and family histories. To get the most out of the interview, "There's a whole series of things we teach the students," Wallace says. "For instance, you want to ask open-ended questions at the beginning. If they're coming in with chest pain, you might say, 'Tell me about your chest pain.' You might say something empathetic like, 'That must have been quite frightening for you. Tell me about it.' You want to give the patient an opportunity to say what they're experiencing. What that does is to give the patient a sense that the doctor cares about more than just what the doctor needs. And that builds trust. 'This guy cares about me. I can ask him the question I'm most worried about, which is, "Is my headache a brain tumor?" ' My satisfaction with this encounter is going to be different if I can't get that question out."
In the midterm, every time a student doctor said good-bye and left the exam room, the actor/ patient hurried to a computer and filled out a 30- to 40-question form assessing everything from whether the physical exam included all the requisite maneuvers to whether the med student "listened actively, [paying] attention to both my verbal and nonverbal cues; used facial expressions/ body language to express encouragement; avoided interruptions; asked questions to make sure s/he understood what I said." The student's grade for the exam would be based on this checklist. But Wallace makes it clear that grading the students is only part of the exercise.
The midterm, which features different cases every year, was also designed to be a learning experience, so while the patients were filling out their questionnaire, the students were doing the same thing -- enabling comparison of the two perspectives. Then the students came back into the exam rooms and spent ten minutes talking to the actors (no longer in character). "How did you think it went?" the actors began that interaction. They ended the feedback session by asking what the student would take away from the experience. Wallace said the hope was that the students would go into the next exam room and practice working on the skill they had just identified as needing improvement. "What we know from the research is that you have to practice it immediately or you lose it," she told me. "And it takes about three months of using something before it becomes part of your behavior."