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Join Esther Covington, a professional standardized patient. Esther shares her firsthand experiences, shedding light on the critical role communication, empathy, and assumptions play in medical education. We delve into the impact of assumptions on patient care, the importance of empathy in health care, and how health care providers can cultivate these essential skills. Discover how Esther’s insights as a standardized patient offer a unique perspective on the challenges faced by medical trainees and practicing physicians.

Esther Covington is a professional standardized patient.

She discusses the KevinMD article, “The impact of assumptions on patient communication in medical training.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Esther Covington. She’s a professional standardized patient. Today’s KevinMD article is titled “The impact of assumptions on patient communication in medical training.” Esther, welcome to the show.

Esther Covington: Thank you very much. Glad to be here.

Kevin Pho: So we’ll talk about your article in a little bit. First off, briefly share your story and journey.

Esther Covington: Unlike most of your guests, my background is in the performing arts, although both of my grandfathers were doctors, my brother’s a doctor and my other brother’s a nurse practitioner, so medicine certainly runs in the family. It was my brother who’s a radiologist who encouraged me to write about my experience as a standardized patient.

I started working as a standardized patient 18 years ago. I was in a theater company, and I ended up falling off the set during a show. They sent me to the nearest hospital, which happened to be a teaching hospital, and when they asked me how I hurt myself, I said, “At work.” They said, “What do you do?” I said, “I’m an actor.” They said, “Upstairs.” I said, “Upstairs?” And they said, “Yes, there are actors who are hired to play patients for medical students.” That was in 2005, and that’s when I started working as a standardized patient. Since then, I’ve been working at a number of medical schools in the area where I live.

I also enjoy writing as a hobby, and my brother, the radiologist, was the one who encouraged me to write about some of my experiences, because he mentioned that there is a lot written on KevinMD about the medicine side but not a lot about the patient side. So I wanted to add my voice, especially because as you see thousands and thousands of medical students, you start to see some consistent patterns, and I wanted to bring that.

Kevin Pho: So for those who aren’t familiar with how medical education works, take us through a typical day of what you do as a standardized patient.

Esther Covington: Fortunately, there is no typical day. But generally, the thing you have to understand as a standardized patient is that you’re going to see a lot of students, and it is about consistency. It’s making sure that every single student gets the same answers if they ask the same questions, but each experience will be different, because each student brings their own understanding of medicine into it. It can involve a lot of monotony, especially in the cases where you’re supposed to be in pain, and you’re thinking, “Oh, I have to pretend to have pancreatitis for 12 hours today,” and that can be very, very draining. The other hard part is that oftentimes you’re asked to provide feedback or fill out a checklist on what they did, and after seeing maybe 12 students in a day, you forget: “Oh, wait, did they palpate my abdomen? Did they listen to my heart?” So that’s probably the hardest part.

The best part, of course, is that you don’t have the same day twice, which I like, and that you get to see students over the course of their medical education, from the first day, when they come in and they’re shaking as they listen to your heart, to their fourth year, when they’re confident and they know what they’re doing. It’s wonderful to see that growth.

Kevin Pho: So I’ve always wondered, how much creative license do you have as a standardized patient? How far off script are you allowed to go?

Esther Covington: Not very far at all, and that’s part of the reason why they call it standardized: They want to make sure that you give the same experience to every student. However, there is license based on what they ask. If they ask you questions that aren’t in the script, you can provide some of your own detail, but you are encouraged, of course, to keep your answers short, because you don’t want to divert at all. It’s not like that episode of Seinfeld. When most people hear about this, that’s what they think of, that episode of Seinfeld where he’s like, “It was a long day.” Unfortunately, you don’t get to do any of that, but you can sometimes add something lighthearted or add a personal touch.

Kevin Pho: Now, you obviously have a background in the performing arts. If someone were interested in becoming a professional standardized patient, how would one go about doing that?

Esther Covington: If there’s a medical school in your area, the best thing to do is to find the education director at the medical school, contact them and ask about it. Although most of the standardized patients I know have backgrounds in the performing arts, there are a number of people who don’t. It’s a fabulous job, especially for retirees. In fact, my father, who’s never been an actor, started doing standardized patient work at his local school once he retired. The main thing is that you have to have a lot of availability, you have to be willing to take direction well, and you have to memorize a set amount of information, but it’s usually not too hard.

Kevin Pho: All right, let’s talk about your KevinMD article. You mentioned that there are patterns you’ve seen after doing thousands and thousands of these. It’s titled “The impact of assumptions on patient communication in medical training.” How did the article come together?

Esther Covington: This came about because of one particularly heinous encounter with a student who completely went off the rails, which is very, very unusual. Most students actually keep within the confines of their assigned case, but this particular student completely went off the rails and told the patient that she was completely nuts and crazy. The underlying message, though, is one that I’ve seen a lot, with students, and with doctors in my own experience. I have a number of health conditions that require me to see a lot of doctors. There are a lot of people who think that they know better than the patient, that they have more knowledge about medicine, which they do, but who aren’t willing to either listen carefully to what a patient says or trust a patient. That is consistently where students and doctors get into a lot of issues: by making assumptions based on what they think they know, when in essence they’re not actually listening to what their patient is saying.

Kevin Pho: So give us an example. What would be some phrases they would say? What would be a story you could share that would really illustrate that?

Esther Covington: In my own experience, I went in a few years ago because every time I would get a cold, I would have a cough that would linger for months and months. So I went to see a pulmonologist to see if maybe there was something to that, and they ended up doing some breathing tests. Despite the fact that I had told the doctor what my issues were, she had apparently pulled the wrong patient’s results off the printer, and so she came to tell me basically that there was nothing wrong with me, that it was all in my head. I don’t even remember what she thought the issue was, but I was trying to tell her, “No, this isn’t the case.” Then another doctor actually came in and said, “Oh, you have the wrong patient’s results, and here are the real results,” and it turns out I actually had terrible asthma. But because she was unwilling to listen, had she not gotten those results, she would have sent me away saying, “No, no, no, you’re fine. You can breathe. It’s all in your head.” There was this moment of, “Oh, sorry,” but that was also the moment when I said, “I’m never going to go back to this doctor,” because she was not willing to listen when I said I was having trouble breathing.

Kevin Pho: Now, in your role as a professional standardized patient, if you encounter a student who may not be listening as well as they should, how would you give feedback to improve that?

Esther Covington: A lot of the time we don’t get to give one-on-one feedback. We have to fill out a checklist, and that’s the sort of thing I would note for the instructor, and we’re always encouraged to do it in a professional manner. If I am allowed to give one-on-one feedback, I’m always going to let them know how I felt, because my experience as a patient may be very different from someone else’s; maybe our personalities were different or whatnot. But I will always let them know, “When you said X, Y and Z, I felt this way, and I would encourage you next time perhaps not to say this,” or “Next time, say something empathetic.” I try to give them some sort of useful or corrective feedback if possible.

Kevin Pho: So you used the word “empathetic,” and this is a question I often ask: Do you think empathy can be taught in an educational setting, or do you think it’s mostly innate, something students bring to the profession?

Esther Covington: I think genuine empathy can be taught, but the way it is often taught is in phrases that sound very hollow. A very common thing at medical schools is, “Oh, I’m sorry to hear that. Oh, I’m sorry to hear that,” and they keep repeating it. You could actually be sorry to hear it, but if I hear that over and over again, it sounds hollow. You don’t have to say the words “I’m sorry.” Sometimes it can just be, “That sounds rough,” or “Looks like you’re in pain. I’m going to make sure that we take good care of you.” There are all sorts of ways to show it. I think the empathy is innate; it’s the way to express it that can be taught, and in some ways maybe it should be taught differently. Somebody who innately isn’t comfortable saying “I’m so sorry,” but is comfortable saying “Oh, you look like you’re in pain,” is showing empathy, and I think a lot of students just need to go with their instincts more.

Kevin Pho: Now, again, you have a background in the performing arts. Do you think there are techniques from acting that physicians or medical students can learn to be better interpersonally in the exam room?

Esther Covington: I think one of the reasons why they like actors is that we are able to show pain, perhaps realistic levels of pain, better than somebody who isn’t an actor. But I think it’s especially useful to hire actors for the really emotional cases, where you’re told that you have cancer, or that you just lost your baby, or that somebody has died, because we are able to bring real tears, or real anger when you’re talking about the PTSD cases or that sort of thing. You can see the students really react. The more real your reaction is, the more real the student’s reaction is, and that’s where it is very valuable to have somebody with a performing arts background over somebody without one.

Kevin Pho: Now, you’ve been doing this for many, many years. Have you seen any trends among the medical students and in the medical education settings you’ve been in? Has anything changed or evolved over the last few years in terms of your interactions?

Esther Covington: Yes. The main thing I’m encouraged by is that a lot of the medical schools are focusing on inclusivity more than they were when I first started, and I think that’s wonderful, especially since one of my previous articles was about cultural sensitivities and differences. So I’m really glad to see that being addressed.

Unfortunately, the trend I’m seeing is that a lot of medical students are being coddled more than before, and that doesn’t do anybody any good. Passing a medical student who is not performing well clinically can have dire consequences for the safety and health of patients. Even though they need a safe space to learn, they also need to learn that medicine is a tough profession and people’s lives are at stake, and so in some cases it’s, “Suck it up, buttercup. You’ve got to deal with this.” So that’s sort of the downside I’ve seen.

Kevin Pho: Now, we have a lot of medical students who listen to this podcast. For their interactions with standardized patients, do you have any advice you could share with them, and for that matter with physicians as well? Because interacting with standardized patients is really just a reflection of how we interact with real patients. So tell us what kind of advice you have to share with us.

Esther Covington: Don’t go in with any preconceived notions about who this patient is, and listen, listen, listen to what they have to say. If you are thinking in your mind of the next question you want to ask, you’re going to miss what your patient is saying. Whether it’s in the doctor’s office or in an actual clinical setting, your patients are going to give you hints and clues, especially about hard-to-talk-about subjects or things that they’re uncomfortable with. The more you listen and watch their body language, but mainly just listen to what they have to say before speaking, the better, and that goes such a long way.

Kevin Pho: We’re talking to Esther Covington. She’s a professional standardized patient. Her KevinMD article is titled “The impact of assumptions on patient communication in medical training.” Esther, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Esther Covington: First of all, thank you all so much for the work you do. Medicine is incredible, and I’m so grateful for the wonderful doctors out there. My other message would be to trust your instincts as a person. Everybody has something to add. Don’t worry about being the best clinician; if you know that you are a great listener, then maybe share that with your fellow doctors who aren’t. But just trust your patients. We’re not lying to you. We are there for care, so trust us when we come in with a real issue. And especially for those who are working with standardized patients: We’re not there to trick you. We want you to succeed. We want you to pass. We are on your team. Medicine is a team, patients and doctors, and we all want the same outcome.

Kevin Pho: Esther, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

Esther Covington: Thanks. It’s been a pleasure.