Aching for a role

On a given day, Tom Wyatt might be told that he's abusing alcohol and tobacco. Or that he has cancer. Or, several times over the course of a shift, that he just became a widower. On the Johns Hopkins medical campus, it's Wyatt's part to suffer the slings and arrows of outrageous medical fortune over and over again. He is a "standardized patient" (SP), engaged to portray sick or injured people or their concerned family members in order to help medical students develop people skills.

A middle-aged Baltimore actor, choreographer, and director, Wyatt is one of 150 SPs at the School of Medicine's Simulation Center. It is the SP's role to present burgeoning physicians with the charged human interactions they'll face once they take their MDs, and it's hardly a star turn. "We're not here to put on a show," Wyatt says. "It's all about helping students, getting them to identify things in the ways they deal with people that they might not be aware of."

SPs do more than create conversational characters. They serve as guinea pigs for aspiring physicians, acting as patients. They perform cameos as homeless patients and battered women. Specially trained actors make presentations and instruct students how to sensitively conduct examinations of the genitourinary tract and abdomen. They help train physicians on how to bring up the idea of organ donation to devastated loved ones, and how best to disclose medical errors and apologize to patients and their families for making them. The Simulation Center, a bustling place with various medical classes receiving instruction—often with the help of "Sim Man," a manikin that mimics a batch of medical conditions and is most often used in cases where resuscitation is called for—provides the setting. Members of the medical school faculty watch the student-SP encounters through one-way glass. Almost all of the simulated meetings are videotaped and discussed with students later.

During one simulated case, six senior med students are asked to diagnose the breathing problems of a patient (Sim Man, portraying someone called "Mr. Hill") and deal with his worsening symptoms, which, they eventually figure out, are caused by giving him an antibiotic he is allergic to. But the students botch the resuscitation effort before saving Mr. Hill—something each must then explain to SPs who portray Mrs. Hill. The actors' emotional responses vary, with some appreciating the honesty of students who tell them of the mistake. Others let them have it. ("This is Johns Hopkins! Y'all are supposed to be better than that," bellows one.)

Often, SPs in similar situations are called upon to cry—with real tears. Neva Krauss, an SP since 1999 and a trainer of them for the past three years, calls on her knowledge of Constantin Stanislavski's century-old method-acting techniques to get the waterworks going. To open the faucet further, she'll picture the scene in Titanic right before the big boat sinks. "There are days when you have to cry on cue over and over again—stopping it on a dime, and then getting the tears flowing again," she says. "That's a draining day." Wyatt, who has been an SP since 1996, seconds that post-death scenes take their toll: "When we're doing the end-of-life scenarios in the morning, I'll have to go home, take some Tylenol, and get a nap in before returning in the afternoon." Wyatt adds that portraying someone in intense physical pain is even harder than playing another who is emotionally devastated. "Not only do I have to constantly grimace and groan, but I have to remember what the med student is saying so I can grade how they do," he says.

Otherwise, Wyatt finds the job more taxing on his brain than his heart. Because SPs must learn and understand a wide range of scenarios, memorize the facts of cases that often involve complex medical and social problems, and get a grasp of the family dynamics in many of them, they are challenged to juggle several shards of information at the same time—and sometimes several roles per day.

Not surprisingly, the annals of SP life are filled with eye-rolling anecdotes about callow med students—such as one who summarily blurts out that a loved one has suddenly died, and another who habitually ends her sentences with ". . . OK?," telling a mother, "Your son has just died, OK?" (The SP responded with, "No, it's not OK!") Sometimes, SPs angered by the insensitivity of a student have flipped them the bird—all of which is recorded on videotape. "We tell them that's a big no-no," Krauss says.

Still, perhaps because of the work of SPs, students are getting better at handling simulated situations, says Wyatt. "There's been dramatic improvement. We try to be open to what the student brings to the situation, and then add reactions and observations. A lot of times, we'll be there afterwards to discuss how an encounter went. Our instinct is to be judgmental—'Oh! I hated how he handled that!'—but we're here to be constructive."