Improv in the hospital room
Actors paid to help medical and nursing students prep for illnesses, injuries and diagnoses
James Hartley and Andy Allen lie in hospital beds in different rooms, each recovering from a motorcycle accident that left them with bruises and a broken leg, temporarily unable to speak and unable to remember what happened.
Mr. Allen wears a puzzled look that flickers between frustration and relief as the nurse tries to answer his questions, check on his injuries and put him at ease. In the other room, Mr. Hartley is doing the same.
Fifteen minutes later, the men are once again alone in their rooms. Another nurse walks in, answers the same questions, checks the same injuries and again, tries to put them at ease.
And another again 15 minutes later.
And again.
Through the course of the day, Mr. Hartley and Mr. Allen will have met with at least 15 different nurses.
The two men are professional actors in a standardized patient simulation at Robert Morris University — an exercise that asks people to portray various medical conditions and situations. “Standardized patients” help train nurses, doctors, physician’s assistants, physical therapists and occupational therapists and, some say, there is room to expand to even more fields.
In the makeshift hospital room at RMU in September, bruises have been carefully painted on with stage makeup and the inability to speak is explained by a fake “trach” (a tube placed in a hole in the patient’s windpipe to create another airway).
Confusion and frustration is created through skilled improv on the part of Mr. Hartley and Mr. Allen.
“We added a lot of layers to this one,” said Janet Barber, the standardized patient manager at RMU. Her job is to cast and train the actors, to prep the scripts and to set up each simulation.
These close-to-real-world experiences supplement students’ work in lectures, with mannequins and during clinical instruction at hospitals. Many school administrators and students say it helps remind them that patients are human, too.
“The first time every student goes up to their first standardized patient, they have no idea what to say,” said Gabi Gundermann, a second-year medical student at Penn State University. “And then by the end of the year, you know how to introduce yourself, talk to the patient, the questions you need to ask, how to do the physical exam without thinking you’re going to hurt them.”
Bringing lessons to life
The practice of using actors to portray medical scenarios has been around since the 1960s.
It gained prominence in the United States in the 2000s,
according to Valerie Fulmer, president of the Association of Standardized Patient Educators and program director at the University of Pittsburgh.
In order to obtain a license to practice medicine in the United States, students now must pass a “hands-on” exam that includes working with standardized patients. In the 2015-16 academic year, the most recent data available from the Association of American Medical Colleges, 133 medical schools required a Standardized Patient or Objective Structure Clinical Examination, which is another tool that tests through direct observation.
Almost 20,000 students graduated from medical school in the 2017-18 academic year, according to the organization. The American Association of Colleges of Nursing represents 543,000 students from 825 schools, based on data from August 2019.
At Pitt, medical students work with standardized patients starting in their first semester — learning to relax and gather information.
They progress to discussing sensitive issues like the right medication and sharing bad news. In their last semester, they meet with 10 standardized patients in a row and must diagnose “what every one of their patients is going through,” Ms. Fulmer said.
Along the way, students learn how to work with someone with post-traumatic stress disorder, how to communicate with someone who does not speak English, how to work with a parent who does not want to vaccinate a child.
At Slippery Rock University, students in the physician’s assistant program learn to conduct a physical exam and gather a patient’s history.
At Duquesne University, nursing students work with people with disabilities, from Parkinson’s disease to spinal cord injuries to developmental disabilities.
At Carlow University, nursing students simulate working with patients battling alcoholism and addiction, elderly people with health problems resulting from years of smoking, and patients at risk of committing suicide.
“They need to learn to talk and be empathetic, it’s just not a given anymore in society,” said Deborah Evers, an assistant nursing professor at Carlow. “Anybody can run a machine ... so I would much rather have a nurse that would hold my hand and show empathy to me than knowing how to run the monitor.”
The cost of a standardized patient program can be hard to quantify. According to Stacey Carmo, who is in charge of the program at Penn State, a small program could cost around $100,000 a year to maintain and a large program with big class sizes could cost $1 million.
Before each scenario, students are briefed lightly on what to expect, just as they would be in a clinical setting. Once in the room, the students — and the actors — do their best not to break character, although the student may call a timeout to ask a question.
Following the simulation, students, actors, instructors and faculty gather to talk through what the student did well, what they could improve on and how the patient felt throughout the procedure.
“They get to see from a human perspective what the patient’s experience was like, and I think that informs their practice for the future,” Ms. Fulmer said.
Improv in the hospital room
From the actor’s perspective, the work can supplement income, working the same acting and improv “muscles” they would use for other gigs.
Most standardized patients are compensated for their time — about $20 per hour according to an estimate on GlassDoor.com — but it’s generally not a full-time job, and the work is not always consistent. Most maintain additional jobs as well.
At the University of Pittsburgh, standardized patients are paid different rates based on the skills required for a simulation. Those willing to participate in a gynecological exam are paid at a different rate, Ms. Fulmer said.
The challenge of the job, many actors said, comes in learning to give feedback and working with students.
“Here you have to split your brain, be in the scene to be believable for the student, but you also have to be watching them behind the eyes of your character so you can give them feedback,” said Mr. Allen, one of the actors in the motorcycle accident simulation at RMU.
Joanna Lowe, who has worked as a standardized patient at Pitt, said the shift in focus from herself as an actor to the student was intimidating. It was easy to focus on how much pain she should be in with appendicitis, she said, but she also had to think about “What is the goal of this encounter? What is the most productive for the student?”
School faculty take the actors through training before each scenario, instructing them on things like how to portray a medical condition.
For example, when acting as a patient recovering from a stroke, raise one eyebrow. Thus, the other side of the face will appear to be drooping, mimicking the facial droop common in stroke patients. Or they are instructed on the pain level or type of reaction they should display. Like, if a doctor delivers bad news about your child, act hysterical.
Schools hire a wide range of people to play the roles. Some are professional actors, others are theater students, others work in related health fields like EMTs or a birthing coach, and some are community members looking to get involved.
Patricia Myers, who has been working as a standardized patient at Penn State College of Medicine for 17 years, got involved after hearing of the opportunity through her work as an usher at the local theater.
So far, she has been a mother receiving news that her son has died on the operating table and a patient with dementia. She has also acted as part of an Amish family for a “cultural competency case,” or situations that require students to think about how cultural differences will affect a patient’s medical care. Ms. Myers said her late husband, who often worked with her, liked to tease the faculty about that one.
When they arrived for the simulation, her husband would ask, “Where should I hook up my horse and buggy?”
Ms. Lowe, an actor by profession, has also portrayed her fair share of medical experiences. She has listened as her young daughter received a grave cancer diagnosis. She has been told the baby she is carrying has passed away. She has had bouts of schizophrenia, struggled with raising a child with ADHD and been a victim of sexual assault.
The job can be taxing, emotionally, mentally and physically, she said.
“Sometimes I need ibuprofen and a glass of wine, but it is always worth it because I got to be the step between the patient and the doctor,” she said. “I got to help them be ready.”