‘The first time students see a patient of colour should not be in hospital’: The need for diverse patient actors

The first patients Ontario’s medical students encounter are actors—standardized patients (SPs) trained to imitate the symptoms and signs of illness. Students practice how to diagnose and disclose cancer, how to motivate patients to quit smoking, and a host of other clinical skills.Mostly retirees, young students and some professional actors, SPs are asked to adopt a patient role and be interviewed or examined in exchange for roughly $20 an hour. Medical schools recruit them locally, largely through word of mouth and job boards.But experts say the low wage and casual nature of the work contributes to a lack of age and ethnic diversity. A report by the Black Medical Students’ Association of Canada (BMSAC) states that “some faculties [of medicine]” plan to “increase diversity of standardized and volunteer patient programs to enhance understanding of Black health” but most “did not provide information on how they plan to complete this call.” Advocates across groups say increasing SP diversity is crucial to prepare Ontario’s future doctors to care for the province’s increasingly diverse patient population.The first SP program started at McMaster University in 1971. Today, all Ontario medical schools employ actors as a safe way for students to learn and be tested on clinical skills. After a medical interview or physical examination scenario is evaluated by faculty, SPs provides feedback to students, often incorporating their experiences as patients to help students learn clinical bedside manners.Queen’s University employs more than 100 SPs, says Mitchell Doherty, Manager of Operations at the Experiential Learning Program and Clinical Simulation Centre. Roughly 10 per cent of those are people of colour—and students and faculty are pushing for more. Medical schools might use mechanical models to simulate diverse skin tones but “[they are] kind of a blunt tool,” says Doherty. “There are areas where [a real body] definitely is helpful on physical assessment.”For example, rashes look different on different skin tones, says Kassandra Coyle, chair of the BMSAC. Diversifying SP pools is “a priority for all students, not just the ones that are identifying as Black because when [doctors] go into practice, [their] patient population is going to be diverse.”With physical diversity, language and cultural diversity should also become familiar to medical students through clinical training, says Eva Vieira from the Canadian Association of Latin Medical Students.“From the patient’s perspective, the language barrier kind of affects both their understanding of the diagnosis and also their compliance to treatment.” From the doctor’s perspective, key factors such as the patient’s medical, social and family history need to be collected to ensure doctors are making a “well-informed diagnosis,” says Vieira.SPs from different backgrounds can help reverse the typical power dynamic between doctors and patients, says Sydney Forbes, from the Indigenous Medical Students’ Association of Canada. Patients who may have nowhere else to seek care may fear a loss of access or substandard care if they critique their doctor. However, SPs can correct students and doctors when they err.“The simulated patient aspect of it really gives the power to the actor who’s there,” says Forbes, “whether they be Indigenous or otherwise, because they’re the teacher in that situation . . . whereas in the clinic, with a patient, [a doctor] is probably never going to be corrected. (Patients) are just going to clam up and move on.”Sijyl Fasih was a standardized patient for seven years in Ottawa before she became a Queen’s medical student herself. She wears the hijab and was worried her appearance as an SP would disrupt the standardized nature of one scenario—a young woman seeking sexual health counseling. “When [students] saw my hijab . . . they were like ‘Wow. I didn’t expect to see that coming.’ ” Now, she tries not to assume anything about patients before she meets them. Learning this in the simulated environment “is much better for [students] than having to do that in a real clinical setting.”These harms were recently acknowledged in the Canadian Medical Association’s apology to Indigenous peoples. “Mistrust of the profession” has led to “serious health concerns going undiagnosed or without proper treatment,” it said in apologizing for its past and current harms.Most Ontario medical schools hire SPs locally, but not every community has a naturally diverse set of models, says Eugenia Piliotis, Associate Dean of Queen’s University’s medical school. The casual, low-paying nature of the work can prevent individuals with regular work or other responsibilities from participating. Both the University of Toronto and Queen’s University have SPs who have been with the programs for more than 30 years.“I think part of [the reason for few Indigenous SPs] is also due to the relationship that health care has with Indigenous peoples,” says Forbes.Landon Montag, former program assistant of the SP program and current medical student at Queen’s, says she has hired some SPs who had “a really negative experience and wanted to be part of the solution toward the future of health care.” They wanted to “help train doctors to have a more patient-centred approach and to really put the patient’s feelings into consideration.”The curriculum also needs changing, Montag says, to provide scenarios with greater age, ethnic and gender diversity. As program assistant, she advocated for broadened age and gender requirements, allowing her to hire more diverse SPs.Intentional recruitment can also help. “Hopefully, by going to specific communities and clinics we’ll be able to get better breadth and diversity,” says Piliotis. Representatives from the University of Toronto and Western University also described community outreach as a current or planned strategy to meet their SP diversity objectives.Fasih says getting this right is important.“The first time [students] see a patient of colour should really not be when they’re in hospital.”Dr. Suffia Malik is a health reporter and resident physician in family medicine. She is a fellow of the Dalla Lana Fellowship in Journalism and Health Impact.This article is a re-print from Healthy Debate.

‘The first time students see a patient of colour should not be in hospital’: The need for diverse patient actors

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