I was recently given the opportunity to act as a standardized neurology patient in a case simulation for a group of medical students. When I was in training, we often did simulations with mannequins, but since it is difficult for a mannequin to display subtle neurologic findings, having a neurology-trained doctor play the patient can make the simulation far more realistic. I have since played the parts of a stroke and a seizure patient multiple times, and I continue to be struck by the uniqueness of the experience. The students I have seen have impressed me with their knowledge and abilities, but have also reminded me how overwhelming medicine was when I started my medical journey.
The students often begin by forgetting to ask me my name, which is not an indicator of a lack of bedside manner. I remember doing the same thing when I was in training. Although a simulation is meant to be representative of real life, there is an undertone of surrealism that is very difficult to overcome -- the stillness of a simulated patient's room simply does not match the hustle and bustle of a true emergency department. Combine this with the stress of playing a role they have not finished training for and the fact that I look nothing like a 56-year-old with a brain tumor (spoiler alert!), and the students often forget I am not playing myself. Although I am meant to be "Emily Clarke," the students often autopilot to using my actual name. For unclear reasons that I find very amusing (and could probably fuel multiple papers on the doctor-patient hierarchy), in simulations I am often "Ms. Howard" -- I keep my name but lose my doctorate.
The patient I am playing is suffering from abulia -- a lack of motivation to do anything due to dysfunction of the frontal lobes of the brain. What this means for the poor students is that I will be an absolute nightmare to examine. I am thoroughly apathetic and answer most questions with a shrug. When asked if I know where I am, I respond with "I don't care." I pull away from attempts to formally assess my strength and at one point, when asked if something is bothering me, I respond in true abulic fashion with "You are." To make matters even worse for the students, at some point I will fake an aggressive seizure in front of them.
As they work through the case, I am fascinated (and often greatly entertained) by watching the students realize that what they have learned in books and lectures has left them unprepared to fully practice medicine. For example, when prompted with the fact that my blood pressure is too high, they must name an appropriate lowering medication (which they are usually able to do) and dosage (which is usually harder -- one group guessed a dose of labetalol that was 50 times a normal dose). Universally, the students have attempted to consult neurosurgery for the brain tumor without getting an MRI first (which usually results in an irritated neurosurgeon), and they always want to admit me to an intensive care unit even though there is no reason to believe I am imminently dying.
None of this is surprising. The students are only in their second of four years of medical school, and everything they have learned so far has been from a lecture or a textbook. As they go through the next 2 years, they will continue to be exposed to how medicine is practiced during their clinical rotations in the hospital. The most learning, however, will come during their first year after medical school. This is when they will be formally assigned the title of "doctor," and will take on the responsibility of ordering tests and treatments for patients themselves. Having seen firsthand how much the students have already picked up, I am fully confident they will adapt quickly to that role.
My experience as a standardized patient has been more than just entertaining -- it has given me hope. There is more to being a doctor than knowing how to read a CT, when to call neurosurgery, or what dose of which medication to give. There is a human aspect of doctoring, of caring about the patient, that is nearly impossible to teach. It is tempting for medical professionals to get lost in the data, and forget the patient is sitting in front of them. This is especially true of a simulation when the "patient" is, by definition, just there to provide information for a fabricated case. Yet, in multiple rounds of simulations with these students, not a single group has forgotten me. Throughout the cases, they have checked in to make sure I was okay and explained to me what they were thinking about or why they were ordering certain tests or drugs. Their care for a fake patient matched some of the best doctors I have worked with and is what makes me certain these future physicians will be a positive force of change in medicine. Any patients they see will be in good hands.
Danielle Howard, MD, is a PGY-5 and Multiple Sclerosis Fellow at Brigham and Women's Neurology.