Left:Veteran SPs chat about their assigned diseases before testing begins. Right: Jo-Ann Reteguiz, MD, gives students last-minute instructions.

THE OSCES CATCH ON
Finding a good method for judging students' competence with patients, however, was a long time in coming. Other formats were tried, but fell short. Then Howard Barrows, MD, trained a healthy artist's model to play the role of a patient with multiple sclerosis at the University of Southern California. It was so successful, Barrows suggested other medical schools try the same method. SPs are now used nationwide.

The program began at NJMS in 1987. Jo-Ann Reteguiz, MD, medicine clerkship course director, has given some 500 students OSCEs. She's written many of the cases herself and is the co-author of a student textbook, "Mastering the OSCE and CSA."

"Over the last 30 years, the standardized patient examination has evolved into an important tool for the teaching and assessment of physicians," she says.

Ann Smith is Reteguiz's right-hand-man. As coordinator of the standardized patient program, she recruited the first actors from drama departments at local colleges and from an acting troupe known as The Mental Health Players. Soon people came from far and near. "Since we're so close to New York City, we have a lot of extremely talented but unemployed actors working with us," she says. "Every case is rehearsed to perfection - right down to the exact moment the patient is supposed to cry out in pain - so the SPs give remarkably realistic performances. In fact, there are reports of SPs being in physicians' offices, and even they couldn't tell that some of their patients were actors."

Anxious students wait their turn to begin the day's testing.

SPs earn about $20 an hour, but playing sick involves much more than just acting. Prospective SPs must go through 12 hours of training - funded by the Foundation of UMDNJ - memorize several different scripts and pass a mock exam. Once a "patient," they have to pay strict attention to detail. After the student leaves the room, the SP must recall and record the tasks the student did or did not perform, using a checklist of up to 25 items. Nonverbal cues are also noted: Did the student seem aware of the need for modesty, was he or she arrogant, indifferent, interested, bored, and/or empathetic? The list must be finished in less than five minutes.

And such quick thinking is the order for the entire day. "You never know what off-the-wall questions a student might ask or what procedure he may think is necessary," Smith says. “We once had a student who wanted to do a rectal exam. Mortified, the SP asked to use the rest room, then came and told me what happened." Smith says that SPs now have a card with the results of either a rectal or pelvic exam to give the student, if those tests are required as part of the scenario.

Some SPs are people who have actual medical conditions, but are stable and have the stamina to play a role. Right now Smith has a woman who has multiple sclerosis on her SP roster, and in the past she's had diabetics, recovered heart attack victims and people with irregular heartbeats.

"We're very sensitive when asking someone to play a particular part," Smith says. "Some cases are too close to home, and the SP doesn't want to relive it, even if it is only a simulation. "She's also careful that prospective standardized patients don't have a hidden agenda, such as a loathing for physicians or the medical profession in general. "Believe it or not I've had people who feel that way, because they had a bad experience."


Future physician Ryan Jander listens intently to a "patients" complaints.

THE TESTS BEGIN
On a typical test day, the SPs arrive early and are treated to a complementary breakfast. They chat and perhaps go over their scripts one last time. Smith applies makeup on those who need it.

"Makeup is very important because it's a major clue to the patient's illness, "she says. "We go to great lengths to make it look like the real thing. "Reteguiz helps Smith, who has become quite the makeup artist. For a case of hepatitis, Smith spreads a yellow cream all over the SP's body and puts fluorescein drops into the eyes. The whites of the eyes turn yellow, but they are not at all harmed.

To make a woman look as if she was physically abused, Smith applies bruises to the patient's body, adjusting the color, depending on how old they are meant to be: A newly inflicted bruise will be purple and black, and one that has started to heal will have a touch of green. She paints a pseudo-gangrenous foot dark green and black with a sponge, and has the patient sit in a wheelchair with the foot elevated. A gout sufferer gets his big toe painted red and a heat pack placed under his foot, so it's hot to the touch. A rash - used in a variety of cases - is red paint dabbed on the body with a cotton swab. The same method is used to put track marks on the arm of a supposed junkie.

Maladies like heart attack, stroke, hypertension, ectopic pregnancy, Parkinson's disease, and meningitis don't need makeup. Neither do SPs playing an addict who is pretending to be ill in order to get prescription drugs.

Dressed appropriately, the SPs go to their assigned examining room or station. On the outside of the station door is pertinent background on the patient: age, occupation, main complaints and vital signs. The time allotted for that station is also posted; usually it's no more than 15 minutes. Official clock-watchers outside each door signal when time's up by knocking. When the student leaves, the SP fills out the evaluation form and the process begins again with the next student.

Meanwhile, the student moves either to another station or to what's called an interstation. Here he or she has about 5 minutes to interpret additional information on the previous patient. The interstation following a possible heart attack victim, for instance, might contain that patient's EKG and chest x-ray. The student may also be asked what blood work should be ordered to confirm the diagnosis.

There are 40 different cases currently being used at NJMS, but not all deal with the physical aspect of health. Those that don't are among the most difficult. In one scenario the student must explain to a man that his wife, who was in an auto accident, is brain-dead and will never recover. The student then asks permission to turn off the respirator and harvest the wife's organs. continued