By Ken Sakamoto, Star-Bulletin
Dr. Michael Nagoshi works with standardized patients,
from left, David Andreli, Scott Uehara and Wes Chang.
Standardized patients are used for testing by University
of Hawaii medical students.

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A twist on the
man-bites-dog tale:
Doctor teaches people
how to be sick

Such people can simulate
various illnesses, testing
students' bedside manner

By Rod Ohira
Star-Bulletin

Michael Nagoshi is a physician who teaches people how to be sick.

It has nothing to do with his Central Medical Clinic practice or his duties as Kuakini Medical Center's assistant chief of staff.

In order to develop clinical skills, aspiring doctors at the University of Hawaii's John A. Burns School of Medicine need real people to practice on.

Nagoshi, a member of the school's faculty, has been training healthy people to act sick since 1989 so medical students can be tested on their history taking (patient interviews), physical examination, patient education, and communication skills.

The Standardized Patients Project is administered through the medical school's Center for Clinical Skills at the Wo Educational Center on the grounds of Kuakini Hospital.

"Much of medicine is not knowledge; it's what the physician does with knowledge," Nagoshi said. "The most important thing that standardized patients do is test bedside manner.

"Communication relies on interpersonal skills, and it's a part of medicine that medical schools have not taken seriously until recently."

Standardized patient projects are so widely accepted now that by 2001, clinical skills will be included as part of the national examination for physician licensing, says Nagoshi.

For the national board exams, standardized patients will undergo 10 hours of training, he added.

Training for local exams usually takes about two hours, and "patients" are paid $10 per hour, Nagoshi said.

Nagoshi develops the cases and training materials, and has two full-time trainers to assist in teaching people how to be sick.

"They could either have an acute, chronic or life-threatening problem," Nagoshi said. "An acute case would be a patient who has a nagging cough or bad back pain.

"Chronic cases are ones where the diagnosis is known and the patient is coming in for a follow-up check, such as someone with diabetes. An emergency situation is appendicitis or someone who's having a heart attack complaining of chest pains."

Nagoshi added that other test categories include "well care," where a patient is feeling fine and simply taking an annual physical exam; "psychological or emotional," which involves a person suffering from depression; and "grave illness," which involves cancer-type cases.

The simulations are set up by stations, and using standardized patients allows students to be tested in near-identical situations.

"It's like a merry-go-round: The students move from room to room," Nagoshi said. "With standardized patients, we can judge whether a student is competent on a level playing field."

Before standardized patients were available, medical students were graded on their skills with real hospital patients.

"Not all patients were the same," Nagoshi said. "If students had good patients and the right faculty member, they passed. If their patient was bad, they'd fail.

"With standardized patients, everyone is evaluated in the same setting. We can also have a patient with the right medical problem when needed."

UH medical students are tested with standardized patients at the end of their first and second years, during their third year and again at the beginning of their fourth year.

Nagoshi said the simulations are realistic.

"If a patient is supposed to have stomach pain, we tell that person to use method acting to describe the pain," he said. "The case may call for the patient to have had the pain for four hours."

The patient is prepped to provide answers for only certain questions, and goes through a rehearsal before testing. Patients are even made to look sick with a spray solution that creates a sweaty appearance, Nagoshi said.

"It's amazing how people who have never acted before that pick it up so quickly," he observed.

There's currently a pool of about 100 standardized patients.

"We get them mostly by word of mouth -- people who like doing it getting friends to come in," Nagoshi said. "We haven't had to advertise, but we may have to at some point in the future."

Nagoshi said the project has helped him in his own practice, and noted there is a swing in medical education toward improving communication with patients.

"Sometimes physicians forget that medicine is more than the application of science," he said. "We can also make patients feel well by the way we practice communication skills."