Sarah* stared sympathetically into her webcam, trying to make it seem like she was looking into the young mother’s eyes. It was crucial that her patients felt listened to, even if they couldn’t be in the same room. Sarah asked the mother for consent to record the session and then started taking her child’s history, asking follow-up questions where necessary. “These are the vaccines your child will need,” Sarah said. “We’ll get you set up with those before we finish up today.”
“How are we gonna do that over telemedicine?” the mother asked.
“And I was like, ‘Ohhh yeah, whoops!’ ” Sarah told me as she recounted the story later, also via webcam. Fortunately, the mother wasn’t a real patient, but then again, Sarah isn’t a real doctor—yet. Rather, the woman was a simulated patient, while Sarah is one of the thousands of medical students across the country now practicing their clinical skills from home. “Another day of Zoom University School of Medicine,” she sighed.
The past few months have seen a great rush to get activities online, especially in the fields of education and medicine. At the intersection of these two fields lies a conundrum: How are trainee doctors supposed to practice examining patients when they can’t be in the same room as them? Since March, the Association of American Medical Colleges’ guidance has recommended medical students not be involved in any direct patient care in COVID-affected areas. But while medical students may not be essential, human interaction is essential to medical training. Enter: remote SPs.
First introduced in 1963, standardized or simulated or sample patients—SPs—have since become a regular part of medical education. (Rob MacAulay, president of the Association of Standardized Patient Educators, tells me simulated is the more globally accepted term—the organization is considering a name change down the line.) While medical students do still interact with real patients under supervised clinical settings (at least in nonpandemic times), human role-players allow students to practice certain skills in a simulated environment, including meeting a patient for the first time, giving bad news, taking medical history, and performing physical exams—listening to hearts and lungs; looking into eyes, ears, nose, and throat; taking blood pressure or pulse; and checking reflexes. SPs are often given a “case” to portray, one feasible for their age and sex, although not all are as theatrical as Kramer’s famous gonorrhea characterization in Seinfeld. SPs can be a teaching aid, helping students improve their skills by providing direct feedback, but they can also be an assessment tool, performing a more rigid standardized role in OSCEs, clinical exams in which students complete a circuit of stations treating a different “patient” at each. Now, they are helping students continue to learn remotely, improving their bedside as well as their webside manner.
There appear to be two main ways medical schools are running simulations online. Some are simulating telemedicine encounters, in which the students and SPs act as if they are meeting via a screen, often acknowledging the existence of the pandemic. Others are still simulating “in-person” medicine, in which students and SP must suspend their disbelief—even more so than usual—to act as if they are in a face-to-face consultation. Sometimes it’s not clear what is going on, whether they’re in a clinic pre-COVID-19 or whether that dog in the background is really there. Even post-pandemic, it’s expected that this type of learning and telemedicine more broadly will continue. The challenge is making both feel human.
Prior to early 2020, very little SP work was done online. Elizabeth Krajic Kachur, a medical education consultant who has been working with SPs since 1982, said that medical schools in homogenous or rural areas have in the past used remote SPs to expose their students to more diverse patients, like a medical school in Georgia calling in Latino SPs from other parts of the country. In 2019, the AAMC introduced an insomnia video-visit assessment, simulating a patient with depression in a medically underserved area, noting the current lack of telemedicine training opportunities.
When COVID-19 hit, medical schools across the country were forced to adapt on the run. “Everything has always been in person, until April, so this is all brand-new for us,” says Harvard OSCE director Susan Farrell. Within two weeks of everything shutting down, the Harvard team had turned to telemedicine training.
Educators across the country have swapped extensive notes. After figuring out the tech, conversation turned to how best to alter their training and assessment—especially when it came to “physical” exams.
In some schools, students are asked to record themselves performing the physical on a member of their household or on a pillow divided into quadrants with masking tape. In others, they indicate what they would do on a diagram of the human body or simply verbalize what they would do and in what order. SPs need to tell the students what they “feel” during these “actions” (as per this remote SP briefing: “I’m pressing in your left lower quadrant” “That hurts, like an 8 out of 10”) or show them a card with what they encounter, much like during in-person simulated exams. Other schools, those simulating telemedicine more literally, have had students run physician-directed self-exams, talking their SPs through what they want them to do on screen—things such as lying down on the floor and moving their legs around in a certain way. Farrell says these encounters have been “charming,” with students sometimes acting out the maneuvers they want to see: “When you’re sitting in a white coat in an exam room, you’re less likely to go through all of those maneuvers yourself.” Web-based simulations are also being used to mimic heartbeats or other sounds that a learner might hear on a stethoscope. “Little by little, with more and more creativity, people will come up with ways to do it,” says Kachur, noting that people are still coming up with these strategies for real-life telemedicine too.
But in other ways, remote SP encounters don’t differ all that much from live ones. When taking a patient history, communication remains at the heart of the process, and the goals and criteria are the same. MacAulay, who is a former SP himself and also the director of simulation education at UCSD School of Medicine, tells me that at the end of the day, the essential question is still “Did you feel listened to?” Showing empathy can be harder over Zoom, and body language needs to be adjusted, but with telemedicine likely to stick around, students are learning difficult skills that will serve them well into the future.
While it’s still possible to express empathy over Zoom, there are concerns surrounding how other emotions play out online. UCSD School of Medicine runs a number of cases where students are required to deliver bad news, such as a case where someone’s cancer has metastasized. MacAulay wondered initially whether these cases would still be meaningful for students, but students told him they felt “just as real to them as the exercises they’ve done in person.” On the flip side, many simulation program organizers are concerned about how SPs will handle these cases at home; it can be an emotional experience for them. “There’s the isolation factor, the fact that they are in their place alone, they are maybe portraying a difficult case, something related to death and dying,” says Kachur. She says that extra care needs to be taken with cases relating to child abuse, depression, dementia, and racism. Then there’s Zoom fatigue. “We’re trying to be mindful of our SPs doing five-hour exams, talking to them about the importance of giving eyes a break, going outside, getting some air,” says MacAulay.
Many SPs are simply relieved that the work has come back, even if it’s online. Most SPs are independent contractors and had all their upcoming work canceled when things first shut down. (Many are also working actors, meaning their other income streams dried up too.) Matthew Huston, who works across a number of schools in the Chicago area, says it only took a few weeks for institutions to start getting back to him with new dates; 90 percent of the SP work he has done since then has been over Zoom, and he’s still getting paid the same rates. (Pay varies on a case-by-case basis, but is usually about $15 to $20 per hour.)
Some SPs are enjoying the new acting challenge. Wally Zialcita, a theater artist who has worked as an SP on and off since 2001, thinks being able to see his own face on Zoom is improving his performance. “Not that it was bad before, not at all,” he says. “But now I have a keener awareness of and control over the acting choices I’m making, and I can replicate those choices from one student to the next.” There is something missing, though. “I feel as though my encounters normally feel more organic to the personality of the student,” he says. “Everything about that student—their body language and facial expressions, the way they move, the chemistry that I feel from being in the room with them—prompts characterization on my part.” Valerie Weak, an SP in the Bay Area, also trains and observes other SPs to ensure consistency for exams. “I describe it to my theater friends as it’s kind of like I’m a director and a dramaturg and a stage manager all at the same time.” She’s been running training remotely, ensuring SPs know how best to light and position themselves for video calls. Some of her trainees are using Zoom backgrounds to portray particular socioeconomic settings and even changing their names and profile pictures on Zoom so as not to break “character.”
But some medical schools aren’t bothering to attempt virtual exams at all. Caroline Sposto, founder of Savvy Civility, a remote staffing business that specializes in role-playing actors, says 85–90 percent of her SPs still want to work remotely, but some schools have simply hit pause. On the bright side, now that things aren’t being done in person, SPs are able to work for a wider range of schools, and Sposto, who has always trained her staff remotely, is able to link up actors with institutions on the other side of the country: “I can beam someone from Boise, Idaho, into Pennsylvania.”
Med students, too, have been enjoying some elements of the experience—more than one student has taken to #MedTwitter to joke about examining SPs while wearing gym clothes and a button up, or disconnecting their Wi-Fi to buy some time when they don’t know what to say. But many seem exhausted. Sarah, who is in her second year at a school in the Midwest, says students were asked to prerecord themselves doing the physical exam on somebody at home, which meant no live feedback from an SP. (Unsurprisingly, her sister, a dentist, did not know how the musculoskeletal exam was supposed to go.) Even the history-taking has been difficult for Sarah. Looking at a webcam, she says: “It feels like I’m vlogging. It doesn’t feel like I’m having a conversation with a human being.” James*, a third-year med student whose school has students verbalizing physicals over Zoom, finds the encounters “kind of awkward”: He’s been narrating everything, from washing his hands to “knocking on the door” before entering the room. There are also genuine technical difficulties, with frustration over audio and internet cutting out. “There’s all this frustration and there’s nowhere to direct it because it’s nobody’s fault,” says Sarah.
When I asked if there had been any positives to this, both said they were glad to have gained some experience in telemedicine. James says he has learned where telehealth can actually be effective—“psych would be pretty chill”—while Sarah knows it’s something they otherwise might not have gained experience in until they were already on the job—as many doctors are doing now. She said being at home, in her own comfort zone, has also allowed her to “take a moment to myself” before going into what can be a stressful assessment. Looked at another way, many of Zoom’s physical limitations could also be a plus, sharpening students’ other senses. “Their skills of observation—just by watching the way someone is positioned, the way that they’re breathing, the way that they’re moving—can provide a lot of information,” Farrell says.
But it’s hard to ignore the limitations of remote clinical training. Some types of learning simply can’t be done via Zoom, and some skills can’t be practiced remotely—actually listening to patients’ hearts or lungs, for example. For these, medical schools need to get back to in-person learning, stat, and many have spent the summer preparing for its return, COVID-19 or no. Sarah says her school is planning to start doing physical exams in person, but history-taking will still be practiced remotely to limit their time in the building. Physical exams also won’t include looking in eyes and noses, with students and SPs wearing masks unless absolutely necessary not to. MacAulay says the decision as to when to bring back in-person encounters is up to individual institutions, with “the welfare and safety of our SPs paramount.” But many SPs say they won’t return to in-person encounters this semester regardless of what schools decide to do. When UCSF School of Medicine sent out a survey to its SPs asking if they would be willing to come in for first-year physical exams in the fall, Valerie said no.
Med schools may be trying to get some live training up and running, but it’s clear remote simulation is also here to stay—some expect it to stick around well past the pandemic, with an ongoing need for telemedicine coaching. Educators have learned how Zoom works and that it works; many have also realized how much time and money can be saved by not having to bring SPs to campus, with more than one bringing up the headache of on-campus parking. When it comes to physical exams, however, nothing will ever replace face-to-face learning—even if it has to be face mask–to–face mask.
*Name changed to protect privacy