Pa­tient Sim­u­la­tion

The Monthly (Australia) - - CONTENTS - by Paul Con­nolly

Of all the places Tim Rat­cliffe has pre­tended to be un­well – and over the years he’s feigned can­cer, bleed­ing from the bowel, angina, high blood pres­sure, faint­ing fits, kid­ney prob­lems, and limb and joint com­plaints – Sun­bury Day Hos­pi­tal in Mel­bourne’s north-west is one of his favourites. “Friendly staff and nice con­sult­ing rooms,” he ex­plains. It was there, late last year, that Rat­cliffe played the part of a mid­dle-aged man (“What was his name – Doug?”) who had been ex­pe­ri­enc­ing dizzi­ness and at one point fainted. “He put it down to a re­cent change in med­i­ca­tion, a sit­u­a­tion that wor­ried him,” Rat­cliffe says. His char­ac­ter con­veyed as much to the third-year med­i­cal stu­dents who, one by one, came in to con­duct a con­sul­ta­tion. Also in the room was a univer­sity ex­am­iner.

Sim pa­tients are em­ployed to as­sist med­i­cal stu­dents to prac­tise more in­va­sive pro­ce­dures, such as breast checks, pap smears and rec­tal examinations.

“If they dove straight into in­for­ma­tion-gath­er­ing or I got the sense they were obliv­i­ous to or dis­mis­sive of my con­cerns, I’d use the dis­cre­tion I’d been given to ramp things up,” says Rat­cliffe, a hint of amuse­ment in his voice. “I’d say some­thing like, ‘I pick up my grand­child from school and I don’t want to do that one day and faint and crash the car and kill him!’ When that hap­pened, I could see the stu­dent think, Fu­u­u­u­u­u­uck, as it’s rammed home that they are not just deal­ing with a col­lec­tion of symp­toms but a per­son, and one whose ill­ness can have mas­sive reper­cus­sions.” Rat­cliffe, a per­former and theatre pro­ducer, has en­joyed side­line work as a sim­u­lated pa­tient ever since his first gig as a sore knee for Univer­sity of Mel­bourne phys­io­ther­apy stu­dents some 15 years ago. The work of a “sim” pa­tient – a per­son trained to present the symp­toms of an ac­tual pa­tient – is as re­ward­ing as it is chal­leng­ing, he says. For in­stance, in ob­jec­tive struc­tured clin­i­cal examinations (OSCEs), which test, among other things, his­tory-gath­er­ing and ex­am­i­na­tion skills, Rat­cliffe can be re­quired to “de­liver the same in­for­ma­tion in the same way” to as many as 30 stu­dents in a sin­gle day. At other times, such as with OSCEs (pro­nounced “os­kies”) de­signed to test a stu­dent’s abil­ity to deal with emo­tion, he’s al­lowed more flex­i­bil­ity in his re­sponses, and more scope for ex­pres­sion. That said, a sim pa­tient must re­sist any urge to chan­nel their in­ner Ham­let or to scream “Stel­laaa!” if a sore point, whether phys­i­cal or emo­tional, is be­ing poked. “It’s not meant to be a per­for­mance,” says Rat­cliffe. Sim pa­tients are com­monly used for the teach­ing and eval­u­at­ing of stu­dents in the health sciences, such as medicine, nurs­ing, phys­io­ther­apy, oc­cu­pa­tional ther­apy and psy­chol­ogy, and the work varies. For OSCEs, which are com­monly set up as a num­ber of 10-minute “sta­tions”, they may play the role of a pa­tient who is com­plain­ing of a vague phys­i­cal ail­ment, with the vague­ness a prob­lem for the stu­dent to re­solve. Call­ing upon a script that pro­vides an­swers to likely ques­tions, the sim pa­tient must en­gage with the stu­dent with­out vol­un­teer­ing in­for­ma­tion or lead­ing them in any way, ex­plains Dr An­drea Bergman, the sim­u­lated-pa­tient trainer at Monash Univer­sity’s fac­ulty of medicine, nurs­ing and health sciences. “The in­tent is that every stu­dent re­ceives the same par­cel of in­for­ma­tion, and it’s how they process and pros­e­cute that that helps you as­sess their clin­i­cal skills.” At the other end of the scale, sim pa­tients are em­ployed to as­sist med­i­cal stu­dents to prac­tise more in­va­sive pro­ce­dures, such as breast checks, pap smears and rec­tal examinations. Linda [who asked that her sur­name be with­held] is a teach­ing as­so­ciate with the Univer­sity of Queens­land’s 22-year-old sim­u­lated pa­tient pro­gram, but has for many years also per­formed such sim pa­tient work at UQ. Stu­dents, she says, usu­ally find hav­ing to prac­tise in­ti­mate pro­ce­dures on sim pa­tients ini­tially con­fronting. Many wouldn’t have seen a naked per­son be­fore, she adds, and they are ter­ri­fied of hurt­ing the pa­tient. “That’s a com­mon be­lief peo­ple have, that [pap smears and rec­tal examinations] are aw­fully painful. But done cor­rectly they are not.” As a re­sult, Linda says that of­fer­ing up her body – for $52 an hour – in the hope of im­prov­ing the skills of to­mor­row’s med­i­cal pro­fes­sion­als, and thus the ex­pe­ri­ences of their fu­ture pa­tients, is not a big deal. “It’s not din­ner at the Ritz,” she quips, “but I don’t dread it.” Be­fore work­ing with trained ac­tors, nurs­ing stu­dents at the Univer­sity of Syd­ney use each other as mock pa­tients in ther­a­peu­tic com­mu­ni­ca­tion skills train­ing, but trainer Dr Jo River finds many don’t take this se­ri­ously enough. “It isn’t just be­cause they are en­gag­ing with fel­low stu­dents but they see com­mu­ni­ca­tion skills as ‘soft skills’, as com­pared to putting in an IV drip. The other prob­lem is that ev­ery­one thinks they com­mu­ni­cate well. That’s not nec­es­sar­ily the case in a pro­fes­sional set­ting.” Ac­tors, says River, help ad­dress this prob­lem, as do the con­fronting char­ac­ters and sce­nar­ios she and the ac­tors co-cre­ate. Such char­ac­ters could in­clude a dis­tressed fam­ily mem­ber of a child who is in surgery with a se­ri­ous head in­jury, or an el­derly per­son who is in an aged-care fa­cil­ity against her will. “I’m in awe of my sim pa­tients,” River says. In 2015, River re­jigged the fac­ulty’s pro­gram by hav­ing stu­dents team up to in­ter­view sim pa­tients. This made stu­dents ac­count­able to their peers in what be­came an as­sess­ment task. It also al­lowed strug­gling stu­dents to use a “time out” card to gather them­selves and work­shop the is­sue with their team­mates. River also worked to en­sure the pro­gram em­pha­sised hu­man­is­tic, “per­son-cen­tred” com­mu­ni­ca­tion, en­cour­ag­ing stu­dents to en­gage with pa­tients and get a sense of their lived ex­pe­ri­ence be­fore rush­ing in to fix things. “Even in hur­ried en­vi­ron­ments like hos­pi­tals this can be done and I’d ar­gue it ac­tu­ally saves time in the end,” River says. She be­lieves the ben­e­fits ex­tend even fur­ther. “Nurses who com­mu­ni­cate bet­ter tend to be hap­pier and more ful­filled in their jobs than those who are merely task fo­cused.” Colleen Cook, who works along­side River at the Univer­sity of Syd­ney, says be­ing a sim pa­tient is “one of the most ex­hil­a­rat­ing things I’ve done as an ac­tor”. Stu­dents, she says, en­ter a train­ing sce­nario know­ing it’s a drill, but they soon for­get as they are drawn into a com­plex ex­change with a sim pa­tient whose con­vinc­ing dis­plays of emo­tion and sto­ry­telling break down their

bravado and as­sump­tions. “This wouldn’t work un­less I can stay in the truth of the char­ac­ter,” says Cook, who has a long per­for­mance his­tory in mu­si­cal theatre, stage and tele­vi­sion, in­clud­ing parts on Rake, Love My Way and Wa­ter Rats. “The ones who come in with set ques­tions can get con­fronted very quickly,” she says, adding that the in­ten­sity of the train­ing is mu­tu­ally ex­haust­ing. “Bring­ing things to an emo­tional head, I can end up ner­vous, taken aback, bawl­ing. I come out of these ses­sions like a worn-out dishrag.”

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