A Medical Actor Writes Her Own Script
February 4, 2014 6:28 PM   Subscribe

The Empathy Exams: Acting out pain until that pain becomes real, for $13.50 an hour. "My job title is Medical Actor, which means I play sick. I get paid by the hour. Medical students guess my maladies. I’m called a Standardized Patient, which means I act toward the norms of my disorders. I’m standardized-lingo SP for short. I’m fluent in the symptoms of preeclampsia and asthma and appendicitis. I play a mom whose baby has blue lips..."
posted by homunculus (34 comments total) 40 users marked this as a favorite
Obligatory link.
posted by kewb at 6:34 PM on February 4, 2014 [5 favorites]

posted by cmoj at 6:34 PM on February 4, 2014 [3 favorites]

Strange minds think alike, cmoj.
posted by kewb at 6:36 PM on February 4, 2014 [1 favorite]

I mean, it's the only logical response.
posted by cmoj at 6:40 PM on February 4, 2014 [1 favorite]

Somehow I was one of a handful of people in my hometown community theater group who got recruited into doing this for my hometown's EMT testing once. In my case I was playing someone who'd gotten accidentally hit in the head with a baseball bat and knocked out, so I just had to lie there; some makeup was used to give me some telling symptoms that were supposed to indicate a particular kind of skull fracture. The woman who conducted the testing for my particular ailment did all the talking and explaining of "what happened" as about 20 or so pairs of potential EMTs came in to do a mock evaluation. The woman who ran the testing told me the kinds of things they were looking for (did anyone try to roll me from my side onto my back without stabilizing my head and neck, for instance).

I remember getting pretty annoyed at the people who forgot to do that ("dude, you could have broken my back"), but I also remember being very moved by the one guy who not only did everything right, but sat there next to me the whole time holding my two "unconscious" hands reassuringly the whole time he and his partner were conducting his investigation of my "symptoms". I can only hope he passed with flying colors and is serving my hometown well.
posted by EmpressCallipygos at 6:52 PM on February 4, 2014 [43 favorites]

About 2002 I used to read a blog kept by a woman who was part of a US Army field hospital unit in Kosovo. There wasn't any combat, so they only rarely got patients. (Car accidents, and other normal every-day trauma, mostly.) But they trained a lot.

She blogged about one training episode where some members of the unit pretended to be a squad that had been shot up. Her role was to be a psych case, someone driven crazy the by the events. And in particular, her job was to try to smuggle a (rubber) knife into the hospital in her boot. And she did it, too, and the judges decided she managed to wound someone (in simulation).

Part of processing incoming patients is to scan them for weapons, and the guys responsible for that blew it. (And got chewed out for it.) One of the rules is that everyone gets scanned, but she made such a ruckus and struggled so much that she managed to get past them.

Of course, that particular error was harmless, but I'm sure those guys were a lot more conscientious the next time real patients came in.

I wish I could find that again, but I'm not even sure it's online any more.
posted by Chocolate Pickle at 7:01 PM on February 4, 2014 [3 favorites]

I'm a medical student and my class just spent the day interviewing SPs. The cases today were all of people who present with superficially physical complaints that are masking deep unhappiness or psychological torments or both. This is such a good article to be reading tonight -- thanks homunculus.
posted by saturday_morning at 7:23 PM on February 4, 2014 [4 favorites]

When I volunteered with the ambulance company near my college, I once recruited a bunch of my friends to play people injured in a mock massive car crash. They were paid in pizza (from the ambulance company) and beer (from me). Practicing stuff I had done hundreds of times before on people I actually knew was a totally surreal experience.
posted by Itaxpica at 7:43 PM on February 4, 2014

That's not even the strangest medical-education associated job. There's another very special job- teaching "sensitive" exams such as pelvic, breast, inguinal (hernia) and prostate (rectal) exams. These instructors explain the exam procedure, and then you do the exam ON THEM while they continue to give instruction and constructive criticism. Like, while your (gloved!) finger is in his butt or as you're searching blindly for the cervix with a speculum while she watches with a hand mirror. This happened in a small mock-exam room with about 5 students present at a time. So we all had our own turn, but watched each other as well. (These are NOT our regular instructors at school, these are special instructors who go to all the medical schools in the area doing this.)

Definitely in my top 5 most surreal moments in my medical education, at least so far. And how anyone ends up with that job is a total mystery to me, but I am always suggesting standardized patient as a job to people. I've done many SP encounters and some of them aren't that great, but some are AMAZING. I had a teenage (well, she played a teenager but I suppose she may have been older) but a teenage girl with a psychological issue- paranoia, hallucinations, the whole bit- she was amazing. That's a hard thing to act, but she was great. It makes the exams so much easier for the students, too- if we can believe you're a real patient it's so much more intuitive than when you can tell someone's just saying lines. For example as EC mentions above, about the hand-holding- I feel silly being overly empathetic to people who are just flatly saying lines because I know their medical problem is not real. Because I'm not actually worried about them, I end up focusing on myself ("Oh God, did I remember to do All The Things? What are they going to take points off for that I missed??") But empathy comes naturally when the actors are good, and the whole encounter improves because I focus on them and start to forget it's an exam. I once had to tell a standardized patient that I was worried he had a terminal diagnosis, and the look on his face in reaction to the news was so real- I was practically in tears by the time I left that room.
posted by GastrocNemesis at 7:44 PM on February 4, 2014 [29 favorites]

My friend worked as a contractor for a company that was in charge of selling a new type of vaginal speculum to doctors and training them in the use of it. She got to be the patient. She got paid something like $200 per vaginal exam, and could end up doing five or six a day. A pretty lucrative job, but not one you feel comfortable telling strangers about at most parties.
posted by lollusc at 7:49 PM on February 4, 2014 [4 favorites]

Thanks for this link. It's a very nice narrative.

I, too, am a medical student. The work that standardized patients do is invaluable. Giving a physical exam might be a skill that anybody can acquire with enough practice and repetition, but the amount of time it takes to get comfortable with the immense amount of trust that the patient places in the physician is substantial. Nimbly working a blood pressure cuff while confidently establishing rapport, observing the patient's condition, taking a history, all within ten minutes time (as it's all about efficiency these days) ... I would not want to try and figure all that out for the first time on a real patient! I am very grateful for standardized patients.

Here are some articles about standardized patients for female pelvic exams.
posted by gemutlichkeit at 7:56 PM on February 4, 2014 [3 favorites]

I remember an episode of Dr. Kildare with these guys.
posted by The Underpants Monster at 8:02 PM on February 4, 2014

Also of interest. One of the licensing exams for physicians in the U.S. is the USMLE Step 2 Clinical Skills Exam, usually taken during 4th year of medical school. It consists of twelve SP encounters in a row (except for a lunch break- they feed you lunch.) It is often referred to by students as "the most expensive sandwich you'll ever eat" or some variation of that- it costs about $1300 to take the exam. I can only hope most of that fee goes to the SP's.
posted by GastrocNemesis at 8:24 PM on February 4, 2014 [1 favorite]

My friend's mother apparently has a talent for this. She's in high demand as an elderly violence victim.
posted by Tell Me No Lies at 8:30 PM on February 4, 2014

GastrocNemesis: "I can only hope most of that fee goes to the SP's."

Sixteen dollars an hour. The rest pays for some paper that proves you, 97% of the other test takers and I can speak English and remember to wash our hands. Don't get me wrong-- I loved my SP sessions in MS1 and MS2, but the TOEFL is $180, I'd be happy to wash my hands in front of any number of residency directors during my interviews, and the thousand dollar balance could have set me up for a month on Lake Atitlan.

Can you tell I just registered for CS?
posted by The White Hat at 8:42 PM on February 4, 2014

This is the standard gig for actors in Portland. I know tons of folks who do this at OHSU.
posted by Lutoslawski at 8:46 PM on February 4, 2014

Thanks for sharing, homunculus. I like how this is more than just the author being a standardized patient, but also a look at the complicated role of empathy.

The line "I care about your pain is another way to say I care if you like me" really struck me. There's an emphasis now in medicine (in addition to being efficient) for physicians to be empathetic. While overall I think that's great, it can also be looked at as selfish: if a patient will like their physician, this will result in better patient evaluations, which can mean a better salary and less risk of lawsuits.

And she describes how complicated people/patients can be: she describes one situation where she wished the physician would understand why the patient was concerned (Dr. M), but then she also liked how another doctor (Dr. G) was so matter-of-fact. So, while physicians are trained to be empathetic, how to appropriately do so is really a moving target.
posted by slomodinkens at 8:47 PM on February 4, 2014 [1 favorite]

Whoa, that was way more intense than I was expecting.

I was originally thinking I would share this story of a medical actor who was actually diagnosed with what he was pretending to have. Now it seems not serious enough to follow the original piece, although maybe some uplifting news about saving a life by a coincidence will help.
posted by carolr at 9:17 PM on February 4, 2014 [1 favorite]

Wow, yeah, really intense essay and not what I expected either. Thanks for sharing.
posted by threeants at 9:23 PM on February 4, 2014 [1 favorite]

When I first started reading I couldn't help but be reminded of a series of similar articles that ran on McSweeney's a few years ago, and wondered if it was something about a starving English student that made for a particularly convincing SP or just a particularly compelling story. Then this piece ended up being about far, far more. Thanks for posting.
posted by lilnublet at 9:26 PM on February 4, 2014 [1 favorite]

> These instructors explain the exam procedure, and then you do the exam ON THEM while they continue to give instruction and constructive criticism.

I have a friend who has done this job. She was already a nurse practitioner and working for an ob-gyn and in low-income women's clinics. It is VERY good extra money for someone of a certain temperament who isn't modest, can laugh it off when they go home, and who already spends their workdays being unembarrassed and straightforward with women to educate them about gynecological health.
posted by desuetude at 9:36 PM on February 4, 2014 [2 favorites]

So, while physicians are trained to be empathetic, how to appropriately do so is really a moving target.

That's the point, surely?

It's tough, though, because the med students are graded on their behavioural performance of empathy, as an adjunct to very directive action (which is also directed, by the problem-solving goal). I don't imagine it's easy.
posted by cotton dress sock at 10:12 PM on February 4, 2014 [1 favorite]

In my army days, including a tour of Bosnia 94-95 I've been the simulated patient and been the responder a number of times, including all-out full-make-up-and-pyrotechnics exercises. A number of good (amateur) performances are still fresh in my mind. My hobby at the time was pen-and-paper RPGs, and I tried to put something into every performance. Mostly everyone agreed that you gained a lot more from the training if you acted it out and/or suspended your disbelief.

I think the training is still with me, on those thankfully rare occasions everything goes south and I need to maintain a level head.
posted by Harald74 at 11:53 PM on February 4, 2014 [1 favorite]

Reminds me of the summer I helped to train call handlers for the local police force. Every session there was at least one person freaking out thinking that the calls were misrouted and I was a real live emergency.

It never occurred to me you could get paid for doing it.
I think that may very well have been my perfect career.
posted by fullerine at 2:40 AM on February 5, 2014 [1 favorite]

My friend worked as a contractor for a company that was in charge of selling a new type of vaginal speculum to doctors and training them in the use of it. She got to be the patient. She got paid something like $200 per vaginal exam, and could end up doing five or six a day.

Oh my goodness. That is the most awkward dream job I can possibly imagine.
posted by two or three cars parked under the stars at 7:06 AM on February 5, 2014

Okay, so how does one get into this SP gig? Just call medical schools? Seems like something I could pull off pretty well and would be useful extra money.
posted by feckless fecal fear mongering at 7:47 AM on February 5, 2014

I've been a standardized patient for about six years now, and these days I take a lot of the rough emotional cases. (A couple of days ago I was talking about facing the end of my life; tomorrow I'll be getting serious news and not taking it very well.) It means a lot to me to hear from med students who appreciate our work. We try hard to give you guys a safe space to learn and practice in.

For somebody who wants a little useful extra money, this is probably not the gig. SP work can be very intense, even if you aren't playing one of the obviously intense cases. I get paid a little more than the CS folks and the author, but I also do hours of largely unpaid preparation so I can do my best to make the situation feel real.

The empathy goes both ways. Medical school is hard. As an SP, I'm of the med-school system but I'm not quite of the medical school itself; that sometime seems to allow students to tell me things that, I think, they haven't been able to tell anyone else. Also, a mock clinical situation that feels real -- even a simple one -- can bring a student right smack up against his or her fears about becoming a doctor. You hear a lot about imposter syndrome, especially deep in the grind of the second year. Sometimes people cry.
posted by sculpin at 9:28 AM on February 5, 2014 [6 favorites]

GastrocNemesis: "I can only hope most of that fee goes to the SP's."

Sixteen dollars an hour

That's sad. I mean, I was being facetious when I suggested that most of the fee might go to the SP's. I knew it wouldn't, but $16/ hr? The students they hire to facilitate and record the SP sessions make more than that. And the USMLE patients HAVE to be good, I mean, they're part of our licensing procedure. They deserve more. And having had both good and bad ones, I think medical students deserve for SP's to be paid more too. I can honestly say I only learn from the good ones, the crappy ones are just a waste of time. It should be higher paid to attract better people.

So, while physicians are trained to be empathetic, how to appropriately do so is really a moving target.

Absolutely. That's why they make us do SP exams so frequently. And I don't know about everywhere but in my case the SP sessions were preceded by a small-group class led by a behavioral scientist to discuss the issue at hand that time (eg breaking bad news, asking personal questions, persuading people to change bad habits, etc.) Then our recorded session was graded on a whole bunch of criteria (eg expressing empathy, paraphrasing the conversation back to patients, allowing adequate time for asking and answering questions, even our body language.) Then we had to meet with the behavioral scientist for a one-on-one review of our performance. If we failed, we had to do it over. It's tough. Many people I know failed at least once (uhh, including me. Good thing I'm not going into oncology.)
posted by GastrocNemesis at 9:37 AM on February 5, 2014

It should be higher paid to attract better people.

The real problem, to my mind, is retention. Burnout is an enormous issue, and it gets hard sometimes to justify how much work and thought and intensity I'm putting into this gig for that pay.

Even somebody who has the basic temperament for becoming a good SP will take a while to get there. (Training as an actor can help, but not nearly as much as people tend to think, from what I've seen.) If we can keep SPs around longer, we'll have a better pool of SPs.
posted by sculpin at 9:45 AM on February 5, 2014

Empathy isn’t just something that happens to us—a meteor shower of synapses firing across the brain—it’s also a choice we make: to pay attention, to extend ourselves. It’s made of exertion, that dowdier cousin of impulse. Sometimes we care for another because we know we should, or because it’s asked for, but this doesn’t make our caring hollow. The act of choosing simply means we’ve committed ourselves to a set of behaviors greater than the sum of our individual inclinations: I will listen to his sadness, even when I’m deep in my own. To say “going through the motions”—this isn’t reduction so much as acknowledgment of the effort—the labor, the motions, the dance—of getting inside another person’s state of heart or mind.

This confession of effort chafes against the notion that empathy should always arise unbidden, that genuine means the same thing as unwilled, that intentionality is the enemy of love. But I believe in intention and I believe in work. I believe in waking up in the middle of the night and packing our bags and leaving our worst selves for our better ones.
For anyone who gave up when the fun SP anecdotes slowed and the weightier analysis started, I'd encourage you to read the whole article. There's a lot of really good insight, about both demonstrating and needing empathy. Great read.
posted by vytae at 2:31 PM on February 5, 2014 [3 favorites]

I've done this for free for friends, it does involve a lot of preparation. You memorize not just specific symptoms but a whole personal history.
posted by subdee at 7:09 AM on February 6, 2014

That's not even the strangest medical-education associated job. There's another very special job- teaching "sensitive" exams such as pelvic, breast, inguinal (hernia) and prostate (rectal) exams. These instructors explain the exam procedure, and then you do the exam ON THEM while they continue to give instruction and constructive criticism.

This isn't just a job, it's a fucking public service. The last time I had to have a vaginal exam, it was just terrible... I was fine, but I couldn't help thinking that there are a lot of women (and girls!) out there that it wouldn't be fine for, and hoping that they didn't wind up at that walk-in clinic on that doctor's day.

So thanks, pelvic exam instructors and standardised patients out there, for the good work you do!
posted by snorkmaiden at 1:06 PM on February 6, 2014

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