Simulated Cases, Real Skills

In a conference room down the hall from his office, Frederick D. Haeseler, M.D., is talking to three visitors about a patient named Noah Savage.

“Noah was short of breath when he exerted himself, so he stopped taking his daily walks. After his feet began to swell, he was given a prescription for a diuretic called Lasix, and the symptoms got better,” Haeseler says. “But then an echocardiogram revealed that he had severe idiopathic dilated cardiomyopathy, an uncommon, but not rare, heart condition. In this case it’s progressive. Medication can help relieve symptoms, but ultimately Noah would need a heart transplant to survive.”

If Noah, an attractive middle-aged man with a ruddy complexion and bright eyes, appeared remarkably relaxed given the seriousness of his diagnosis, it was for good reason. He doesn’t really have a life-threatening heart condition—he’s a character being portrayed by an actor named Jeff Savage. The three visitors Haeseler was addressing are other actors preparing to begin work at the School of Medicine as standardized patients—actors trained to assume the lives and symptoms of patients in order to help students take medical histories, conduct physical examinations and hone the interpersonal skills necessary to be effective physicians.

Training through simulation—whether by such standardized patients as Savage, by mannequins or by virtual computer technology—has become an increasingly accepted methodology in medical education. Medical schools, including Yale, are devoting significant resources to exposing students to these training opportunities. In addition to Haeseler’s program, Yale now has an array of human-patient simulators, or mannequins, for students to “treat,” as well as a simulation laboratory equipped with computers that allow students to practice everything from suturing techniques to performing a colonoscopy.

Instructors say these simulation tools are useful for both teaching and assessment. Students can practice and make mistakes without harming real patients; these tools can simulate unusual cases students wouldn’t often see in practice; and the tools are ideal for comparative evaluations of clinical skills, because each student faces an identical set of patient challenges.

The use of actors is the oldest of these patient-simulation techniques. Yale’s program, which was launched in 1993 with eight actors, was part of the primary care clerkship. The early response from students was resoundingly positive, says Haeseler, associate clinical professor of medicine and director of the Yale Standardized Patient Program. “Their only complaint was that it wasn’t offered until the fourth year.” Today, students begin working with standardized patients in the second or third week of medical school in the longitudinal communication skills program directed by Auguste H. Fortin VI, M.D., M.P.H., associate professor of medicine, and taught by a multidisciplinary faculty. Haeseler has trained 30 actors and written 75 scripts that represent a range of medical disorders and psychosocial issues. All are designed for the small-group workshops with standardized patients that occur throughout the four-year medical curriculum. In their first year students learn basic interview skills and advance to more challenging interactions in subsequent years.

Savage, who’s been involved for about a year, is a 1961 Yale College alumnus, antiques dealer and professional actor who most recently appeared in Our Town at the Thomaston Opera House in Thomaston, Conn. He has played the same patient about a dozen times, his medical condition growing increasingly dire with each performance. On the day Haeseler described Noah Savage’s illness to the other actors, they were preparing for a workshop on breaking bad news. This scenario required Savage to tackle his most challenging medical school role to date—getting the news that he needs a heart transplant.

“Breaking bad news is one of the most challenging things physicians need to do. It is important for students to learn a structured, patient-centered approach that they can practice without causing discomfort for themselves or their patients,” says Haeseler.

The rehearsal began with Haeseler role-playing a student. Following the model for breaking bad news that Fortin introduces to students just before their sessions with the actors, Haeseler asked Noah some general questions about how he was feeling and what he knew about his illness.

Speaking in a slow soothing voice, he gently told Noah that his heart muscle had weakened and that he would likely need a heart transplant to survive. The news hardly seemed to register. “I’ve heard of those,” Noah said quietly, “but I never thought it would be something I’d ever need.” He appeared dazed, as though he needed to go home, talk with his family and think things through before expressing his feelings. Afterward, Haeseler said Savage’s reaction would provide students with an opportunity to listen, respond empathically to emotion and offer continuing support.

The use of standardized patients, also known as simulated patients, programmed patients, surrogate patients, professional patients and patient instructors, has proven to be such an effective tool for teaching and assessing medical students that the United States Medical Licensing Examination (USMLE) has added a clinical-skills assessment that includes standardized patients. The technique has become so widely accepted that now almost every medical school in the country uses it.

This acceptance could hardly have been predicted, given the early reaction to bringing actors into the classroom. In the early 1960s, when the technique was introduced by Howard S. Barrows, M.D., it was dismissed as maligning the dignity of medical education and being too “Hollywood.” Barrows, a neurologist at Montefiore Hospital in the Bronx, N.Y., stumbled onto the technique inadvertently. He used to enlist patients on his floor to be examined by students. One day a patient told him that a student had been so unpleasant to him that in order to get back at the offending student, the patient began inventing symptoms. The incident led to an epiphany for Barrows: why not recruit healthy people to act as patients? Real patients wouldn’t be inconvenienced by gruff or incompetent students; students could be exposed to uncommon clinical events; and it would be an ideal assessment tool, because every student would get the same case.

Barrows’ timing was fortuitous. At around the same time, medical schools were looking for more precise and less arbitrary ways to evaluate students during their clerkships. Until then students generally received satisfactory or better evaluations, because faculty members almost never directly observed them interacting with patients.

The first standardized patient was developed by Barrows when he was at the University of Southern California. An artist’s model played a patient named Patty Dugger, a paraplegic woman with multiple sclerosis. After creating the case, Barrows needed to figure out a way to assess students’ interactions with her. Rather than using a one-way mirror or peeking through a curtain, he decided to give the actress a checklist to fill out after each encounter.

Haeseler trains the actors to respond to students’ open-ended questions, reflections, summaries and empathic statements that they learn from Fortin’s introductory demonstrations. “Facilitative behaviors such as these build trust that in turn helps patients to express themselves and tell a more complete story of illness that includes biological, personal and emotional dimensions,” Haeseler says.

Characters are developed using many sources, including literature, the actors’ own life experiences and real cases. During a standardized-patient encounter, a student is observed by one faculty member and two other students. What enhances the educational value, Haeseler says, is that students may call a time-out at any time during the session and freeze the action. This option gives the student a chance to get feedback and advice, or to get some expert information that might be helpful.

“Everyone has a memory of a doctor who didn’t seem to care or who didn’t explain things well,” says Savage, adding that through his work as a standardized patient, he feels he’s “helping future doctors acquire skills that are extraordinarily important.”

A mannequin with human ailments

Elsewhere on campus, simulated patients of a different sort are being used to help students master other important skills. Last June, Leigh V. Evans, M.D., HS ’02, director of health care simulation for the Section of Emergency Medicine in the Department of Surgery, launched a program using high-fidelity human patient simulators for third-year medical students during their surgery rotations. The lifelike polymer figures are computerized and programmable, so they can simulate just about any condition that occurs in the human body.

The simulators can talk and breathe, their vital signs can change and they can even “die,” although Evans, an assistant professor in the Section of Emergency Medicine, says she’s never made a simulator do that because she worries it would be too traumatic for the students. The major advantage a simulator has over actors is that you can create a medical emergency or practice such procedures as intubation that you wouldn’t perform on a real person.

During a recent session, a white male mannequin lay on an examining table surrounded by six students. Evans, who watched through a one-way mirror, used a microphone and a computer to alter the patient’s vital signs and talk to the students, either as the patient or as an expert consultant. This type of simulation has advanced significantly, thanks to the work of anesthesiologist David M. Gaba, M.D. ’80, at Stanford University. A researcher committed to refining simulator-based teaching techniques, he and his colleagues have developed a program that creates lifelike situations in clinical settings. Gaba’s program has been adopted at Yale, Harvard, Penn State, the University of California, San Francisco, and abroad. [See “A Safer OR,” Yale Medicine, Summer 2003.]

The “patient” in Evans’ class was a 47-year-old man with severe abdominal pain and bloating. The students’ job was to figure out what was wrong with him and prescribe a course of treatment. As they began asking him questions, he complained of feeling nauseated; then he vomited. When he told the students that he still felt “horrible,” they decided to insert a nasogastric tube.

The students then ordered X-rays, which showed that the patient had a large bowel obstruction. When Evans, assuming the role of a consultant, asked what the rectal exam had revealed, the students realized they’d forgotten to perform one. A CT scan finally revealed the problem: sigmoid volvulus—a twist in the colon that caused everything moving through it to back up. Although this condition can sometimes be treated with a rectal decompression, the patient had already had two similar episodes, so surgery was recommended this time.

Simulators can cost between $40,000 and $200,000, says Evans, depending on the sophistication of the software. The current curriculum, which requires third-year students to participate in 24 scenarios over a 12-week block, began this academic year.

“We’re not dependent on what comes through the door, and students can treat much sicker ‘patients,’” says Evans. The simulators are ideal for clinical decision making and developing teamwork skills, she says, but are less effective for teaching physical diagnostic skills, because regardless of the sophistication of their computer programs, they’re still just plastic dolls.

Evans’ students work in groups of six, with a faculty member overseeing the session. During the exercise, participants can call a consultant, talk to a surgeon, order X-rays or request any service that would be available during an emergency. The simulations are videotaped so that participants can review their performances afterward. The Department of Pediatrics now has an infant mannequin, and the Yale New Haven Center for Emergency Preparedness and Disaster Response is also using mannequins to teach students. The next step, says Evans, is to set up a simulation center with a simulated operating room, an intensive care unit, a trauma bed and other hospital settings.

“It’s helpful to be able to see serious cases, unstable cases, and think through everything on your own,” says Kathryn Hogan, M.D., a third-year resident in emergency medicine who led the group that treated the patient with sigmoid volvulus. She says that during the first few scenarios in which she participated, she and the group forgot to ask key questions as they tried to diagnose the patients. But she says they’ve gotten better. “When you learn by doing, you learn fast because it feels like you’re treating a real patient. It’s very dynamic.”

“See one, do one, teach one”—virtually

Another variation on the simulated-patient model—the computer simulator—is now in wide use at the surgical simulation laboratory run by Andrew Duffy, M.D., assistant professor of surgery, director of the surgical simulation center and assistant program director of the surgical residency.

Launched last March, the surgical simulation center resembles a video arcade without all the flashing lights and electronic noises. Several box trainers designed to help students with such skills as performing endoscopic procedures, manipulating remote instruments, developing spatial relationships, hand-eye coordination and suturing are located in a suite of rooms near Yale-New Haven Hospital, so that residents can stop in and practice in between their duties at the hospital.

One trainer replicates the inside of an abdomen. Another is a full colonoscopy procedure simulator. “You can watch yourself zipping around the colon on the video screen. The machine even groans if you’ve hurt the patient,” Duffy says.

The surgical simulation laboratory grew out of the need to teach students and residents more skills in less time. “With an 80-hour limit imposed on surgical residents’ training, and so many new laparoscopic procedures, residents have to learn twice as much in 20 percent less time,” Duffy says.

About 100 surgical, orthopaedic and ob/gyn students and residents use the lab on a regular basis. The machines, which came into use in medical schools about five years ago, are now so popular that some of the hand pieces have worn out. “These machines are essential tools,” Duffy says. He says the next generation of simulators, which are now in development, will include gall bladder and hernia models.

Duffy contrasts this type of training with his own, when the mantra was “see one, do one, teach one” and the main way in which residents honed their skills was by observing experienced doctors at work. “I vividly remember how bad I was and how quickly the surgeon took over,” he says. “We want students to learn and practice on our machines, so that when the time comes to treat real patients, they’ll already be proficient.” In fact, all residents are now required to complete this training before they assist in laparoscopic and endoscopic procedures on patients.

For laparoscopic surgeons, simulators help them learn how to manipulate instruments in a three-dimensional space while looking at a two-dimensional screen. “Dissection combined with computers helps surgeons look at two dimensions, but ‘see’ in three,” says Lawrence J. Rizzolo, Ph.D., associate professor of surgery and of ophthalmology and visual science, and director of medical studies in the anatomy section in the Department of Surgery.

Computer software and patient narratives also help build a clinical correlation between patients and the study of anatomy by transforming the cadaver into a simulated patient. All course activities become centered on clinical problems and procedures. “The software allows us to see internal organs and rotate the images,” Rizzolo says. “In our dissection lab, there’s a computer at every table. The idea is to make it so the software can’t be used without the cadaver and the cadaver can’t be used without a computer,” says Rizzolo.

Assessing clinical skills

Although it’s accepted that clinical skills are central to the practice of medicine, prior to the introduction of standardized patients into the USMLE there was no national approach for objectively evaluating students’ competency in clinical skills. “It was always pointed to as a gap in the medical licensing program,” says Gerard F. Dillon, Ph.D., associate vice president for the USMLE at the National Board of Medical Examiners. That gap was filled in 2004 when standardized patients were introduced as part of the USMLE system. “To introduce it into the examination program was an enormous step forward,” he added.

With this new assessment tool, examiners have been better able to identify students who are deficient in clinical skills. These students, who previously might have flown beneath the radar, now get feedback, and their schools are notified so that they can get help to remedy the deficiency. The other benefit, Dillon says, is that since the USMLE has begun assessing clinical skills, medical schools have put more emphasis on teaching these skills and ensuring that students have mastered them.

As the USMLE assessment program develops, the hope is that it will expand beyond standardized patients to include such other technologies as patient simulators. “With live actors, you can’t assess all of the skills that you would like,” Dillon says. “Our plan is to introduce some other technologies that will allow an even broader assessment, but first we have to make sure that such technologies are reliable and that their presentations are consistent.”

Money is another consideration. At a cost of $1,000 per assessment, which students pay, Dillon says the USMLE program has a responsibility to consider the expense of any additional assessment tools.

Still, despite the considerable investment and inevitable growing pains that come with the introduction of a new program, it’s clear that standardized patients, mannequins and increasingly sophisticated computer trainers are going to become a key methodology in medical education.

“I like it very much. It’s a great addition to the preclinical education. It gives students the chance to develop the skill of eliciting medical histories and physical findings,” says Peter N. Herbert, M.D. ’67, HS ’69, chief of staff and senior vice president for medical affairs at Yale-New Haven Hospital. Herbert says that unlike real patients, actors are able to objectively assess the student’s technique and offer feedback, which he says is “extraordinarily useful.”

For example, if a student makes the common mistake of lapsing into med-speak ( “Is your child febrile?” rather than “Does your child have a fever?”), a standardized patient will quickly point that out.

“I can only say that I wish there had been standardized patients when I was a medical student,” Herbert says. “It would have saved me and my early patients a lot of embarrassment.” YM