UM Miller School of Medicine starts doctors with ‘patients’ early

The University of Miami Miller School of Medicine exposes future healthcare providers to standardized patients at an unusually early point in their studies in order to practice real-life scenarios.

Many medical schools have standardized patients, said Dr. Gauri Agarwal, associate dean for curriculum at the University of Miami Miller School of Medicine. However, what is unique about UM’s medical school is “how early we use it in our curriculum and the fact that we use it throughout our curriculum for all four years. I think that’s the piece that’s a little different about our school.”

“Our SP [standardized patient] program – although we are part of the University of Miami Miller School of Medicine – this is a small subset of what’s known as healthcare simulation,” said Samantha Syms, director of the Standardized Patient Program at the Gordon Center for Simulation and Innovation in Medical Education at the University of Miami Miller School of Medicine. “It’s a type of simulation; we’re using humans to simulate certain findings.”

The history of standardized patients stems from a totally different career flight path.

“For decades, the idea of having simulation prior to seeing actual patients has been in the literature – nationally and internationally – and there have been lots of published studies that show that if you simulate something and allow students to practice before they’re in the actual clinical environment, they’ll perform better,” said Dr. Agarwal. “Whether it’s a procedure, whether it’s a conversation, we want them to have as much practice before the real thing as possible … and a lot of this originally came from the airline industry with pilots … and doing flight simulations before actually getting in the air with people.”

“This idea of a standardized patient is basically another version of a simulation,” she said. “It’s not with a mannequin, it’s with a real human being. But you can now simulate things that are more complicated that you can’t do with the mannequin like a conversation, like breaking bad news, for example.”

The program is housed under the Gordon Center, an internationally known simulation center of excellence, said Ms. Syms. “We work with firefighters, EMT’s. We train their providers. We partner with the Doctor of Physical Therapy program at UM Gables campus. We’ve even worked with the Department of Music Education to train pre-service teachers on how to have conversations with parents when they enter schools to teach.

“So the methodology that we use here with the SP’s is really wide-spanning because we’re focusing on communication skills and empathy towards other people. That really can be applied to many different areas.”

In 2020, the curriculum was changed, said Dr. Agarwal. “It was in the middle of the pandemic. The way our usual med school runs is you do two years in the classroom and then you start seeing patients in your third and fourth year: a two-plus-two model.

“But with our new curriculum, we actually have them start seeing patients right up front in their second year. In the first year, we said ‘they have to be ready at an earlier stage,’ so we started using some actual patients where they actually go to the hospital with their faculty, but we started to use the standardized patients a lot more in the first year.”

The use of standardized patients allows students to practice taking medical history on patients, doing physical exams and talking to patients, said Dr. Agarwal. It was also possible to compare third-year students who were in the old curriculum to second-year students who were in the new curriculum, “and the second years had this big, robust, standardized patient program. They were performing exactly the same in the clinical environment, which was really exciting to see that they were basically able to accelerate their progress and get ready a year ahead of time and perform … on rotations just as well as our older students. That was exciting. I definitely think having … that program helped them develop those skills.”

“I think one of the most influential things that we have done, especially within our first year of medical school, was working with the standardized patients,” said Chris Norberg, a fourth-year Medical Doctor (MD) student at University of Miami, who is part of the first graduating class with the new curriculum. “The main purpose of working with a standardized patient is for us as medical students to really be able to get the practice and the experience of working with patients in a controlled and safe environment.”

“The idea is ultimately to present … various scenarios and different cases for us to either think through and work through, or just really practice our skills with a real person as opposed to … other medical students who might … start giggling and laughing while we’re doing it and talking to each other about other things,” Mr. Norberg said. “It really is something where we get to practice our physical exam skills, we get to practice our history taking skills, interpersonal skills, learning how to handle various situations that might be challenging, such as … disgruntled patients.”

Students are exposed to a variety of cases with the use of standardized patients, said Dr. Agarwal. From breaking difficult news to navigating complex cases such as patients experiencing strokes, students gain the knowledge and hands-on experience.

Typically, within a week or two of students encountering the standardized patients, they are given feedback through an electronic learning system, said Mr. Norberg. Students are also given access to the recording and are able to go back and see how they can improve.

The standardized patient program came to fruition, about five years ago said Ms. Syms. The program began with 17 standardized patients and currently has about 55 from all walks of life. “It has taken a long time to get to where we are now, but we are looking to expand up to 80 SP’s. The reason being is since these folks that join us are part time, they usually have other commitments. Some are in school, some have other part-time jobs. So not everyone is available when we may need them. Plus, for the roles that we’re filling, we want to make sure that we’re providing the correct demographic that’s required.”

“For an obstetrics and gynecology case, we have to have female SP’s and at a certain age; that would exclude our male SP’s, or if a program is looking for older males with chest pain, that would exclude some of our younger female SP cohort,” Ms. Syms said. “So it is very particular in terms of what type of condition we’re simulating or what type of case they want to present to the students, that’s what we cast for.”

Anyone 18 and older is welcomed to join the team as additional standardized patients are being sought, said Ms. Syms. “We want to make sure that we’re representing the patient population that’s reflected in Miami or that the students are going to see when they go into the clinical rotations.”

The first step is to complete the online application, said Ms. Syms. Following the application, the individual is invited to a casting call “where we’ll share a little bit of how our program works, and give [applicants] a chance to roleplay in one of these patient roles.” If selected, the applicant is on boarded as a part-time staff member at UM, and is brought for the onboarding orientation and training. This will be over the course of four to five sessions.

“We train [standardized patients] on the portrayal aspect of it … so we give our SP’s a script where they have to portray certain patient history or effects or physical symptoms,” said Ms. Syms. “Then we go into a little bit of the feedback and debriefing portion because, although one portion of being an SP is the role portrayal aspect, the other side of it is providing the medical students with effective feedback and facilitating debrief discussions in order for the students to reflect on their performance and ultimately improve over time.”

Due to the Standardized Patient Program serving different entities such as EMTs and firefighters, the schedule for the standardized patients is year-round, said Ms. Syms. “We really have no lapse in our schedule, minus maybe the holiday time it slows down a bit, but really the medical school curriculum, because the students are in different phases, it really spans the entire year; we work January through December. It’s not really broken down by semesters, like regular college or undergrad college is.”

“I think people in the general public are concerned about bedside skills: empathy, compassion, the humanism in medicine being potentially lost, especially as we start to hear about expanding technology like artificial intelligence and even the electronic medical record,” said Dr. Agarwal “It sort of takes the eyes of our doctors away from their patients. Really, one of the big parts of this program is to try to rebuild those humanistic skills in our students so that they’re actually looking, making eye contact, sitting at the same level as their patient, being respectful, kind and responsive to their emotions.”