In early June, Melinda Massie told her doctor she’d been experiencing irregular periods. A week later, she’d returned — this time, complaining of diarrhea. The next week, she spoke of dizziness. The next, back pain. 

Massie is a standardized patient, someone trained to act like a patient so students in medicine and other health care professions can practice clinical skills in a simulated environment. She’s worked with the TCU School of Medicine since the school’s first cohort in 2019.

Standardized patients, she said, create space for students to experiment, make mistakes and grow as future physicians without unintentionally harming real patients. “We’re their safety net.” 

Ms. Dugger comes to medical school

The inaugural encounter between standardized patients and medical students took place in the early 1960s, when Dr. Howard Barrows, a neurologist and professor at the University of Southern California, created the case of Patty Dugger. 

Dugger had multiple sclerosis, and her lower body was paralyzed. Barrows, who needed a uniform method for evaluating his students’ clinical skills, based her story on a real patient at Los Angeles County Hospital. He asked a model from the art department to adopt Dugger’s persona and record her interactions with each medical student. 

Initially, the idea garnered skepticism, not support. A headline in the LA Herald-Examiner proclaimed “Hollywood Invades USC Medical School.” Medical schools around the country complained to the USC dean about the practice. Detractors said Barrow’s methodologies sullied medical education by involving “actors.”

Barrow persisted — students loved the technique — and the practice held. Decades later, “nearly all U.S. medical schools,” including the TCU School of Medicine and the Texas College of Osteopathic Medicine, use standardized patients in their curriculum, according to the Association of American Medical Colleges. 

Teaching students to not choke patients

In 2019, Massie stumbled upon the standardized patient opportunity in a Facebook group for actors. 

In college, she’d acted while waiting tables and bartending on the side (back then, the latter was “mainly beer and surliness,” she said). Afterward, she worked as a professional ballroom dancer, event planner, home organizer and performer with the Fort Worth Opera. She’d wanted to get into acting full time when she found the Facebook post. 

“Whenever I saw this, my first thought was, ‘Oooh, acting gig,’” she said. “But being here, and having a tiny, little part in helping shape future doctors — and, you know, the future of medicine … is just really cool.”

Each case requires a three-hour training over Zoom; multiple standardized patients discuss the same case — the patient’s medical history, family history, lifestyle and ailments, filling in personal details like the breed of the patient’s dog, the names of the patient’s children, the patient’s spouse’s job. “All of the little details that make it real,” Massie said. “It’s a big group effort.” 

The standardized patients have a few days to memorize the information and prepare for “encounters,” or interactions with one or more medical students practicing a clinical skill. The day of the encounters, the standardized patients may don medical gowns and add moulage, or mock injuries, to increase the realism for the students. 

Left, Melinda Massie created track marks on her arm when portraying a patient seeking drugs. Right, she used makeup to form a skin rash for a scabies case. (Courtesy | Melinda Massie)

The standardized patients usually have three to five encounters per day, Massie said — sometimes as many as 10. 

The encounters can be “emotional work,” she said, because of the heaviness of some of the cases. The TCU School of Medicine acknowledges the challenge, providing understudies for each case and addressing the standardized patients’ feedback.

“This is about the students and giving them the best learning experience that we can,” Massie said. The school knows “that, if we’re not taken care of, we can’t do that.” 

After each encounter, the standardized patient offers feedback to the students — about their communication, their approach, even their nonverbals like facial expressions and hand gestures. The feedback is formulaic, Massie said, to critique but not discourage. 

Once, during a thyroid exam, a medical student grazed her thumbs on Massie’s neck. During the feedback session, Massie said she felt as if the student might choke her. Massie saw the student in the hallway a few weeks later. “She told me, ‘I will always remember how to not choke out a patient because of you.’”

Adrenaline kicks and a posture of empathy

For students on the other side of the exam table, the standardized patient encounter is “crucial,” said Kendrick Lim, a fourth-year medical student at the Texas College of Osteopathic Medicine. 

Lim began interacting with standardized patients in his first semester. The encounters allowed him to concretize good habits: asking for consent before touching a patient, outlining what comes next in a procedure, keeping his thoughts succinct and organized under the pressure of time. 

In his first semester at the Texas College of Osteopathic Medicine, medical student Kendrick Lim performs an ear, nose and throat exam on a standardized patient. (Courtesy | Texas College of Osteopathic Medicine)

“​​We learn about that in the books,” he said. “But until you really apply that in a standardized patient encounter … it’s very hard to consolidate all the questions, what you’re looking for, into one succinct setting.”

The pressure of the encounter is partly what separates standardized patients from other simulated experiences in medical education — like mannequins and task trainers, said Josh Christian, business operations manager for The University of North Texas Health Science Center’s newly renovated Regional Simulation Center. Task trainers are fake body parts on which students can practice specific skills like blood draws. 

“​​Any time you have an interaction with a new person, especially a new patient, for a student doctor, you get that adrenaline kick,” Christian said. “We need to make sure that you’re able to still think critically and communicate well … within the timeframe.”

Now in clinical rotations, Lim not only has an efficient system, but a posture: He approaches patients with an awareness of their complexity beyond the exam room. 

Once, during his first year, Lim met with a standardized patient whose business had recently burned down. The patient came in for knee pain, but his somberness prompted Lim to match his energy and ask questions. When the patient’s money troubles surfaced, Lim validated the struggle — then referred him to a social worker who could offer financial assistance. 

“Every patient comes from a different walk of life,” Lim said. “They come to the clinic, or the ER, or the hospital to seek help for their medical complaints, but there are so many more things happening outside of the medical aspect of their life.”

As for Massie, the job is part-time. She calls it “the best gig ever.” She earns $20 an hour and pursues other acting roles when she’s not at the medical school. Last year, she played an extra in 12 Mighty Orphans and in Taylor Sheridan’s 1883

Christian doesn’t see the standardized patients as actors, he said, but people from the community who want to further medical education. 

“The standardized patients are such a great group of people,” he said. “They’re the ones that give up their time to make sure that we’re going to have doctors in the future.”

“I would argue the standardized patient program, more than anything else, prepares them to actually work with the community.” 

Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.

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Alexis Allison

Alexis Allison covers health for the Fort Worth Report. When she can, she'll slip in an illustration or two. Allison is a former high school English teacher and hopes her journalism is likewise educational....