Playing the Patient: The Role of Standardized Patients in Medical Education

At the University of Vermont Larner College of Medicine, Standardized Patients (SPs) play a crucial role in the ongoing education of medical students. Trained to accurately and realistically portray patients and evaluate necessary clinical and interpersonal skills, SPs work with medical students to teach them how to perform various examinations, utilize medical technologies such as point-of-care ultrasound machines, take accurate medical histories, and make patients feel comfortable and heard in the clinical environment.

Below, two longtime UVM Standardized Patients, Peter Kurth and Nicole D’Elisa, answer questions about how they became SPs, what their favorite scenarios are, and more.

Kurth (he/him), is an accomplished former journalist and author of five books and has been a Standardized Patient at the University of Vermont Larner College of Medicine since 2015.

A comedian and musician with an extensive theatre background D’Elisa (she/her), has been a Standardized Patient at Larner for just over five years.

Photo taken around half cracked open wooden door. Partially behind the door, can be seen an older man sitting on an exam table in a hospital gown wearing a surgical face mask covering his nose, mouth, and chin.
Standardized Patient Peter Kurth sits in a clinical exam room in the UVM Clinical Simulation Laboratory Assessment Center, waiting for his first practice session of the day with a medical student.  

In your own words, what is a Standardized Patient?

Peter

I prefer the term Simulated Patient, because it conveys more about what the job really is and what we try to do. We aren’t real patients but we are real people. We play assigned roles but bring our own personalities to them, as well as our bodies, which vary in age and condition. Because we’re realistic in our approach and have specific information to share, students can interact with us in the same way they would in a clinical setting. The standardized part of it ensures that, whichever case we’re playing, each of us is adhering to the same format, with the same information, technique, and goals for treatment. All of us are models for physical examination.

Nicole

I see our role as Standardized Patients as a unique and crucial fusion of an actor and a coach. In the most fundamental sense, we guide students through learning and practicing physical exam skills and interviewing skills, through a variety of formats and scenarios — how to ask, listen and touch. Some of the roles we play are scripted, others are more improvised, but everything we do aims to bring the human connection element of the interaction into sharper relief. The sheer variety of the work we do cannot be understated either. In any given week, I might have the opportunity to help students learn how to perform a knee exam, how to ask about intimate partner violence, how to palpate an ovary, how to deliver bad news, or how to deliver a baby.

Young woman with wavy-curly brown hair wearing a surgical face mask covering her nose, mouth, and chin sits on an exam table in a hospital gown, looking at the camera and smiling behind her mask.
Photo of Nicole D’Elisa in an examination room in the UVM Clinical Simulation Laboratory Assessment Center

How did you become a Standardized Patient and what kind of training did you have to receive?

Peter

I applied for the job at the suggestion of friends, two of whom were already working at the University of Vermont Clinical Simulation Laboratory (SIM Lab). I was called to an open interview with other applicants, then trained by UVM Standardized Patient educators Shirley McAdam and Bob Bolyard for each case as they came up. A great advantage was to be placed immediately into the Doctoring Skills course, part of the College’s Vermont Integrated Curriculum Level 1-Foundations course, which trained me in physical exams and, more importantly, in communication skills. I performed as a “Junior SP” with a highly experienced colleague, Vivian Jordan, and was able to learn with her from the ground up.

Nicole

A friend whom I know through the theatre world suggested I apply — I had grown weary of bartending, was eager for something new, and this position fit perfectly with my passion and background in theatre.

I started as a Gynecological Teaching Associate (GTA) trainee. GTAs teach pelvic exams in a standardized, safe, respectful, and monitored environment, using ourselves and other GTAs as the models—an invaluable learning experience for students as they get to practice performing pelvic exams with lots of guidance and feedback. After sharing my theatre background with Shirley and Bob, I slowly began getting recruited and trained for a wider variety of cases. I had never worked as a Standardized Patient anywhere else before, and like many folks, did not even know that such a job existed until I applied.

Older man sits on an exam table looking at the camera. Man wears blue surgical mask covering his nose, mouth, and chin and a hospital gown.
Photo of Peter Kurth in an examination room in the UVM Clinical Simulation Laboratory Assessment Center.

Why did you become a Standardized Patient?

Peter

I wanted to do it at first because I have so much experience as an actual patient. I was diagnosed with HIV infection in 1989 and have been embedded in the medical system for about half of my life. I had written and lectured about HIV and AIDS and regularly assisted my doctors in training interns and residents. Since starting SP work I’ve also had a heart attack, sinus surgery, and cancer, now all in remission. I’m deeply mindful of the challenges presented by illness and the need for strong and empathetic relations with health-care providers.

Nicole

The two things I love most in the world are performing, and fostering meaningful connections with people. This job not only combines these two elements together beautifully, but also envelopes them in a profound sense of purpose. It is always rewarding in theatre to put on a convincing and moving performance for your audience — but this added element of knowing that my performance is directly shaping how future doctors will move through patient encounters is rewarding tenfold, and why I love this work.

Young woman lays on an exam table wearing a hospital gown and blue surgical face mask covering her nose, mouth, and chin. A young male medical student listens to her abdomen with a stethoscope while two male medical students look on from the background.
Medical student Max Breidenstein practices how to conduct an abdominal exam on Standardized Patient Nicole D’Elisa, while classmates Louis Briones (left) and John Burke (right) observe.  

Why are Standardized Patients invaluable in medical education?

Peter

Our first task is to help new students learn to communicate as professionals. Working with Standardized Patients, they practice speaking, asking, listening, and touching. Many students arrive with a natural timidity about performing physical exams. We help them build their confidence in all aspects of interviewing and examination. Our value lies in feedback to them about how it feels to be their patient.

Nicole

In the first few years of medical school, the time students spend with us is their primary opportunity to learn and practice interacting with patients, and we provide a safe and encouraging environment for them to explore these skills. A trusting relationship between a patient and their doctor can be life-altering, and the impact of that relationship often extends far beyond the exam room. For instance, my grandmother unfortunately lost her brother to cancer some years ago, and she always spoke of how incredibly comforting the oncologist was when delivering this news to her, and how this compassionate approach helped her grieving and healing process. This is one of many invaluable skills we help students master through practice and feedback.

Older male sitting on exam table wearing hospital gown and surgical face mask holds two fingers to either side of their neck under their chin. A young male medical student holding a clipboard in one hand and wearing a surgical face masks looks at the older man and holds their left hand up to their own neck under their chin.
Medical student Erik Zhang practices for a Cardiovascular, Respiratory, and Renal Systems (CRR) Clinical Skills Exam (CSE) with Standardized Patient Peter Kurth. In this photo, Kurth demonstrates how to palpate the carotid arteries.  

What is your favorite scenario to work in?

Peter

I do a case for third-year medical students who are in their psychiatry clinical rotation.

What’s special about this case is that it is entirely improvised. Normally we’re given scripts with precise information about ourselves and our health condition, which students need to elicit from us through structured medical interviews. These interviews are designed carefully to cover all areas of concern, beginning with a history of present illness (HPI), a review of symptoms (ROS), a social history, and a review of the electronic medical record to confirm or update the patient’s (our) medical history. In most of our scenarios, all of this happens prior to any physical exam, as it would in a true clinical environment.

With this case, no exam or diagnosis is needed, because I’m portraying a patient who has already been diagnosed with Bipolar Disorder and who has been admitted to the hospital to recover and receive medication following a manic episode.

In this scenario, there is no specific goal except to engage the patient and discover what is bothering him so they can report back to the attending physician. It means that the students also have to improvise, to think on their feet and elicit whatever information they can from a patient who is upset and has been hospitalized  for his own safety.

As the patient, my job is to respond directly to whatever the students are asking me. This gives them a chance to spread their wings and bring their own best judgment to bear on the case. It give us (and them) a chance to see how their communication skills are improving, and, in that sense, each session is unique. We get real insight into the students’ capacity to handle a disorganized interview with an upset and defiant patient. 

Nicole

There is a case I do for psychiatry residents where I portray a woman with Borderline Personality Disorder and Substance Use Disorder. After being admitted to the hospital for attempted suicide following a break up, the woman becomes distraught and attempts to engage in self-harm behaviors. In this scenario, the residents’ goal is to help me deescalate, hand over a scarf which I might use to harm myself, and redirect my focus.

Unlike the scripted and standardized cases we portray, this one is largely improvised, and I allow my own emotions and reactions to the resident’s attempts to communicate with me shape and drive my character – adding a necessary level of passion, seriousness, and reality to the situation.

As someone living with mental health challenges and who has lost two close friends to suicide, this scenario feels deeply personal to me. I hope that by playing this part as realistically, respectfully, and truthfully as I can, I am helping prepare these medical professionals to take a compassionate human-centered approach to similar situations they may encounter, and in doing so, help save and potentially change the lives of their patients and their patients’ loved ones.

Young woman lays on an exam table wearing a hospital gown and blue surgical face mask covering her nose, mouth, and chin. A young male medical student holds a point-of-care (POCUS) ultrasound prone against the woman's lower abdomen while looking at the POCUS machine screen. Another, slightly older man, points to the image on the screen.
Medical student John Burke practices using a point-of-care ultrasound (POCUS) machine on Standardized Patient Nicole D’Elisa while UVM Medical Center emergency medicine resident Noah Rohrer, M.D., guides the session.

What’s the best part about being a Standardized Patient?

Peter

Far and away, the most rewarding and exciting thing is to see students mature toward their goal of becoming doctors. First-year students always arrive at med school with a great capacity for learning. But sometimes learning needs to get out of the way in favor of relating to the patient in front of them. A doctor needs learning, training, and communication to work together. My joy is to see awkwardness transformed into assurance as students move forward.

Nicole

This job is rewarding in so many ways, it’s hard to choose. I think watching students overcome their timidity and nervousness in clinical settings in their first year of school, and become confident, compassionate and skillful in their approach to patient interactions is by and large the most rewarding process to be a part of. A close second would be witnessing students have “Aha!” moments — the first time they palpate the edge of the liver, visualize the ear drum or find the optic disc — as that never ceases to be exciting for me as an SP.

Older male sitting on exam table wearing hospital gown and surgical face masks sits with his back to a young male medical student who is holding a stethoscope against his back.
Medical student Erik Zhang practices for a Cardiovascular, Respiratory, and Renal Systems (CRR) Clinical Skills Exam (CSE) with Standardized Patient Peter Kurth. In this photo, Zhang listens to lung sounds using a stethoscope. 

How has your work as a Standardized Patient changed and transformed over time?

Peter

Basically, I’m now very familiar with our cases and procedures for assessment, which allows for deeper and more authentic presentation and communication with students. Every case we do involves a lot of listening and being present. The key is to be fully real and attentive in simulated encounters.

Nicole

Aside from inevitably aging out of adolescent and pediatric roles, the variety of cases and scenarios I’ve had the opportunity to work in has grown a lot over the last five years. I’d like to think I’ve become a better actor and a better teacher — I am always trying to learn from my colleagues, and maximize students’ feelings of comfort and confidence in clinical settings.

Young woman lays on an exam table wearing a hospital gown and blue surgical face mask covering her nose, mouth, and chin. A young male medical student holds a point-of-care (POCUS) ultrasound prone against the woman's lower abdomen while looking at the POCUS machine screen. Another, slightly older man, stands behind the medical student and look at the image on the screen.
Medical student Louis Briones practices using a point-of-care ultrasound (POCUS) machine with Standardized Patient Nicole D’Elisa, while UVM Medical Center emergency medicine resident Noah Rohrer, M.D., provides guidance.

What’s it been like to be a Standardized Patient during the COVID-19 pandemic?

Peter

The pandemic required, and to some extent still does, an increase in encounters over Zoom, as well as in-person protocols around distancing and cleanliness. For in-person encounters, a smaller number of students are allowed in the practice rooms with us. We may have had five or six students in the past, while now we have only two or three to meet safety requirements. I’m glad to say that COVID hasn’t prevented us from doing our jobs.

Nicole

In the beginning of the pandemic, virtually all our work was done over Zoom. This was challenging for a lot of sessions, as a huge part of our job is teaching physical exams. Fortunately, we have been able to resume in-person teaching for most of these sessions, albeit to smaller groups of students at a time. I feel very grateful to have been able to continue this work during COVID. 

Anything else you want to add?

Peter

Apart from anything else, we have a tremendous amount of fun. The job is always interesting and enlightening.

Nicole

This job is a tremendous amount of fun, and I hope to continue to be an SP for many, many years to come.

To learn more about the University of Vermont Clinical Simulation Laboratory and Standardized Patients, or, if you’re interested in becoming a Standardized Patient, visit https://www.med.uvm.edu/simlab/patients.

1 thought on “Playing the Patient: The Role of Standardized Patients in Medical Education”

What are your thoughts about this topic?