Standardized Patients, Actors, Acting in Medical School Teaching and Empathy

As a follow-up on the issue of teaching medical students empathy through method-acting, I would like to point out that acting out clinical encounters is going on all the time in medical school teaching. If you don’t already know of the role of “standardized patients” as used for this teaching, read on.

For a number of years, more and more medical schools have incorporated professional actors in their teaching programs related to the first and second year students learning how to take a history and how to perform a physical examination. These actors are trained to provide the students with a simulation of a real patient, a clinical case, but with teaching advantages included. Those advantages include interviewing and examining in a non-threatening environment, with the support of a group of fellow students and the instructor-facilitator. This is in contrast to the experience “on the hospital wards” where the students are often alone with a patient and have to struggle with their own uncertainties and inexperience with no immediate assistance.

With the standardized patient, the student who is doing the interviewing can, when their own ability to know what to say or what to do next fails, can call a “time out”. The interview may abruptly stop, with the standardized patient ignoring what follows and the student can then communicate with his or her colleagues and the facilitator for help. When “time in” is called the interview proceeds as though there was no break. Another advantage for the students is the feedback that the standardized patient actor, who is again trained for this function, can deliver to the students. The actor can express how he or she, in the role they played, reacted to the questions and behavior of the student and provide valuable constructive criticism or encouragement to the student. This kind of feedback is not uniformly available from the real patients the student examines. Standardized patients can also provide a more comfortable environment for the student to practice physical examination. Though often pathologic findings may be absent, nevertheless on occasion a standardized patient with an abnormal physical finding may be discovered this becomes a valuable asset.

My experience with teaching first and second year medical students, even when they are role-playing the doctor and patient, is that we never encourage their “acting” out a certain behavior toward the patient except to keep in mind the requirement to be professional in their relationship with their patient with the goal of caring, being empathetic, therapeutic and beneficent.

Teaching “light empathy” as described in the literature, is essentially acting to maintain an emotional posture which is acceptable by the patient even though the student is upset with the patient or has moral differences of opinion but with no real understanding of the patient’s motivations and no intent to change the student’s own attitude or emotions, This may be effective and financially rewarding if the student was going into a non-medical care business but I think is unacceptable in medicine.

If anything, “deep empathy” is worthy of teaching where there is no acting in a theatrical sense. With “deep empathy”, the student is encouraged to pay attention to and try to understand what the patient is going through and try to understand his or her own emotions based on a previous similar personal experience. For example, for a patient complaining of pain, the student might remember some injury long ago which caused pain but the student didn’t know the severity of the injury or how long it would last or whether there would be residuals. Would there be some similarity of how the student felt with that the patient is feeling currently? With this contemplation, the student may be able change his or her own feelings about the patient and the patient’s perhaps disturbing reaction to pain.

So this is what I can tell you about “acting” as a part of the teaching clinical medicine in medical school. I hope it has given those visitors who have not been involved in such teaching an idea of what is going on these days. ..Maurice.