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With limitations on how much genuine clinical experience a medical student can expect to get, there exists a high demand for trained medical actors.

Loulou Callister-Baker investigates Dunedin's very own Simulated Patient Development Unit.

She sits in the waiting room. She feels slightly nervous, despite returning to this same room four times already that day. Her name is called. She approaches the room, acknowledges the three people waiting for her (one of whom is considerably more nervous than the others and even herself) and takes a seat when offered. Who is she? What is she visiting for today? Introductions are made and formalities are addressed. Although she has never experienced discomfort or a rash in her genital area, she describes these symptoms to the question asker. She even shows him or her a graphic photo of the rash that she extracts from her bag. Some information she chooses to withhold unless she is asked in what she perceives as a comforting, caring manner. If the questioner mentions that she has potentially contracted a sexually transmitted disease, she may start to sob quietly.

At the end of the appointment, the questioner will make suggestions as to her next steps and she will acknowledge them (although she will never actually follow his or her instructions). Returning back through the door, she will write a few notes on her interaction with the questioner and, depending on the occasion, she will even grade them on their performance. Throughout the day, she will continue to return to this room over and over again – the only obvious difference being in the person who asks her questions. If she is not a hypochondriac, why does she visit the doctor’s surgery so often? For her, it’s about the money. And as an employee of the Dunedin Simulated Patient Development Unit, it’s her job.

Despite one of the central principles of bioethics, primum non nocere (“above all, do no harm,”) numerous studies around the world have found that approximately 10 per cent of patients who are admitted to hospital suffer from some kind of harm while there. As Carol Fowler Durham and Kathryn R. Alden write for the U.S. National Centre for Biotechnology Information, “The overwhelming majority of untoward events occurring in healthcare settings involve miscommunication.” For their fields, medical students need extensive practice, but to have this there are a handful of hurdles they must overcome, which provide limitations on the amount of times they can practice and the effectiveness of it when they do. As researchers found for a paper for BMJ Quality & Safety (the international journal of healthcare improvement), “The term ‘learning curve’ has repeatedly been used to account for higher complication and mortalities, as well as longer procedure times, among inexperienced practitioners and teams. Climbing the steep learning curve can no longer be done by trial and error, so it is necessary to explore, define and implement models of health professional training that do not expose the patient to preventable errors. One such model is simulation-based training for practice, assessment, teaching clinical skills.”

Healthcare simulation can either involve actors or devices that attempt to create characteristics of patients suffering from health issues in the real world. Either way, the goal is to promote decision-making, good communication, clinical skills, critical thinking, and general medical competence. It also allows students access to situations that they would otherwise be unlikely to encounter, either because they’re less common or because there are certain types of patients who are common but would not want to see a student. In other places around the world, the use of simulation is necessary due to shrinking in-patient populations or when in-patients have become progressively unrepresentative of the spectrum of disorders that students could be seeing.

Cindy Diver and Martin Phelan with the University of Otago Medical School established the local Simulated Patient Development Unit (SPDU) in Dunedin in more recent years (Janine Knowles took it over in 2007 and brought it under the wing of Outstanding Performance, which runs a range of similar programmes). However, Howard Barrows is seen as using the first simulated patient in Los Angeles in 1963, when he used an artist’s model pretending to have multiple sclerosis. Like most changes, Barrows’ innovation was met by some with questioning doubt, particularly as to its perceived costly nature and its potential to be over-acted. But when Barrows moved to McMaster University in 1971, practice of his ideas began to spread and increase. At a similar time in Michigan, the use of simulation extended to teaching interview skills. Lingering doubts were diminished when “unannounced” simulated patients went undetected in several outpatient clinics. Their first use in medical student assessments is likely to be by Ronald Harden and colleagues in Dundee, Scotland, who used them in objective structured clinical examinations.

At a similar time, in the late 1960s and early 1970s, researches from the University of Miami developed the first cardiology patient simulator, otherwise know as “Harvey,” which was both a computer-enhanced manikin and task trainer that was able to reproduce both common and rare cardiac diseases. Then, in the 1980s, computerised manikins were developed for anaesthesiology trainees, which, as the BMJ Quality & Safety article found, “provided opportunities for repeated practice in a safe and pedagogically sound environment.” Now, as most who have done a first-aid course know, anyone can purchase manikins that can breathe, dilate their pupils or even experience arrhythmia (a problem with the rhythm of the heartbeat). However, despite studies proving the benefits of simulation-based training on real patients, “it is currently widely accepted that simulators serve as an adjunctive tool, not a replacement, for patient-based operative experience,” with this area of training and science still being viewed as in its “infancy” stage.

Dunedin’s own SPDU employs actors to play patients for Otago medical students to practise with. As Cindy Diver told the Otago Daily Times: ‘’That became an important branch of our business because it was on-going local paid professional work, but also had the by-product of making our actors better actors, because intimate acting in a scenario with your doctor makes you work really hard at being truthful.” Diver also believes the use of actors is integral to simulation: ‘’Part of the difference between someone just coming in and pretending to be a patient and using an actor is that the actor is at all times analysing why they are feeling what they are feeling, what you’ve just said that makes them react.”

Medical actor Josie Cochrane attended training for SPDU in March last year. The first time Josie did a job, she was nervous as she sat with other actors in a waiting room that is made to look exactly like one found in a real doctor’s surgery. Immediately, however, she learned that the students were normally far more nervous: “Sometimes they’ll get shaky voices. Sometimes they’ll even stop halfway through and say something like ‘hold on, I’m just gathering my thoughts.’ This is particularly the case during exams, which are videoed, or when there’s an examiner in the room. Those are a whole other ball game to skills clinics.”

Now, in 2014, Josie has been a medical actor for a countless number of scenarios involving fourth to sixth year medicine students and sometimes third years – on one particularly busy day she even did a simulation 16 times in a row. Josie’s income ranges between $20-28 an hour – with the pay depending on how much preparation you have to do for the scenario. The first scenario she started off as a teenage girl wanting the contraceptive pill but not wanting her mother to find out, and, in this case, the test was how the medical student talked her into telling
her mother.

In one scenario, Josie had to pretend she was a high school student who had recently had a fight with a person close to her and, sparked by overwhelming teenage anxiety, attempted suicide by taking pills from her family’s medicine cabinet. The actor is provided with a wealth of information about her character’s own lifestyle and interests as well as her family’s background. She is also told to use her own experiences and knowledge when talking about leisure activities (although this isn’t always the case as specific leisure activities can suggest health concerns that the medical student is required to find out through questioning). Throughout the interaction, the actor must analyse the conversation, as well as withhold certain details unless the medical student creates (what the actor personally views as) a comfortable environment and asks questions in a sensitive manner.

The brief for another job required Josie’s character to be pregnant or hoping to be, but (unknown to the character) she had a miscarriage for the third time. In this scenario the students asked her questions about her pregnancy and past. They also asked to see her blood results, which she had on a laminated card. Then, in the most compassionate way possible, the student had to tell Josie’s character that it looked like she had a miscarriage. “Quite often the students were actually unsure themselves, because the facts don’t make it immediately clear. I only learned this from reading up about it afterwards, but the fact sheet does give you a bit of information about what they’re meant to be looking for,” Josie comments.

“Some med students are really good at explaining it, particularly some guys – I find them really sensitive in situations like this. Women are too, but sometimes the guys really surprise you, which is interesting. I didn’t expect that. I’ve had to do a woman’s violence scenario before where the guy looked almost choked up about it, but none of the female med students did.” However, counteracting this observation somewhat, Josie also found her most negative experience involved a male student. In the simulation, this particular student asked her if she knew what endometriosis is; she told him that she did and she had friends who have it. Josie then asked him if it made it more difficult to have children. The student briefly stopped typing at his computer, turned to her and in a casual tone replied, “yeah, you’re probably infertile.” “I was quite taken aback by that reaction,” Josie remarks, but she did comment about that on his feedback after the skills lab (which is set up solely as a learning experience.)

Other students in this scenario have also told her that it wasn’t a miscarriage before. When this happens, “you have to react appropriately, so I’d say, ‘That’s great – I’m really happy about that!’ But you do have that sinking feeling that they’re on the wrong track, although you can’t show this because you’re an actor.”

While common consensus views the use of simulation (by both actors and computer programmes) in health professionals’ education as integral, especially in cities or towns with smaller populations, some research has found certain disadvantages with actor simulation. Some of these were outlined in an article for the Psychiatric Bulletin: “Simulated patients can be stressed by the roles they portray, which is probably a reason for using professional actors in psychiatric teaching, where roles may well be more emotionally demanding than in other areas of medicine.” When I brought this up with Josie she agreed that, “some scenarios are pretty heavy, they can be depressing and you leave on a low – even though you don’t want to be like that because you’re just acting … But,” Josie adds, “my employer does give everyone the option that if they don’t want to do a scenario, then they are allowed to say ‘no.’ I know people say ‘no’ for difficult scenarios – because it’s too close to home. And if there’s a scenario where an actor suddenly feels uncomfortable, he or she can stop (although it will go back to the boss).” But Josie has never been unable to complete a scenario and she has only said ‘no’ for a lack
of availability.

Another disadvantage, despite “predominantly positive” experiences, outlined in an article for the Psychiatric Bulletin was caused after some actors have been trained and find it “tempting not to tinker with their script or performance, so that teaching sessions may become out-dated or repetitive. Actors may draw, inappropriately, on their own experiences and embellish their roles outside the scope intended by the scriptwriter. Occasionally, overacting may occur; for example, simulated patients may be just too depressed or too hopeless.” This issue, however, doesn’t seem to be the case for Dunedin’s SPDU which, Josie tells me, often gets enthusiastic feedback about how consistent the actors are.

In fact, the only problems or “awkward situations” Josie has ever had with the job is when she’s known the med student – a situation that is almost unavoidable, especially in a city the size of Dunedin. “Normally they tell us to give them a list of people we know to try and avoid you being a room with somebody you know, but for one exam I forgot a particular person was doing medicine who I knew reasonably well. He came in for an exam and my character had diarrhoea – it was awkward! He looked at me and I could tell he was thinking ‘fuck, I know her!’ He was so uncomfortable throughout it. I told the examiners afterwards that I knew him because they’d observed that he was very uncomfortable and that he hadn’t asked many questions. But the examiners told me that in a real life situation anyone you know could walk into your doctor’s surgery; you can’t behave like that – you can’t avoid personal questions.”

Another questionable (if slightly entertaining) encounter was when Josie played the character that was asking to go on an oral contraceptive scenario. “The student asked ‘are you sexually active?’ And I said ‘yes.’ ‘Is it with a regular partner?’ ‘Yes, I’ve had a boyfriend for two years.’ ‘When did you last have sex?’ ‘Like three days ago.’ ‘Oh right, how about before then?’ ‘Ahh, five days ago.’ It was purely nerves I think and he became stuck for questions, so he asked, ‘How was it?’ He didn’t really click what he’d said ... or find it amusing at all!” In general, however, the students don’t pry enough. “They should ask questions and delve into it. That’s what the examiners say. As a patient you don’t have to reveal everything unless they make you feel comfortable enough and you feel there’s enough confidentiality to say.”

Ultimately, however, Josie believes that, “most of the students have the compassion pretty down pat. They are learning to be genuine, which is apparently a skill that’s become more emphasised over the last few years with the med school trying to get students to have much more patient contact earlier on. Even in second year, I think it is, they’re made to go out and do community visits to people’s houses.”

While different publications reiterate the need for further research in this field, simulation-based training creates both a fascinating and undeniably significant learning environment for students. With its obvious usefulness, simulation should and is becoming an integral part of the push for safer health care everywhere.