March 2018

The Nation Reviewed

Patient simulation

By Paul Connolly
Some actors intentionally suffer for their art

Of all the places Tim Ratcliffe has pretended to be unwell – and over the years he’s feigned cancer, bleeding from the bowel, angina, high blood pressure, fainting fits, kidney problems, and limb and joint complaints – Sunbury Day Hospital in Melbourne’s north-west is one of his favourites. “Friendly staff and nice consulting rooms,” he explains.

It was there, late last year, that Ratcliffe played the part of a middle-aged man (“What was his name – Doug?”) who had been experiencing dizziness and at one point fainted. “He put it down to a recent change in medication, a situation that worried him,” Ratcliffe says. His character conveyed as much to the third-year medical students who, one by one, came in to conduct a consultation. Also in the room was a university examiner.

“If they dove straight into information-gathering or I got the sense they were oblivious to or dismissive of my concerns, I’d use the discretion I’d been given to ramp things up,” says Ratcliffe, a hint of amusement in his voice. “I’d say something like, ‘I pick up my grandchild from school and I don’t want to do that one day and faint and crash the car and kill him!’ When that happened, I could see the student think, Fuuuuuuuck, as it’s rammed home that they are not just dealing with a collection of symptoms but a person, and one whose illness can have massive repercussions.”

Ratcliffe, a performer and theatre producer, has enjoyed sideline work as a simulated patient ever since his first gig as a sore knee for University of Melbourne physiotherapy students some 15 years ago. The work of a “sim” patient – a person trained to present the symptoms of an actual patient – is as rewarding as it is challenging, he says. For instance, in objective structured clinical examinations (OSCEs), which test, among other things, history-gathering and examination skills, Ratcliffe can be required to “deliver the same information in the same way” to as many as 30 students in a single day.

At other times, such as with OSCEs (pronounced “oskies”) designed to test a student’s ability to deal with emotion, he’s allowed more flexibility in his responses, and more scope for expression. That said, a sim patient must resist any urge to channel their inner Hamlet or to scream “Stellaaa!” if a sore point, whether physical or emotional, is being poked. “It’s not meant to be a performance,” says Ratcliffe.

Sim patients are commonly used for the teaching and evaluating of students in the health sciences, such as medicine, nursing, physiotherapy, occupational therapy and psychology, and the work varies. For OSCEs, which are commonly set up as a number of 10-minute “stations”, they may play the role of a patient who is complaining of a vague physical ailment, with the vagueness a problem for the student to resolve. Calling upon a script that provides answers to likely questions, the sim patient must engage with the student without volunteering information or leading them in any way, explains Dr Andrea Bergman, the simulated-patient trainer at Monash University’s faculty of medicine, nursing and health sciences. “The intent is that every student receives the same parcel of information, and it’s how they process and prosecute that that helps you assess their clinical skills.”

At the other end of the scale, sim patients are employed to assist medical students to practise more invasive procedures, such as breast checks, pap smears and rectal examinations. Linda [who asked that her surname be withheld] is a teaching associate with the University of Queensland’s 22-year-old simulated patient program, but has for many years also performed such sim patient work at UQ.

Students, she says, usually find having to practise intimate procedures on sim patients initially confronting. Many wouldn’t have seen a naked person before, she adds, and they are terrified of hurting the patient. “That’s a common belief people have, that [pap smears and rectal examinations] are awfully painful. But done correctly they are not.” As a result, Linda says that offering up her body – for $52 an hour – in the hope of improving the skills of tomorrow’s medical professionals, and thus the experiences of their future patients, is not a big deal. “It’s not dinner at the Ritz,” she quips, “but I don’t dread it.”

Before working with trained actors, nursing students at the University of Sydney use each other as mock patients in therapeutic communication skills training, but trainer Dr Jo River finds many don’t take this seriously enough. “It isn’t just because they are engaging with fellow students but they see communication skills as ‘soft skills’, as compared to putting in an IV drip. The other problem is that everyone thinks they communicate well. That’s not necessarily the case in a professional setting.”

Actors, says River, help address this problem, as do the confronting characters and scenarios she and the actors co-create. Such characters could include a distressed family member of a child who is in surgery with a serious head injury, or an elderly person who is in an aged-care facility against her will. “I’m in awe of my sim patients,” River says.

In 2015, River rejigged the faculty’s program by having students team up to interview sim patients. This made students accountable to their peers in what became an assessment task. It also allowed struggling students to use a “time out” card to gather themselves and workshop the issue with their teammates. River also worked to ensure the program emphasised humanistic, “person-centred” communication, encouraging students to engage with patients and get a sense of their lived experience before rushing in to fix things. “Even in hurried environments like hospitals this can be done and I’d argue it actually saves time in the end,” River says. She believes the benefits extend even further. “Nurses who communicate better tend to be happier and more fulfilled in their jobs than those who are merely task-focused.”

Colleen Cook, who works alongside River at the University of Sydney, says being a sim patient is “one of the most exhilarating things I’ve done as an actor”. Students, she says, enter a training scenario knowing it’s a drill, but they soon forget as they are drawn into a complex exchange with a sim patient whose convincing displays of emotion and storytelling break down their bravado and assumptions. “This wouldn’t work unless I can stay in the truth of the character,” says Cook, who has a long performance history in musical theatre, stage and television, including parts on Rake, Love My Way and Water Rats. “The ones who come in with set questions can get confronted very quickly,” she says, adding that the intensity of the training is mutually exhausting. “Bringing things to an emotional head, I can end up nervous, taken aback, bawling. I come out of these sessions like a worn-out dishrag.”

Paul Connolly

Paul Connolly is a Melbourne-based freelance journalist and author, and is the editor of the essay collection Father Figures.

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