WASHINGTON — Ted Bell knew his portrayal of a depressed, elderly patient was convincing when the medical student who was examining him broke down in tears. Her instructors had to call a timeout because his flat monotone and unkempt appearance reminded her too much of her father, who had similar symptoms.
Sad personas are part of Bell’s new career. He plays the part of a patient. It’s a big change for the retired civil engineer who spent more than three decades managing construction projects for the Army Corps of Engineers. Emotion was hardly part of the job description.
“That sort of thing was somewhat stifled in a conservative bureaucracy,” he said. “I found it quite rewarding to be able to cut loose.”
Bell, 62, of Greenbelt, Md., is one of hundreds of Washington-area residents whose day jobs are to realistically portray patients in medical cases. They are poked and prodded. They occasionally take off their clothes. Some even undergo breast and pelvic exams.
They come under the direction of medical school clinical directors, who act as casting directors, stage managers and dialect coaches rolled into one. With six major medical schools in the region annually training tens of thousands of students seeking to be doctors, nurses, pharmacists, social workers and other health-care professionals, demand for “patients” is high. Directors compete for those most likely to be convincing, take direction and show up on time.
The formal title is “standardized patient,” or SP for short.
Many are actors, but actors don’t always make the best patients, clinical directors said. Improv is not allowed. People trained to portray a particular type of patient must work from the same facts and deliver responses in the same way to the students examining them.
“They can’t overact,” said Kathy Schaivone, clinical instructor and director at the University of Maryland at Baltimore.
Retired engineers and lawyers are good candidates because they can remember a wealth of information. Patients often have to recall up to 20 different items during the debriefing. Did the student palpate the sinuses? Listen to the heart in all four places? Wash hands before and after touching the patient?
“This is not like working as an extra on a movie, where you’re told to walk across the street,” said Mary Donovan, who handles the training at Georgetown University’s medical school.
At her desk, Schaivone is working the phone, on the hunt three months early to find teenagers for one case. Every few minutes, she jumps up and race-walks down the hall to manage a training session for first-year physician assistant students at Anne Arundel (Md.) Community College. The men and women, in white coats, are waiting to enter five exam rooms to interview today’s “patient”: African-American, high blood pressure, stressed from being laid off.
She fixes one man’s errant collar and signals them to start. “We’re going to hit it,” she announces over the loudspeaker. “Make sure you go in the correct room.”
In Room 1 is AliceAnna Schumacher of Fairfax, Va. She has an acting degree and would love to play Lady Macbeth, but she earns a living as a standardized patient.
For about 30 minutes, she answers questions according to script. Diet? Too much fried food. Exercise? Not enough. Smoking? A pack a day. Now and then, she exclaims, “Praise the Lord!” because her character is spiritual.
Peering at five computer screens, Schaivone monitors the performances of Schumacher and the four other “patients.” There are two real estate agents, a photographer and a retired federal government worker. A few are too chatty. She reminds them not to volunteer too much information.
“In SP land, we need to hold back a bit,” she explains later. “Not hold back too much so that it frustrates the students. We need to keep it realistic but not ‘give away the farm.’ ”
The interview is a practice run; next year the students will be graded. Faculty typically watch and listen on nearby computer monitors.
Immediately after the session, the “patients” debrief the students, filling out checklists and giving face-to-face feedback.
Schumacher praises the first student, Reyadh Al-Banna, 30, for establishing good rapport. She also suggests, gently, that he could have probed more deeply about her layoff. “Then I would have felt more inclined to share more of my distress,” she explains.
She asks whether he has anything to add.
“I thought you did an amazing job,” he replies. “You were very convincing. That really helped. It took the idea of it being a fake kind of made-up thing . . . it just made it really realistic.”
Directors keep their own databases of “patients.” Schaivone’s has about 140 entries. About 30 to 40 of her people are probably in other medical schools’ databases. Neva Krauss, who does training for Johns Hopkins School of Medicine, has about 150 names in hers.
Hardest to find are patients to portray young men and women, or people of Hispanic, Asian and Middle Eastern heritage. Medical schools sometimes advertise on actor websites to get main characters and understudies.
Pay ranges from $17 to $35 an hour, although for the most invasive exams, such as breast and vaginal, the pay goes up to $55 an hour because the “patients” are also instructing students how to perform them.
People who do this full time, such as Bethany Hoffman, can earn about $22,000 a year. The Silver Spring, Md., resident has a theater degree from Towson University and often gets called to play emotionally challenging roles. In one, for a group of nursing students, she portrays a schizophrenic hearing voices via a microchip in her foot.
Like Bell, she is often booked five days a week, shuttling among different medical schools. In addition to Hopkins, University of Maryland, Georgetown, George Washington and Howard universities, the Washington area also has the Uniformed Services University, the military’s medical school. The medical simulation center trains students and active-duty doctors at the sprawling Forest Glen medical annex in Silver Spring.
The use of pretend patients is also spreading to other fields. They portray rape victims to train examiners in sexual assault units. At Hopkins, they have acted as family members of brain-dead patients to teach sensitivity to an organ-donation group. At the University of Virginia medical school, hospital chaplains meet with “patients” who have lost their faith in God because a loved one has died in a car accident.
Getting these jobs is not easy. Directors warn against cold calls or e-mails. They prefer to use people they trust and rely on word of mouth for referrals. It took Schumacher, who has worked in theater and independent films, a year to get hired for her first case.
“This is a very competitive area,” she said.
The patient actors say emotionally challenging cases are the hardest but the most rewarding.
Once a year, at Hopkins, young doctors seeking to become pediatricians practice breaking the news to a couple that their 2-month-old baby has died. Three “couples” each work with a team of doctors. In the script, the couple go out for an evening — their first since the birth. When they awake the next morning, the baby is not breathing. They call 911 and rush to the hospital. They wait in the emergency room “for what seems like an eternity,” the script says. Then a doctor tells them their baby is dead.
The mother goes into shock. Ray Alcala, who portrayed the father two years ago, said his character becomes angry and accusatory. When the doctor informs the couple that an autopsy is mandatory, Alcala has to calm down his “wife,” who by now is hysterical and refusing to have her baby disfigured.
Alcala, 34, of Alexandria, Va., tutored math and science before he started working as a patient nine years ago. The baby case was challenging.
He and his “wife” portrayed the scenario four times in a three-hour period. “I was drained,” he said, but added the work was emotionally satisfying.
“You know how this can make a difference for a couple who had this happen for real,” he said.
It happened to Jason and Beverly Kravitt, whose son Cameron died at birth in 1982 in a Chicago hospital. Beverly Kravitt was allowed to hold the baby for a few moments and then never saw him again. Appalled at the treatment they received, they established a foundation to train doctors to be sensitive.
For each of the past 16 years that Hopkins has held the training, Jason Kravitt, of Chicago, has traveled to Baltimore, participating in panel discussions and offering guidance to future doctors.