Panting, her eyes filling with tears, Nayima Pluviose emitted a ragged moan as she bore down.
"You're so strong, you're doing such a good job," said her nurse midwife. "Listen to my voice now. You've got this!"
Just then, the shoulder of the baby Pluviose was laboring to deliver became lodged in the birth canal. Immediately, the nurse midwife turned the birth over to the attending obstetrician, who had the expertise to safely maneuver the boy into the world. Within minutes, what had been a tense situation was resolved as the obstetrician lifted a plastic doll onto Pluviose's chest.
That's right, a plastic doll.
While the surroundings were authentic — from the replica hospital delivery suite to the warming unit awaiting the newborn — the scenario was staged. The purpose? To prepare the student nurse-midwife and the resident obstetrician for a situation they're likely to face once their training at the University of Minnesota is complete.
At the heart of the simulation was Pluviose, an independent contractor who works as a standardized patient.
Just as pilots train in flight simulators, athletes practice in scrimmages and actors prepare in dress rehearsals, medical professionals-in-training now refine their skills by working with standardized patients. The university calls on about 200 patient stand-ins who take part in hundreds of simulations a year.
"Since I've never really had a baby, I watched YouTube birth videos to prepare," said Pluviose, who played her part wearing a hospital gown and a front pack that contained the doll, a plastic tube representing the umbilical cord and a fabric placenta.
An Aldi associate by day, Pluviose, of Minneapolis, is one of the university's busiest standardized patients. Over the past six years, she has appeared in as many as 100 medical simulations, manifesting maladies from head (migraines) to toe (tingling feet).
Standardized patients have become part of the curriculum in medical education programs across the country. And an emerging body of research has validated their effectiveness in developing clinical expertise for medical students, residents, fellows and other providers.
"Standardized patients give our learners an opportunity to work on their psychosocial skills, not just their hand skills," said Anne Woll, interim education director at the university's Academic Health Center's Simulation Center. "They practice cases with high emotion, like delivering bad news. We also use simulation for incidents that we call low-instance/high-risk, things that don't happen very often, but when they do, a lot is at stake."
The scenarios play out in rooms equipped with cameras, microphones and one-way glass so faculty members can evaluate how students handle intimate, sometimes tense situations with real live humans, albeit humans who are playing a part.
"Our standardized patients are considered a valued part of our education team," Woll said. "We rely on them to really commit to the roles and bring a high level of fidelity to the scenes. I've seen some of our learners come out of a simulation and say, 'I think he really had that.' "
Patient performers
Mary Jo Pehl is still known for her performances on the cable-TV cult classic "Mystery Science Theater 3000." While the Fridley woman likely won't win an Emmy for her role as a standardized patient, she's proud of the work she does for the university.
"I nail the parameters of the post-menopausal woman patient," deadpanned the writer, actress and stand-up comedian.
Pehl, who has worked as a standardized patient for two years, said she relishes the job in part because she's "always hustling for the next thing." But she's also aware of how her work is helping to make medical practitioners more empathetic.
"When I was a kid and went to the doctor, they were the boss and kind of mean," she said. "Now they take such great care to train students in empathy and listening."
Retirees, students and others with flexible schedules can get gigs as standardized patients, which pays between $18 and $22 an hour. But Pehl said her theatrical training helps her to slip quickly into character and stay there. And while the simulations are unscripted, the details of the scenario and the standardized patient's complaint and character are determined in advance, so Pehl and other standardized patients can prepare for their parts.
"They tell us our symptoms, how we're supposed to feel, so we can rehearse," said Pehl. "Some of the trainees that cycle through look so scared; they're learning to work through their nerves with me."
Sensitive exams
There also are standardized patients who have been trained to undergo sensitive checkups — rectal and genital exams for men, pelvic and breast exams for women. Called patient educators, they earn more than standardized patients, but are asked to give more.
"These are among the most intimidating exams for students to do," said Dr. Mark Rosenberg, vice dean of education at the university's medical school. "We don't want them [medical trainees] to learn on their real patients. They need to establish their skills with an experienced educator who is trained to give them feedback."
Patient educator Bernadette Knaeble estimates that she's been on the receiving end of at least 2,000 pelvic and breast exams.
Hers is the female body that scores of University of Minnesota medical students have practiced on as they performed their first digital exams, Pap smears and tests for sexually transmitted diseases and infections.
Knaeble, of Minneapolis, is so skilled at being a patient that she's able to coach students through the experience, explaining what they're feeling with their palpitations and offering tips on their technique.
"The exam is not uncomfortable for me," she said. "I'm in charge and they're relieved I'm going to help them and not judge them. It's a safe environment. I take care of myself; they don't have to take care of me."
Now 66, Knaeble began professionally assuming what doctors call the "lithotomy position" (on her back, knees separated and feet in stirrups) when she was in her 20s and living in New York City. Because of the number of medical schools there, she worked full time as a patient educator, guiding students through sensitive exams.
"As a young feminist in the '70s, I was motivated by my belief that women deserved more respectful health care," she said. "In training medical providers, I know I made a difference then and still do."
Since arriving in Minnesota 15 years ago, Knaeble has supplemented her patient educator career with jobs as a science teacher and a choreographer. Now she trains standardized patients. Still, she considers leading first-year medical students through their introductory pelvic exams to be her most gratifying work.
"Up until then, they've examined hearts and lungs and taken medical histories. This requires a big jump in their skill level," she said. "All of a sudden they have the confidence that they can be physicians. They see themselves differently. It's often transformational."
Training technique
The University of Minnesota is prioritizing the use of standardized patients as a method for training the next generation of health care workers.
Construction is currently underway at the Health Sciences Education Center on campus, where the Simulation Center/Interprofessional Educational and Resource Center will occupy two full floors with expanded clinic, procedure and operating rooms. The center represents an evolution in the philosophy of the medical school.
"Team-based care is the approach in real world, so we use standardized patients in scenarios that foster communication between doctors, nurses, pharmacists, other providers," said Rosenberg. "They're all in there, learning together."
That's evident at the conclusion of every training session, when the standardized patient meets with the students to reflect on the encounter.
Still seated on the birthing bed, Pluviose praised both the student nurse midwife and the resident OB for their calm demeanor and the way they continually updated her on her baby's condition during the faux delivery.
"They always want my opinion, about how it felt from my perspective," she said. "I like knowing I help them on their path."
Kevyn Burger is a Minneapolis based freelance broadcaster and writer.
