Playing the part of the patient

Charmi Shah remembers one of her first encounters with a standardized patient.

“During our first year when we had to do physical exam steps, (the standardized patient) said, ‘I don't think you were in the right spot when you were trying to hit that reflex. Let me show you how to do it,’” the UofL medical student said. “It was really helpful when they would take the time to reshow you. You don't want to hit it wrong on a patient. It's OK to get it wrong when you're in this safe space.”

When future physicians enter medical school, most have limited experience with patients. To help them learn interaction skills, UofL’s Standardized Patient Program provides training sessions in which individuals known as standardized patients, or SPs, role-play as patients with specific medical conditions in a simulated medical setting.

The UofL Standardized Patient Program in the School of Medicine is leading the way in such medical education. Carrie Bohnert '07, director of the program, co-authored curriculum that established industry-standard best practices for standardized patients and was recognized nationally, and the program is responsible for educating future and current health care practitioners across the city.

Along with providing medical students with innovative SP opportunities, the university also instructs those in UofL’s dentistry and nursing schools, in Bellarmine University’s nurse practitioner program and in Sullivan University’s pharmacy and physician assistant programs, as well as medical trainees and nurses at Norton Children’s Hospital.

Why standardized patients?

Standardized patient encounters offer students the opportunity to polish their bedside manner with trained individuals who provide feedback to help them improve their communication and diagnostic skills. In SP encounters, students practice everything from greeting the patient when they enter the room to diagnosing complex neurological conditions.

Third-year medical student Shah said SPs have coached her not only to find reflex points but also to slow down and give the patients time to absorb information and formulate replies.

“When they asked me how I thought the encounter went, I’d always say I know I speak fast. They'd agree and remind me, ‘It's OK to slow down and take pauses even if it may feel a little awkward for you. It allows the patient to process, ask questions and
remember additional details,’” Shah said.

Bohnert manages a team of 30-50 standardized patient employees from a variety of backgrounds who perform multiple scenarios with students throughout the academic year.

“It gives the students a place to explore, to make mistakes and to try out something new in an environment that is understanding of that purpose,” Bohnert said. “It also is a way for us to evaluate students more fairly. No two patients are alike, so evaluating them in the clinical environment would not be as fair. In this environment, we can make sure they have
equivalent presentations.”

Standardized patients follow a script and are trained to portray symptoms and answer questions in a way that is designed to lead the students to diagnose specific medical conditions. They then provide feedback that helps in training and assessing students’ skills.

Students have about one SP session per month through the first three years of medical school. The sessions typically echo the academic units the students are studying at the time, such as the cardiovascular or gastrointestinal system, but the scripts are not always
straightforward, requiring the students to be creative.

“They might not tell you everything,” said Michaela Carter, a second year medical student. “Some (SPs) will tell you anything and everything while some (SPs) will just give you a simple ‘yes’ or ‘no,’ so you have to dig and try to find out what's going on. But you also need to make sure the (SP) feels comfortable.”

School of Medicine faculty collaborate with Bohnert to design case scenarios. They then instruct the SPs in the specific condition and symptoms they will portray and how to answer the students’ questions.

In her 13 years as director of the UofL program, Bohnert has focused on innovation, a culture of patient care and educating students to be affirming providers for all people. For example, she worked to develop scenarios that familiarize students with LGBTQ patients and those with developmental disabilities and another to help students recognize patients who may be involved in human trafficking. For these sessions, she engages people from those populations to authentically guide the students in understanding their needs both as co-creators of the sessions and as SPs.

“We brought in self-advocates from Special Olympics of Kentucky and the drama group of young adults at Down Syndrome of Louisville to develop cases. Those self-advocates got to be in our space and to give a thumbs up, thumbs down to the scenarios,” Bohnert said.

The actor-educator

As assistant director of the SP program, Mimi Reddy helps the SPs remember their “lines,” portray ailments convincingly and provide positive, supportive feedback to the students. She said the SP encounters give the students an opportunity to apply what they are learning to real life.

“When you are a science student, especially a medical science student, you have the muscle memory of studying books. Standardized patients really give the students a chance to turn that learning into a practical, human skill.”

The scenarios can be challenging, requiring SPs to understand medical terminology and complex symptoms. Bohnert said a good memory, intellectual curiosity and flexibility are important traits for SPs, along with the ability to have a calming effect on nervous students.

“The students know they're being filmed and that someone's going to look at their performance, so we really need people who can create a welcoming, calm, peaceful
space,” Bohnert said.

Zack Kennedy ’12, a UofL School of Music alumnus, said the job of SP complemented his night work as a musician. He found learning new scenarios stimulating and enjoyed camaraderie with other SPs.

“I loved learning new things every time I received a new case to study, and I enjoyed watching students progress in their interview skills,” said Kennedy, now a coordinator for the SP program.

Reddy said the program is working to diversify its SP cohort so it better mirrors the
true patient population. SPs are paid hourly, but the hours vary from week to week.
Some people describe standardized patients as actors, but for Bohnert, they are
more than that.

“I fall more on the side of educators,” Bohnert said. “For some programs, the
ability to fool a physician into thinking that you're actually ill would be the gold standard.
But if the SPs are not good at teaching and engaging with a student, it would not be a
worthwhile experience to me.”

A wider influence

In addition to student educational experience, Bohnert also prioritizes educating others in the field. She collaborates with School of Medicine faculty and staff to publish research on standardized patient education to help other schools improve their SP programs. She was a key co-author of the “Standards of Best Practice,” published by the Association of Standardized Patient Educators (ASPE) in 2017 as a resource for other program directors.

The ASPE recognized Bohnert’s contribution to the profession with the 2023 ASPE Outstanding Educator Award. Bohnert began with an interestin education, but the UofL public administration master’s alumna and doctoral candidate in sociology has pursued
a career outside the classroom.

“I carved out a career in nontraditional education spaces. It was always more about the application or the ability to integrate learning into a more real-world environment,” she said. “Truly, that is what keeps me here. I am so deeply committed to learning. I adore our students and there's always a chance to innovate. It's a place where I can apply this intellectual rigor and my passion for people.”