I asked MacAulay whether any physical condition would preclude someone from becoming a standardized patient. "We have a lot of exercises where there's no physical exam, so we can hire anyone for the roles," he replied. "We can hire people like diabetics and hypertensives if they're under control." Scars or lumps might pose a problem for cases in which an examination will be required. "We don't want any scars that are going to confuse the student as to our intent. Say, for example, I had had open-heart surgery, and I was playing a case where I was having chest pains for the first time in my life. When the student took my gown down and saw the scar, they would say, 'Well, no wonder you're having chest pains. You have a history of cardiac disease.' " But nothing would prevent the person with the chest scar from playing a knee-pain patient.
A strong sense of physical modesty can be a bigger problem, MacAulay indicated. Although the students never do breast, pelvic, or genital exams, the standardized patients often wear nothing but underwear and a hospital gown. If a woman's complaint is chest pain, "It would be appropriate [for the medical student] to lower the gown," so the patient will be sitting there in her bra. "And bear in mind that we're also videotaping these sessions, and we're sitting in the monitor room watching." MacAulay says that's not an issue for most professional actors, accustomed as they are to sharing dressing rooms. "But for the nonactors, it can be a little unusual." Anyone who appears too uncomfortable with either the exposure or physical contact would not qualify.
If preexisting physical conditions don't preclude anyone from becoming a standardized patient, the lack of certain physical symptoms also usually isn't a problem, the trainer says. "There are a lot of tricks of the trade. For example, we can rig blood-pressure machines to give an elevated reading," he says. Makeup can be used to simulate cuts, bruises, and scars, and patients who need to be sweating can spray themselves in the face with a bottle before the student comes in. "Or we give them hot cloths that they hold in their hands, so that they seem sweaty." MacAulay says, "A lot of the stuff that we can reproduce is like a magic trick." A collapsed lung can be faked by having the actor hold his or her breath while moving the shoulders as if breathing hard. "The students are so focused on listening that they don't realize the patient isn't breathing," he says. "We had a student actually leave the room once and say, 'We've got to get this person to the ER!' "
In addition to the classic categories of stage acting, film acting, and TV acting, "This is like a fourth category," the trainer says. "It's two people in a room, but they're not playing a scene." The actors are answering unscripted questions, and at the same time they're trying to keep track of questions the doctor-to-be should have asked but didn't. They're scrutinizing the physical maneuvers. "So they have all these numbers and stuff in their heads, plus they have to make a mental note of specific things the student said and did that made them feel a certain way. It's a mental marathon!"
To understand it better, I asked MacAulay if I might audition for him. He agreed, giving me a two-page description of a woman who was experiencing severe head pain, along with some unusual visual phenomena. I could take ten minutes to study the woman's history, he told me, and as I did, I felt pretty confident I could pull off the impersonation. MacAulay then led me to one of the examining rooms, as believable a set as anything concocted by Hollywood. (The facility was once occupied by a group of internists.) He gave me a quick rundown on what I should watch for in the physical exam: He could choose to check the reflexes in either my wrists or my elbows and in either my knees or my ankles. But he had to check both the arms and the legs. He should test the strength in both arms and both legs, too. There was more.
Before leaving the room, he instructed me that I should be sitting on the examining table. "Bear in mind this is not an acting scene. So you have no agenda," he said. He recalled how he had entered the room one time to find the auditioner striking a dramatic pose and declaring, "Doctor! I have this headache!" Another time, the person trying out had picked up one of the medical instruments in the room and was playing with it to show her nervousness. "No, no, no!" MacAulay exclaimed at the memory. "When you go to your doctor's, you're sitting on the exam table."
A jolt of adrenaline surged through me a moment later when MacAulay, wearing a stethoscope, reentered the exam room, introduced himself, and started asking questions. If I'd forgotten that he once had made his living as a professional actor, his demeanor provided a swift reminder. It was still friendly, but he seemed subtly more formal and commanding -- the embodiment of a medical professional. For a while, I had no trouble answering his questions, but then he fired, "What do you do for a living?" at me, and the words "I'm a nurse" came tumbling out of my mouth, unplanned and unbidden. As I said them, my answer struck me as ridiculous. (What kind of nurse would be worrying about a brain tumor when she was having a routine migraine?)
"Oh," the faux doctor said. "Is that a stressful occupation?"
"Um, no," I stumbled, adding with no forethought, "I work in a rest home." The voice inside my head bellowed, "You MORON!" and for a fraction of a second, I teetered on the brink of laughter. I kept a straight face, but I felt flustered enough that when MacAulay a few minutes later took a 30-second time-out from our scene to ask if I could crank up the level of discomfort I was portraying ("Let's do more of a ten-out-of-ten for pain"), I told him I would, then promptly ignored the directive. During the physical exam, I struggled to keep track of all his brisk actions, but when I filled out the 18-question checklist, I marked down that he'd examined my retinas incorrectly, when in fact he hadn't even attempted to examine them. It wasn't my only error.