It’s Friday, and I’m splayed out on an examining table at Bellevue Hospital, an oxygen tube in my nose, an IV line taped to my arm, having a heart attack every twenty minutes. A parade of young resident physicians enters the room one at a time. Each confers briefly with the nurse at my side and begins giving instructions. If they give the right ones, I remain coherent. If they mess up, I pass out.
No worries: My heart is fine. I’m one of hundreds of actors statewide who supplement their income — in some cases earning the majority of it — working as standardized patients (“SPs”), involved in the education of medical professionals. New York State’s sixteen medical schools graduate about 11 percent of the country’s new doctors annually. All of them, in order to practice, must pass a licensing exam that includes evaluation of their clinical skills: the way they interact with patients. My colleagues and I help prep them for that exam. We also provide “continuing education” for doctors already at work; today’s heart attack scenario is one of those exercises.
Back at Bellevue — we’re actually in the New York Simulation Center, a partnership of CUNY and NYU Langone Medical Center — a second door opens and a member of NYU’s medical-school faculty, who’s been observing our little dramas through one-way glass, enters and asks each doctor how they think they’ve handled the situation. Meanwhile the “nurse,” like me an actor, leaves the room to complete a checklist on a nearby computer. The instructor asks my opinion about the doctor’s performance. Then the “nurse” comes back and we set up for the next round.
It’s a long day’s work: From 8 a.m. until 5 p.m., we play the scene 24 times. But it’s also important work: These “objective structured clinical examinations,” as they’re called, let students and residents practice communicating with and getting information out of patients, sometimes in awkward, sticky situations.
The “standardized patient” concept is about fifty years old, developed by Dr. Howard Barrows, a neurologist then at the University of Southern California; he later introduced his proposals at Southern Illinois University. Barrows saw a need for students to learn to problem-solve on their feet. Feeling that mere paper-and-pencil exams wouldn’t, by themselves, create strong doctors, he pioneered a new way to evaluate and build clinical skills: by training actors to simulate patients.
Why the push for clinical competence? According to Dr. Mark H. Swartz, a cardiologist who established a center based on Barrows’s strategies at Mount Sinai in 1991 and now runs his own company, the Clinical Competence Center of New York, or C3NY, “The national exam started due to the fact that 85 percent of all malpractice suits in the U.S.A. are based upon a failure of doctor-patient communication. It’s not that the doctor didn’t know enough…. [It’s that] he or she did not communicate well enough with his or her patient!”
This issue has been raised repeatedly, in various forms, within the medical community. “Like most work, medical practice is largely unseen by anyone who might raise one’s sights,” wrote the surgeon Atul Gawande in a 2011 New Yorker piece. “I’d had no outside ears and eyes.” He was referring to the need for individualized coaching for doctors (even experienced ones), but the idea is the same here: Standardized patients, while not experts in medicine, are outside ears and eyes on a doctor’s bedside manner and interpersonal skills. As such, they can help reveal blind spots, from missing the underlying problem by failing to ask the right questions to being too brusque and causing the patient to withdraw.
Medical students and residents encounter standardized patients up to several times a year. According to Dr. Sondra Zabar, who directs the NYU School of Medicine’s standardized patient program as well as its primary care internal medicine residency training program, SPs are filtered into NYU students’ experience “from when they walk in the door until near graduation: at least forty different SPs in teaching environments.” The process continues even after doctors are on the job, she says, with encounters that focus on clinical reasoning, communication skills, and diagnostics. “Some [doctors] are too nice but not effective at data-collecting; others are not good at patient rapport,” she says. “This method brings everyone along to integrate those skills.”
What’s it like on the flip side? For actors seeking “survival jobs” with flexible hours, being an SP can be a great fit, while also satisfying a need to do good. Doug Ramsdell, an actor who records audiobooks and has worked as a standardized patient for two decades, agrees. He enjoys using his acting chops and staying in character regardless of what the students give him back. (Some of his roles: “high-strung creative guys with GI problems,” a bartender with painful knees, a prediabetic patient.) And he’s in awe of the students he works with, as he sees them improve. “They’re so smart, so fast; they seem so much more developed, much more comfortable in their own skins,” he says. “I love the opportunity to be useful in their learning process.”
Among the most important qualities for an SP to have, according to Dr. Zabar, are reliability and a willingness to be a cog in a bigger project. “It’s like running a show. Everyone needs to show up,” she says. “They [also] have to understand the goals of the case and… realize they’re part of the educational system.” (A 1998 episode of Seinfeld, in which Kramer played a “fake patient” with gonorrhea, totally misrepresents the process; his leering, theatrical performance would get him fired immediately.)
Communicating compassion is a big reason Evan Stern, an actor and cabaret singer who also leads walking tours of the Village and tends bar in Broadway theaters, does this work. He looks much younger than his 35 years and finds himself playing teen roles: the undergrad who goes into urgent care because he’s having trouble peeing and who tests positive for chlamydia; the 19-year-old crack addict having a panic attack. “How do you deal with someone who’s not interested in quitting?” he asks, about that last case. “You get to help doctors and students learn to communicate and express empathy. They might be brilliant on paper, but if they can’t relate to the patient, they’re going to be ineffective.”
The encounters, typically held in spartan rooms containing a table, a couple of chairs, a sink, and a computer, last about fifteen minutes, during which the student takes a medical history, performs a physical, and prepares the patient for follow-up. Sometimes the encounter is recorded, to be scrutinized later. Other times, the one-way mirror allows an instructor to watch and critique the interaction, or the SP provides direct feedback. (“It’s a huge challenge to memory,” says C3NY’s managing director, Anna Lank, a former SP and actor herself. “You don’t have to remember lines, but you do have to remember exactly what the [student] did and said, and you’re not allowed to take notes.”)
In all these cases, the student — who is aware that the “patient” is an actor but has been instructed to forget that fact — must elicit the history efficiently while simultaneously projecting an attentive attitude. Too relaxed, nervous, or hesitant and the clock runs out before she’s finished her examination; too stiff and formal, and the SP might criticize her “bedside manner.”
It’s a process Dr. Cary Blum, a resident in internal medicine at NYU, has survived; working with SPs was one of his first experiences as a student at medical school. “They throw you in the water, give you an experience of what it’s like to see a patient right off the bat,” he says, recollecting a couple of his early cases. “One was a teenager with poorly controlled asthma. Nothing technically difficult from a medical standpoint.” But another scenario involved discussing sexual history, always a challenge for students. “It’s pretty uncomfortable the first time you do that.”
Dr. Blum’s opinion about the value of SPs has evolved over the past few years. “Initially I wasn’t a huge fan,” he says. “I thought it was manufactured or artificial.” But he’s come to see his encounters with standardized patients as huge learning opportunities, “things that sculpt you as a practitioner, and get you to feel more comfortable doing physical exams.” He recalls one occasion, in which a guy “complained of chest pains during exertion; as soon as I found out he smoked, I said something judgmental that may have come off the wrong way. There was probably a better way I could have said it, so the patient understands I’m trying to help and not judge them.”
Bedside manner is particularly important when you’re dealing with intractable patients, or people afraid to share. Actress Marlena Dater, 28, began working as an SP during college in Rochester, playing a girl with pelvic pain, before moving to New York City. Her forte? “Difficult teenagers,” she says. “[Medical] students are challenged by…how to connect with them.”
The work can sometimes feel shockingly relevant or yield unexpected, creative fruit. Peter Musante, for one, envisions extending the process. “My job as an SP is to bring about a higher level of understanding. That’s the role of the doctor: to understand the patient,” he says. But “how about practicing a routine traffic stop? A lack of empathy could lead to violence. Cops have to learn to ask hard questions, the way doctors and lawyers are trained. I’d love to be an SP for cops.”
Meanwhile, Amanda Yachechak is turning her experiences as an SP — the Natalie Portman lookalike plays “a lot of teens: a diabetic ballerina with an eating disorder, abdominal pain cases, appendicitis, ectopic pregnancies” — into a Web series, along with two colleagues. (“We’re all writing it together, producing it, performing in it,” she says enthusiastically.) Yachechak has other sideline gigs but relishes the educational aspect of SP work and the improv practice it provides: “It’s great to have an opportunity to act when you’re not actually acting.”
Word of mouth, and stories in trade papers like Backstage, swell the ranks of actors eager to become SPs. Compensation ranges from $25 an hour in Manhattan to slightly more for assignments involving long commutes to outer boroughs; actors mobilized as “secret shoppers,” who infiltrate clinics to monitor the behavior of entire medical staffs, are paid from the moment they arrive until they leave, including, sometimes, hours of waiting around. While the money doesn’t match the union scale they might earn from film or stage productions, the process is rewarding, and offers a chance to network with other theater professionals during downtime in the hospital’s “greenroom.”
Experienced hands even see their roles grow; they might participate in the development of new “cases” or help shepherd sessions. Megan Lawrence supplements her SP gigs — “a sixteen-year-old who needs a note to be on the swim team, but she’s drinking a little, smoking a little, having a little sex; a young executive who hasn’t had her period for two years, but she really doesn’t have time for this” — with managerial stints, “proctoring” day-long sessions in which medical students rotate from room to room, encountering different problems behind each door.
Roles are often double- and triple-cast so that replacements are available if an audition or a more lucrative assignment comes up. But the conventional wisdom about show business — that you can make a killing, but you can’t make a living — falls apart here. Last year Eileen Lacy, already collecting Social Security and a civil service pension, earned a little under $27,000 from her SP work, she says, playing people between 55 and 78. A performer in her youth, she spent many years working for the State of New York and came back to acting after retiring in 2001. Dater says that during the “busy season” (from February through June, when students are preparing to take the clinical exams), she makes as much as 75 percent of her income from her roles.
As acting work goes, it’s also pretty age-neutral — even friendly toward elders. SPs are needed across multiple specialties, from surgery and obstetrics to geriatrics and cardiology, so there’s demand for actors both young and old, including those who can credibly suffer from diabetes, heart problems, and Alzheimer’s. Joan Kendall, who has been performing since the 1960s, began doing SP work in 1995. “It’s a second career, but I still have two agents and am auditioning for film and television,” she says. This year she appears in Jim Jarmusch’s Paterson, starring Adam Driver. “On a movie, you make a minimum of $1,000 a day. It takes a long time to make that as an SP, but it adds up. It’s psychic income, happiness income. Every day you do this work, someone says thank you. That’s wonderful.”