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How do you teach medical students bedside manner? Hire an actor

by Kevin Ferguson | Off-Ramp®

Standardized patient and real cancer patient, Esther Mercado. Kevin Ferguson/KPCC

In the world of academia, is there anything tougher than medical school? Years of math, science, anatomy, pharmacology and dissections committed to memory; tests, labs, residencies… but how do you teach what might be the most sensitive and human part of being a doctor: bedside manner?

And who do you hire to do it?

There’s a lesson plan for that, too. And when I started looking, I found out it started here in Los Angeles.

​When Esther Mercado found out she had cancer, she was 66. She was an accountant and she acted in her spare time.

She'd had trouble sleeping and she didn't know why. She drove herself to the emergency room thinking she acid reflux, but they kept her.

"The doctor came in after performing some tests, and said to me, ‘we see something, and it could either be a cyst, a tumor or some kind of growth.'"

It was a surreal moment for anybody, and even stranger for Mercado. For 17 years, she'd been working as a standardized patient. About six times a year, Esther, the part-time actor, goes to USC’s Keck School of Medicine and pretends to be a cancer patient.

Like the nude model in art class, or the customer at the beauty school salon, Esther is a human learning tool. She stands in front of classes while medical students practice interviewing her. In exam rooms, she goes one-on-one in a mock patient visit, and then she'd grade the students: Was she asked about all the relevant parts of her medical history? Did they listen to her heart? Was the student compassionate?

The program she participates in at USC is one of the first in the country, founded in 1963. She’s one of a couple dozen other actors who are trained to play any number of symptoms: liver disease, terminal cancer, diabetes.

Sound familiar to you? Maybe you graduated medical school recently. Or, you've watched "Seinfeld": 

www.youtube.com/watch?v=JvCVg4MrhUE

Dozens of schools all over the country have standardized patient programs. The U.S. Medical Licensing Examination, a mandatory test for practicing medicine in the US, includes 12 visits with standardized patients. Los Angeles is ably equipped to staff programs like this, with over 70,000 actors — like Bob Rumnock.

Rumnock has been a standardized patient since 1999. It nets him about $15,000 a year. He says the money is good, sure, but it goes beyond that.

"It really isn’t just acting a case and improvising. It’s acting a case, improvising, remembering what went right, remember what went wrong," he says. "Remembering to phrase feedback in a way that will be positive."

Rumnock's patient characters run the gamut — at different times he’s been homeless, he’s been a businessman, he's been a cancer patient who’s run out of options. 

For students, the visits are staged like real doctor visits: the student enters the room, talks briefly with the patients about their medical history and examines them. Is the patient's heart rate normal? Are they coughing?

The visits are short, and before they can be seen by another student, the standardized patients review the visit they just had. These notes will form the basis for the students' grades. 

Emma Montelongo, a fourth year medical student and a veteran of standardized patient exams, says the exams can be a double edged sword — she's had real moments of connection with patients where she's found herself caught in the moment. Working with a standardized patient can become very, very real sometimes, and she finds value in that. 

But how do you grade for something like compassion?

"It’s pretty subjective, how you’re being graded. And you can feel, as a student, like 'I asked all these questions, and I felt as though I was being sympathetic, or as though I was being really thorough,'" she says. "But, on the other hand, how patients assess you in the real world isn't necessarily a fair assessment, either."

In peer-reviewed journals, papers have found programs like these can be effective in certain areas. Esther Mercado, the actor with real-life cancer, insists it makes a difference. She's seen real doctors working the field who examined her as med students at USC.

"I feel I’m doing something for the community at large. These are future doctors," she says. 

Esther's in remission now. When she found out she had cancer, she didn’t let it stop her from being a patient actor. It made her more present and available as a standardized patient, because sometimes she isn't acting.

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