It was a year since Stephen Rogers, a schoolteacher, had been diagnosed with lung cancer, and six months since he had surgery to remove nodules on his lungs and one of his lymph nodes. Subsequent tests showed no remaining cancer, and Rogers was feeling great today. Dressed in a bright blue polo shirt and khakis, he excitedly stood up to greet his Johns Hopkins oncologist and told him how good he was feeling.

The oncologist, unfortunately, had bad news: “I’m sorry to say, I do think the cancer came back.”
“Really?” Rogers asked. “Because there was nothing there six months ago.”

The oncologist noted that there were spots in his chest, on another lymph node and his liver. “I wish I didn’t have bad news like this to share,” he said.

This was the second of four interactions Rogers and his oncologist would have, and ultimately, the cancer would metastasize and take Rogers’ life.

While cases like this are unfortunately common, this one was a little different — it was a simulated exercise. The role of Rogers was being performed by Tom Wyatt, an actor and educator known as a standardized patient (SP) at Johns Hopkins, who is trained to portray particular illnesses and injuries. As simulated patients, SPs help medical students, fellows, residents and faculty members develop their communication and clinical skills.

The oncologist in this case was a Johns Hopkins hematology and medical oncology fellow learning how to help a patient navigate cancer diagnosis, treatment and recurrence.

Over the course of four interactions totaling just one hour, 16.5 months would pass in the case. Wyatt changed his clothes, yellowed his skin, pretended to be itchy from an infection, acted lethargic and simulated having trouble speaking toward the end. He created a palpable feeling of tension and sadness, and the fellow responded with empathy, taking the concerns of his patient seriously and walking him through all details of treatment.

After the end of the exercise — which the Johns Hopkins Medicine Simulation Center has been running with hematology and medical oncology fellows at the Kimmel Cancer Center for nearly 15 years — Wyatt gave feedback. He first focused on positive aspects (empathetic language and warnings when bad news was coming) and asked the fellow how he thought it went, then offered some respectful pointers (speaking too quickly at times, giving too much information too fast). Wyatt ended by asking how the fellowship is going.

"I believe you can’t be a good SP unless you love the students a little bit,” says Tom Wyatt, who has worked as a standardized patient at Johns Hopkins since the mid-1990s.

“I believe you can’t be a good SP unless you love the students a little bit,” Wyatt says. “You have to really care about them and want them to succeed at all times — not only for us now, but for the future, for the people who actually need them as doctors.”

A Menu of Possibilities

Wyatt is one of more than 160 SPs at Johns Hopkins, a group that includes health care professionals, lawyers, writers and professors, in addition to many actors, ranging in age from their 20s to 80s. Some hope their work as an SP can help prevent others from having bad medical experiences they — or a family member — have encountered.

Wyatt has worked as an SP since the mid-1990s. A trained theater actor, director and choreographer, he joined the Johns Hopkins program when he moved back to Maryland after working as an actor in New York City.

It’s a job that requires multitasking — sticking to a story and prompts while critically observing and improvising in reaction to the learner’s actions, responses and body language, all while the SP might be crying or screaming and acting confrontational or simply in utter disbelief.

Among the newer SPs is Janet Serwint, professor emerita of pediatrics and public health at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health. During her three decades on the faculty, she mentored many pediatric trainees and worked extensively in resident education and faculty development with a focus on communication, humanism and physician well-being.

A longtime professor of pediatrics, Janet Serwint saw so much value in the standardized patient program that she decided to become an SP herself.

Serwint also led the Cameron Kravitt Foundation’s annual death and bereavement seminar, which offers pediatric and medicine-pediatric residents a chance to practice telling parents (played by SPs) that their child has died.

She saw so much value in the SP program that she decided to become one herself.

“There’s good evidence to show that if you trust your doctor or if you feel your doctor cares about you, the outcomes are better, and you’re more likely to follow their advice,” Serwint says. “A lot of medicine is fact-based, but there’s still an art — the interaction we have with patients.

“When a patient walks in the door, you never can predict what they’re going to say, so you’ve got to be able to react and have a menu of possibilities on how to interact with them in the most positive, compassionate and humanistic way.”

SPs at Johns Hopkins work across a diversity of cases — including in exercises dealing with organ donation, domestic abuse, caregiver well-being, disclosing medical error and malpractice. They take part in well-person visits or act as peers of the doctors or other staff members. They also work closely with first-year medical students as the students practice taking medical histories and performing basic exams.

Since joining the SP team, Serwint has served in cases involving abdominal pain, breathing issues and medical errors — cases that allow her to focus her feedback on the quality of the physical exam as well as the learner’s ability to describe the diagnosis and plan. She’s found that she’s very good at acting angry. And in working a case in which her “husband” dies, she also discovered that she can cry in the moment.

This ability for both SPs and trainees to emotionally commit to such scenarios is precisely what puts the learners in the mindset of treating these as real cases.

“In a lot of ways, you do feel the difficulties and real emotions that you’d have in clinical scenarios,” says Reed Jenkins, a fourth-year medical student. “I’m always impressed that they can very subtly lead you and show you what you’re maybe not picking up on. They’re very skilled at improving my interaction within the moment.”

In addition to the pool of SPs at Johns Hopkins, there are genitourinary teaching associates, who are teachers and practice models for genital, breast and rectal exams; and physical exam teaching associates, who teach and act as models for the core components of physical exams, including abdominal, neurological, cardiovascular and pulmonary.

Microaggressions — and More

The concept of standardized patients dates back to 1963, when Howard Barrows, a neurologist and educator at the University of Southern California (USC), was inspired by a neurology patient who faked symptoms to get revenge on a hostile medical student. Barrows wondered if a nonpatient could fake symptoms and created the first standardized patient, “Patty Duggar,” a woman with multiple sclerosis and paraplegia complaining of bladder control issues. After coaching an artist’s model, Rose McWilliams, from USC’s art school to fill the role, he created a checklist for her to fill out after her interactions with students.

Johns Hopkins first began using SPs in 1973 with students in the Health Associates program to help build their interpersonal communication skills. While SPs were tapped sporadically over the years, the current program traces its roots back to 1991, when the Clinical Education Center was launched to serve medical and nursing students from Johns Hopkins and area medical schools.

The SP program at Johns Hopkins ramped up under the late John Shatzer, who had a Ph.D. in educational psychology and was director of the Office of Medical Education Services at the Johns Hopkins University School of Medicine from 1991–2005.

In the beginning, SPs were mainly involved in exercises to practice basic skills — how to do a physical exam, take a medical history and generally talk to patients. Now, among their diversity of cases, they also help teach medical students about microaggressions and upstander skills, and they work with nonmedical employees (including front desk teams) to improve patient registration and with security staff on de-escalation. They even serve as ultrasound models. In addition to teaching exercises, SPs participate in formal exams for medical trainees in which they fill out checklists and rating scales to measure learner performance.

The exercises and exams take place at the Johns Hopkins Medicine Simulation Center, which has two locations, one in the Levi Watkins, Jr., M.D., Outpatient Center, and the other on the seventh floor of the Alfred Blalock Building. Additionally, SPs work cases at the Johns Hopkins University School of Nursing’s Center for Simulation & Immersive Learning and other locations on and off campus, including at other institutions.

The simulation center features a variety of simulated exam and operating rooms, and the ability for faculty members and other SPs to watch and listen through double-paned glass or video recordings.

SPs all begin their Johns Hopkins journey with a two-day training that includes role-playing exercises and training in providing feedback. Afterward, newly minted SPs observe other SPs in simulations before they take part in their first exercise, which is observed by a more senior SP. For every exercise or exam, even ones that SPs repeat every year, a training takes place to ensure the SPs know the cases well and understand what is expected of them.

Each simulation and training is informed by Johns Hopkins faculty members: They design the clinical scenarios and offer SPs guidance on affect, temperament and behavior.

Practicing in a Safe Environment

Julianna Jung

Hopkins’ Julianna Jung, an emergency medicine physician and associate director of the Simulation Center, says that while SPs are not in a position to judge clinical reasoning or diagnostic acumen, they are experts at providing constructive feedback from the patient’s perspective in a manner that clinicians rarely get from real patients.

“They know how the words of the doctor made them feel. They know if the doctor understood them or didn’t. They know if they were persuaded to follow a course of action or weren’t convinced, and they know that to a much greater degree than we do as faculty observers,” she says. “They know better than anybody else what it’s like to be in the shoes of a patient. They’re the experts in that, so their feedback is absolutely crucial, and it’s impossible to get in any other way.”

Faculty members observe and give feedback to learners in many simulations, and sometimes give feedback alongside SPs. Jung says when she’s working with SPs in training, she tries to help them tailor their feedback to the learner’s level — feedback for a first-year student could be drastically different from feedback for a fellow.

Serwint has seen the feedback from SPs evolve over time, from simple checklists to tangible advice. “Just to say, ‘great job’ doesn’t help someone,” she says. “Being specific and also making sure that it resonates with them — I think the learners really appreciate that.”

Nate Irvin, an emergency medicine physician and one of the core educators in the Department of Emergency Medicine, sees the SPs as partners in teaching medical students. He values their acting skills and their ability to nudge learners to provoke specific actions, and he places high importance on the opportunity for learners to grow from feedback.

Nate Irvin

“One of the SPs told me the reason he does it is to make sure that the doctors of the future don’t make the same faux pas as the doctors that have interacted with him and his family,” Irvin says. “I think it’s a really cool opportunity to pay it forward.”

In simulations with difficult patients, Wyatt reminds learners during feedback not to get defensive — it’s not about them, it’s about the situation. Patients may just want sympathy and to talk it out.

“It will, in some way, diffuse the situation and you can get to the real issue, the reason the person is there,” he says. “We can give critical and helpful feedback as long as we frame it as behavior attached to emotion. There is as much of a responsibility to be a good teacher as there is a good actor. In fact, some of our best SPs don’t have any acting background at all.”

Elana Liebow-Feeser, a fourth-year medical student who has worked with Wyatt in several simulations, values having exercises in which she and her fellow students can learn from mistakes.

“These cases are so helpful — to practice in a safe environment where maybe you don’t say the right thing,” she says. “You can talk about it [with the SP], and then when you’re in with a real patient, you’re not as flustered and not causing harm to someone’s care.”

Crucial Representation

As the variety of cases SPs work on has evolved, so has the pool of SPs, with the goal being to have SP demographics reflect Johns Hopkins’ patient population. While there are a number of Black SPs, the group skews older and white. There is also increasing demand for bilingual SPs who can speak Spanish.

Helene Hedian

One gap in the pool was recently filled thanks to an influx of six new transgender and gender-diverse SPs. Most were recruited by Helene Hedian, an internal medicine physician who says about one-third of her primary care patients identify as transgender or gender-diverse.

Among this new group of SPs is Nikki Hartman, a transgender woman in her 60s who began medically transitioning five years ago. Hartman has had her share of difficult and disappointing medical experiences — in the 1990s, in the wake of the AIDS epidemic, a doctor backed away during a visit when they learned she wasn’t sexually binary. Even an open-minded doctor wasn’t able to help her transition due to lack of training in transgender health.

Hartman says she jumped at the opportunity to become an SP.

“I really wanted to give something back to my community because my own journey with doctors, finding a gender-affirming primary care provider, has been a difficult one,” she says. “It’s really wonderful to be seen — to be able to share without fear or being rejected.”

Hartman, a professional director and professor of theater at the University of Maryland, Baltimore County, says learners at Johns Hopkins have been eager to hear more about caring for transgender patients. In some cases, these interactions have been their first with a transgender person.

“It’s critically important to have a doctor who is knowledgeable in the sensitivities of the journey of a transgender person, what it has been like historically in our lives to be rejected from society, ostracized and made to feel inadequate,” Hartman says. “[They need to] see that we’re human beings, and we have particular medical needs.”

Hedian says caring for transgender patients was only superficially covered during her years in medical training. She has since bolstered her knowledge and skills on her own by researching guidelines, joining professional societies, attending conferences and seeking other self-education.

Now, with funding from a Shark Tank grant from the Institute for Excellence in Education at Hopkins, she is working to measure the efficacy of transgender SP training in combination with a workshop on prescribing hormones. Residents participating in exercises with transgender SPs are given pre- and post-exercise surveys that assess their comfort and knowledge in caring for transgender patients, including care related to hormone therapy. Hedian aims to publish the results.

At the same time, Hopkins is working to attract more transgender patients to its primary care practices, which will help patients access medically necessary care and trainees gain experience caring for this patient population, she says.

“I think we should be better preparing our trainees for how to care for trans patients in a consistent way across the board,” says Hedian.

“I really wanted to give something back to my community because my own journey with doctors, finding a gender-affirming primary care provider, has been a difficult one,” says standardized patient Nikki Hartman.

A Profound Exercise

The ultimate goal, says Jung, is that trainees walk away from these experiences better prepared to work with — and communicate with — patients across the vast spectrum of health care.

For Wyatt, one particular story illustrates how impactful the work can be.

It was during an exercise in which the patient was going to die, and the learner cried a little bit during the exercise and the feedback period. Wyatt asked if something triggered her, and she told him that she had met him her very first week of medical school, and that he had been her SP four different times.

“She said, ‘When I was talking to you, it never occurred to me that I would have to tell a patient they were dying, and it would be somebody I like. That just wrecked me,’” Wyatt recalls. “It was incredibly profound and beautiful for me — a validation of everything I hope that my SP work can be.”

Photos by Jennifer Bishop