Sara Press //
On Saturday, May 5th, 2018, I went in to the BC Children’s Hospital to see a doctor about a lump in my neck. It might seem strange that a twenty-seven-year-old was going to a Children’s Hospital. Perhaps even stranger that I was seen by fifteen medical residents that day, and had to tell them all the same story in the same examination room in a set amount of time. That day, I was a nineteen-year-old named Erin, with increasingly worrisome symptoms pointing to lymphoma. Tomorrow I could be a thirty-three-year-old named Hannah, concerned with the welfare of my infant child. I should explain: I was there as a standardized patient.
Standardized Patient Programs enlist actors to perform patienthood and roleplay the symptoms of various diseases and disorders. This simulation is used to help improve the communicative practices and knowledge-based skills of future healthcare workers, such as physicians, physiotherapists, pharmacists, and nurses. My focus is on the use of these programs for medical students and doctors. What can be learned from these fictionalized patient narratives? And how might these changes impact real patients’ encounters with future medical doctors?
Leslie Jamison also explores aspects of these questions in her beautifully crafted collection of essays, The Empathy Exams. Having worked as a standardized patient herself, Jamison weighs in on the affective components of the Standardized Patient exam. To be a good patient actor, she suggests, one must inhabit a world of feeling in which fiction can no longer be discerned from reality. Jamison explains,
Medical acting works like this: You get a script and a paper gown. You get $13.50 an hour. Our scripts are ten to twelve pages long. They outline what’s wrong with us—not just what hurts but how to express it…The scripts dig deep into our fictive lives: the ages of our children and the diseases of our parents, the names of our husbands’ real estate and graphic design firms, the amount of weight we’ve lost in the past year, the amount of alcohol we drink in a week (1).
The simulated exams take place according to strict, time-sensitive rotations. Rooms are furnished with examination tables, and depending on where these exams take place, they may also be fitted with surveillance cameras. In the U.S., standardized patient actors are trained to complete a checklist at the end of each simulation to evaluate various aspects of medical students’ competencies. Jamison recalls various questions she had to answer during her evaluations, and foregrounds one aspect of the medical interview in particular.
“Checklist item 31,” she notes, “the most important category: ‘Voiced empathy for my situation/problem’” (3). Jamison goes on to detail how she was trained to grade empathy, and reflects upon the variability of her encounters with student doctors.
In my own experience as a standardized patient in Canada, I remember one particular medical resident who invested so deeply in my condition that we brought each other to real heights of emotional concern. My nineteen-year-old character had recently lost a significant amount of weight, and in addition to loss of appetite and frequent night sweats, I (the fictional patient) had just found a lump in my neck.
“This must be really hard for you,” the student doctor said, laying her hand on my arm. I had just revealed to her my revelation of illness. “You must be feeling really anxious.”
“I am,” I said, feeling my voice quaver. I knew we were both acting, but I felt my anxiety mounting as I imagined what it would be like to have all these symptoms.
“We’ll figure this out,” she told me. I already knew what “this” was, though.
After having experienced this student doctor and her genuine concern, I was disappointed when later in the day another resident swung me around on the examination table and lifted my gown (without asking) to aggressively palpate my coffee-bloated stomach in search of my liver.
While Jamison aptly demonstrates the importance of medical practitioners learning to empathize with their patients, she does not reflect on her position as a white woman, or the fact that medical students might interact with patient actors differently based on how they look. Regardless of the script, each standardized patient inhabits a body that has already been marked with the signifiers of age, gender, and ethnicity. How might my body as a white woman tell a different story than another actor’s, even as we share the same medical script?
A recent study of patients with chest pain found that “women were less likely than men to be admitted to hospital” because they are generally “treated less aggressively” in health care encounters until they “prove they are as sick as male patients” (Hoffman and Tarzian 17). Take this gendered example and layer it with all the other personal signifiers that might complicate a patient’s profile. For example, Adil Haider and associates have found that “physicians prescribe fewer analgesics for Blacks and Hispanics in the emergency department despite similar estimates of pain” (949). Such studies demonstrate how internalized biases can have profoundly dangerous consequences when they infiltrate health care. But how can medical educators and practitioners combat these biases?
Jonathan Metzl and Dorothy Roberts suggest medical schools contextualize health disparities, rather than just diagnose them. While standardizing practices like cultural competency increase medical awareness of gendered and racialized health disparities, they do not teach medical practitioners about institutional racism, which is embedded in the social structures of our institutions. As Metzl and Roberts explain, by addressing these overarching structures of oppression, we can “in turn, shape doctors’ diagnostic knowledge, influencing what happens in the clinic in profound ways” (675). For an initiative like the Standardized Patient Program truly to succeed, medical schools need complementary courses in history and the social sciences to instill in students the uniqueness of each individual patient. Patients need empathy, but they also need equal opportunities to be seen and heard.
Haider, Adil H., et al. “Association of Unconscious Race and Social Class Bias with Vignette-Based Clinical Assessments by Medical Students.” Journal of American Medical Association 306.9 (2011): 942-951.
Hoffman, Dianne E., and Anita J. Tarzian. “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain.” The Journal of Law, Medicine & Ethics 29.1 (2011): 13-27.
Jamison, Leslie. The Empathy Exams. Minneapolis: Gray Wolf Press, 2014. Print.
Metzl, Jonathan, and Dorothy E. Roberts. “Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge.” American Medical Association Journal of Ethics 16.9 (2014): 674-690.