Yale PA Online Innovates with Virtual Standardized Patient Exercise

In January 2019, a patient told a Yale School of Medicine (YSM) Physician Assistant (PA) Online student that if her pregnancy test was positive, she “would feel overwhelmed” and that she “was at capacity with three kids.” After letting the patient know that she was in her first trimester of pregnancy, the student assured the patient that there were several options, which she wanted to walk the patient through, so that the patient would have all the tools she needed to make an informed decision. The student paused often as she described the alternatives, trying to offer comforting words in reaction to the patient’s obvious emotional distress, and reassuring the patient she had time before she had to make a decision.

One twist to this scenario: the patient was a “standardized patient” (SP), meaning an actor playing the role of a patient as a pedagogical tool for students. Although SPs improvise to some extent, they are trained to have predictable or “standardized” responses and behaviors to aid in training. The use of SPs now is a common practice in medical schools. 

Another twist, which is not a common practice: while the SPs were on the Yale campus, the students were in their different home communities across the country. The Yale PA Online Program is structured so that students live at home as they earn their degree, participating in interactive online didactic learning, and in-person clinical rotations near their homes. This was the first time YSM students participated in a virtual SP exercise since the Standardized Patient Program was founded at Yale in 1993. It also was the first time the 11 participating SPs had done virtual training, though all were experienced SPs.

In-person SP training workshops at Yale typically involve small groups of students and a faculty facilitator. Each student interviews an SP, while the others observe. Feedback is provided during mid-session “time outs” and a debriefing at the end.

In the PA Online SP exercise, the training took place over three consecutive Fridays in January. Each SP was in a private room for their “appointment” with a student, and they connected using the video technology platform Zoom. The 41 students each engaged in two scenarios, difficult news and shared decision making, with a different SP for each exercise.

The YSM Teaching and Learning Center (TLC), which coordinates SP training for the school, provided the SPs with special guidance for the online exercise. For example, because Zoom essentially captures people from the shoulders up, the SPs were instructed to try to convey emotions accordingly. SPs also had to be trained to look into the web camera, instead of the computer screen, the more natural inclination, in order to have eye contact with the student.

Yale PA Online student Mary Garrison ’20, who had never before participated in an SP exercise, either in-person or online, felt well-prepared for the exercise. Garrison said a key element of preparation was ensuring she understood the underlying medical issues, so that she could confidently and clearly explain them to the SPs. Moreover, she explained the students were provided with training modules and lecture materials on shared decision making and delivering bad news. She used this guidance to help her outline her approach for each scenario, and she then practiced these scripts in her head. Garrison also practiced with her Family Medicine clinical rotation preceptor the day before the SP exercise.

She noted that the PA Online Program’s Behavioral Medicine course had a workshop on shared decision making, as well as a training module. She also had an assignment where she was paired with two other classmates to practice taking a sexual history, which made her feel more comfortable asking the sexual history questions she needed to ask in the SP exercise.

In preparation, she also tried to anticipate the SPs’ potential responses. While she was assuming that the SP who would learn that she a sexually transmitted infection (STI) would be upset, Garrison did not anticipate the SP would “talk about hiring a hit man to kill her partner.” However, Garrison said she “had enough training to know that when someone is really emotional, to just let them talk and listen empathetically,” and then return to the medical facts and options.

Barbara Hildebrand, program manager at the YSM TLC, said that many of the SPs had doubts the exercise would be effective when they first heard about it, but “all were pleasantly surprised by how easy the technology was to use. Afterward, they unanimously thought the entire experience was a success.”  Hildebrand added that the SPs did report “missing the human element that they have with the patients during the in-person exercise.”

Deirdre Dolan, who has participated in SP exercises at least 100 times, expanded on this idea. “I was doing a ‘bad news’ case, and although many of the PAs were extremely and authentically empathetic, there was a ‘remove’ for me emotionally.” Similarly, Susan Kulp, who has three years of experience as an SP, but never before in a virtual setting, describes how in an in-person setting “you gain a greater personal connection to your provider. There is body language and other non-verbal cues that connect you as a patient.” Kulp could foresee a situation where a patient might not be as forthcoming and the provider “would not be able to pick up on all those non-verbal indications from the patient that might cue them to dig deeper.”

Garrison, however, did not feel disadvantaged engaging with her patients using Zoom, essentially “feeling like she was in the same room with them.” She found that “their facial expressions and words made their emotions absolutely clear. The fact that I could not see, for example, a leg twitching made no difference in my ability to know how to react. The only thing I might had done differently, had I been in the same room, is hand the patient a box of tissues.” Dolan commented that when students, such as Garrison, looked into the camera, were skilled with the technology, and were prepared from the very start of the encounter, “it made the technology disappear.” 

While the reduced physical proximately might be viewed as a downside, Yale PA Online Program director Jim Van Rhee, MS, PA-C sees benefits.

Hildebrand said several SPs told her “the exercise was helpful for the students, with so much of medicine happening through online interactions now.”

Another advantage of the online exercise: improved feedback. The video allows for more detailed faculty review after the session, instead of just real-time feedback. Students also have the opportunity to view and personally critique their own video, as well as receive feedback from a peer reviewer.

Both Dolan and Kulp pointed to an unexpected benefit of the virtual exercise, and perhaps virtual medicine in practice. Dolan explains, “I was portraying a scenario that usually engenders feelings of shame and embarrassment for me. I found the online experience much less embarrassing and shameful. I felt more open to discussing the situation in more detail, a definite positive outcome.” Similarly, Kulp said her character “was a busy professional, very practical about life and had a suspicion of what the outcome of her pregnancy results were already. I think a person like this would appreciate being able to connect with their provider in this online format. It offers privacy and efficiency.”

Garrison said the SP exercise “was really good practice,” and then shared examples of why. Garrison just completed an ob-gyn clinical rotation and said both scenarios she practiced with SPs occurred during her rotation and the SP exercise helped her feel more prepared to respond in a knowledgeable, professional, and empathetic manner.

Citation for this content: Yale School of Medicine Physician Assistant Online Program