Later, there would be more debriefing. In a group with their professors, the students would review all four of the cases. They would compare what they'd learned about the patients and how they came to their conclusions. They'd brainstorm about ways they could have fine-tuned the interactions. After that they would study videotapes of their performance.
Although the med students may be the stars, the actors were getting closer attention from Rob MacAulay during the recent encounter. One of two UCSD staffers who hire and train the standardized patients, MacAulay explained that part of his job is to watch the exam scenes while filling out the same checklist the actor/patient he's observing must complete. This helps to ensure that the actor/patient is grading the students fairly, he explained. And also, "With a lot of actors, if you leave them unchecked, they get comfortable, and sometimes their performance drifts."
MacAulay reminded me of a young and handsome Grandpa Who in the Old Globe Theatre's annual production of How the Grinch Stole Christmas. That's probably because he filled that role for six years, between 1998 and 2003. He'd moved to San Diego from Toronto to take the part, and he later performed in the Globe's production of The Full Monty, as well as various roles with the North Coast Repertory and Sledgehammer theaters. He also earned money working for UCSD medical school as a standardized patient (something he'd done in Canada). But he eventually decided being a professional actor in San Diego was "not an option," he told me. Whereas much of his income in Canada had come from appearing in national commercials, most commercial work in San Diego is low paid and local, he learned. "So I was faced with the reality that as much as I loved acting, as much as there's amazing, great theater to be done in this city, it doesn't pay on the scale of the Globe, which is what you need to make a living here."
MacAulay thought about returning to the work he'd done before becoming a professional actor. "I was a medical underwriter in the life-insurance industry." Underwriters interpret the information people supply when they apply for insurance, determining what premium they should pay. "Your job all day long is to look over doctor's reports," MacAulay says. He found there were no underwriting jobs available in Southern California ("because it's only at the head offices that that's done"), but one day he heard that UCSD's standardized-patient program was looking for a trainer. "I thought to myself, 'If this job doesn't have my name on it, no job does.' It was the perfect combination of medical and acting work."
He started in his current position in 2004, and in 2005, "We offered around 130 contracts," he told me. "We actually hire more actors than most of the theaters. Some of those contracts are just for one day. Others are for three months. But we offer a lot of work." The standardized patients' pay -- between $15 and $25 an hour -- is also more than what most actors in non-equity theaters make, according to the trainer.
MacAulay says the department recruits the performers by advertising with the Actors Alliance, the local "association of actors that everyone goes to if they want to know what auditions are going on. We have a really great relationship with them." Word of mouth brings others in to audition, he says, adding, "We don't just hire actors. Actors tend to come with some preparation. You know that when they're in that room, they're not going to have a lot of anxiety. But we have a lot of nonactors who do well too." Certain professions excel at the work, MacAulay says. Social workers, teachers, policemen, and firemen all stand out as prospects. "Teachers know how to communicate," he says. Cops recall details.
Still, he says the work is so demanding it's a constant challenge to find the right people. To audition them, MacAulay gives each applicant a two-page case to review, along with a checklist that's an abbreviated version of the one used to grade the medical students. "I do a sort of mock interview with them," he says. "And then they fill out the checklist at the end." The trainer says that's usually enough to allow him to judge whether the applicant can look believable, along with meeting several other requirements. Standardized patients are not supposed to volunteer too much information, something that's difficult for a lot of people, he says. "Human nature is to help," MacAulay observes. "So someone might say, 'Well, I have this pain, and it's been going on for two days.' But that's too much. Better to let the student ask how long it's been going on. We want to test whether the students know which questions to ask."
At the same time, the standardized patients must be able to think on their feet. They get about 12 hours of training, but the med students invariably ask questions that weren't included in the preparation. MacAulay mentions one character who supposedly was from Seattle. A med student who hailed from that city perked up and asked which neighborhood the standardized patient was from. "I live by the university," she replied, a great answer, according to MacAulay. "She didn't have a clue where that was." But it satisfied the student and maintained the illusion that the patient was real. In contrast, he recalls one woman who had a mosquito bite on her arm that she scratched several times during her audition. "As a good student, I said, 'I notice you keep rubbing your arm. Is there anything wrong?' And she said, 'Oh, it's just kind of tingly.' Well, if I were a real student, I'd be thinking stroke or cardiovascular disease or diabetes -- you know, numbness and tingling." The most innocuous thing can set off alarms. "She should have just said, 'I have a mosquito bite.' "
Sometimes the student doctors' questions are ambiguous. MacAulay trains the actors in how to respond then. A student might ask, for example, "When you went to the washroom this morning, what color was the toilet water?" That would count, according to MacAulay, as an attempt to learn if the patient had seen blood in his or her urine. "Even though they didn't say, 'Was there blood in your urine?' you know the intent was to find out if the color was different."