A “standardized patient” is an actor trained to simulate a patient to help medical students and others learn empathy and the art of diagnosis.  A recent review concluded that “…the body of literature regarding the use of SPs is overwhelmingly supportive of their use in medical school over the course of a student’s education, starting in the first year and extending into residency” [1].

In a variety of industries where reliability is critical– aviation, the military, nuclear power, and others– simulation-based training has long been central to preparing for the demands of the field. Today, nearly 90% of medical schools use some type of medical simulation, where actors portray patients with various disorders. But that wasn’t always so. The pioneer in this field was Harold Barrows, MD, a UCLA neurologist, who first developed simulations in the 1960s. The concept grew, slowly and then quickly, over time. Today the emphasis in health care is on high-fidelity simulation, meaning “simulation experiences that are extremely realistic and provide a high level of interactivity and realism for the learner and can be applied to any mode or method of simulation; for example, human, mannequin, task trainer, or virtual reality” [2].

Standardized patients also play a role in Objective Structured Clinical Examinations (OSCEs), which evaluate clinical skills in a structured, standardized manner. OSCEs comprehensively assess a learner’s ability to perform clinical tasks, make diagnostic decisions, and communicate effectively with patients [3]. Originally, the OSCE was “a timed examination in which medical students interact with a series of simulated patients in stations that may involve history-taking, physical examination, counselling or patient management” [4]. It is now employed to assess the student’s ability to “obtain/interpret data, problem-solve, teach, communicate, and handle unpredictable patient behavior” [5].

Dr. Anderson’s involvement in the development of the standardized patient dates to 2005, when he was an Assistant Professor working under David Leong, Professor and Chair and Producer of the VCU Theatre Department.  Trained in children’s theatre, Leong had coached hundreds of actors who went on to perform across the nation, on Broadway, in TV and film, in regional theatre and in universities. In his reading, Leong happened upon an article in New Yorker Magazine describing a crisis in healthcare. The article argued that patient care was suffering because physicians lacked adequate communication skills. Intrigued, Leong sought to learn more.

Leong approached Richard Wenzel, MD, an infectious disease specialist and epidemiologist on the VCU Medical School faculty, and former President of Medical College of Virginia Physicians, the School’s faculty practice. Dr. Wenzel confirmed the New Yorker report. Students have a lot to learn in their four years of medical school, so time is scarce, and precious. Time needed to address technology had to come from somewhere, and often the “somewhere” was that portion of the curriculum previously dedicated to teaching and learning the bedside manner. As technology grew ever more complex, the time it required expanded.  Technology was “squeezing the doctors”:  too few young physicians had been taught the “bedside manner;” Worse, few professors remained available to teach it. Developing rapport, and getting to know patients better, suffered. In modern times, the average duration of a physician encounter is a mere eight minutes.

Wenzel asked Leong: “Can you teach my fellows?” Leong turned to Aaron Anderson for help. Dr. Anderson readily accepted, as the assignment fit his wide-ranging skill set. His education, after all, was interdisciplinary, meaning that it was methods based, not discipline-based. Interdisciplinary training is rooted in learning how to apply the methods and practices from one field in another. Traditional training emphasizes only the methods and practices of one discipline. A traditionally trained theatre practitioner, for example, would know how to make theatre AS theatre, while interdisciplinary training prepares one to apply and modify theatre training in other contexts. The interdisciplinarian asks: “Can you unplug an idea from one field and apply it another? How do ideas mix and match?” Moreover, Dr. Anderson was the only person in theatre, at least at VCU, trained in classical research. This combination of skills and knowledge made him the logical choice for the role.

Academician that he was, Dr. Wenzel wanted not only to offer this instruction to his trainees but to study its results. The question Wenzel wanted to answer: Could we use theater skills to teach listening to doctors? Alan Dow, MD was chief medical resident at the time, and agreed to participate. Eventually, Dow, with Leong and Anderson and others, published a paper, documenting efficacy. “Collaborative efforts between the departments of theater and medicine are effective in teaching clinical empathy techniques” [6].

This publication attracted widespread attention from the lay media, including the Voice of America, NPR, the Chicago Tribune, the San Francisco Chronicle, and most notably, the Washington Post. The Post story, “New Doctors Develop an Old Skill,” was widely cited and read [7].

A good example of the value of these newly enhanced communicative skills arises when the physician must confront what Dr. Anderson calls an “unwinnable” situation: the doctor has to give bad news to a patient, to a loved one, or both. That happens all too often, of course, especially in certain specialties. One cannot tell a patient of his newly diagnosed fatal disease and bring joy to the listener. There are ways, however, to make the shock less painful, the news-bearer more empathetic, and the circumstances less dire. Educating doctors in the arts, and providing them with simulations, helps them achieve these goals.

Aaron Anderson wears an assortment of academic hats, and has taught in an array of colleges and universities. It would be a mistake, though, to see him purely as a scholar. He enlisted in the military to travel, to see the world, and to seek adventure. He went into ordnance, specifically, to “blow stuff up.” In a lemonade-from-lemons episode, Anderson learned about being “present” while recuperating from an injury sustained during his military service, a fall causing serious musculoskeletal and less serious internal organ damage. When there was doubt he would regain his ability to walk, Anderson learned to be “in the moment,” to connect with others in the room, and to listen better. Moreover, teaching actors how to fight, or how to fence, as he has done since, is hard to classify as pedantic.

Swashbuckling notwithstanding, Dr. Anderson has been lauded for his contributions to the field. He won the 2024 a2ru Award for Excellence in Arts in Health Education, established “to recognize outstanding and innovative pedagogy that supports the rapid growth of arts in health.” The judges wrote that Anderson has demonstrated the ability to build bridges across academic disciplines while publishing extensively and remaining active as a theatre artist…What’s most impressive, though, is the extent to which he has reached out not only into his home university but to other universities. His collaborative style has truly made a difference.

A Renaissance man, indeed.

Beyond Theatre

Since the simulation movement began, with its emphasis on acting, the concept of providing arts education to doctors in training has expanded beyond theatre.  Med students and young doctors visit art museums to learn how to better attend to a painting’s details so they can read a composition in its frame.  They are exposed to music for the lessons it teaches on empathy, teamwork, and yes, listening. The arts, he says, capture ”what this moment feels like.” Quoting Bob Dylan, Anderson says the arts are good at “freezing time,” and, better than other domains, at communicating phenomenological feelings. Physicians exposed to art works and to artistic thinking learn to relate better to patients, resulting in better transmission of better information, deeper understanding between treater and patient, and improved patient adherence. Dr. Anderson advises that arts and humanities in medicine has become so well-developed that the field has its own literature and conferences. He points the University of Florida as a pioneer and still one of the leaders in this realm, though one can find programs all over the country, including at many of the nation’s most competitive and highly regarded med schools.

Contrary to what some might expect, deans and other leaders embrace these learning opportunities,  Anderson says, even though they have but four years to inculcate vast treasuries of clinical knowledge into young minds. Med school leaders recognize the value of artistic experiences, and nowadays may even need them for accreditation purposes. There is such a thing as too much lecturing, after all. At VCU, a professor of medicine identifies his objectives for the students, and relies on Dr. Anderson and colleagues to provide a set of experiences to aid in their attainment.

The flip side of these training opportunities is art as therapy. Pediatric oncology patients participate in plays, or in dance, Dr. Anderson says, where they can, for a time, “stop being kids with cancer, and just be kids,” period. Musicians and painters come to see hospitalized children, to enlighten, enliven and inspire. Nor are these benefits limited to youngsters[8].

The Business Connection 

Dr. Anderson explained how he came to be affiliated with VCU’s Business School. Hamilton Beach, the maker of blenders and dozens of other household products, is headquartered in Richmond. Its President read the WaPo story and became fascinated by the idea that theatre professionals could have an impact in a field, such as healthcare, seemingly far removed from the performing arts. He called Aaron Anderson and asked, “Can you do this with business people, too?” The first lesson all actors learn, says Dr. Anderson, is to say “yes” to all offers given, and he did not forget that principle in this exchange. After all, businessmen have to communicate too. Soon, Hamilton Beach executives were theatre students, learning to use new communication skills to interact with their own reports, their supervisors, their suppliers, and their customers. Other companies got the message, and it has become fairly common practice for executives in companies of all kinds to improve their communication skills through exposure to the arts.

The Future

Anderson acknowledges that, for all its success, and its prevalence, the case for standardized patient needs to be strengthened. For one thing, many of the published studies are small. The means scalability is questionable. Return on investment has not been carefully measured. Studies should be devised and completed to assess scalability, ROI, and other questions, such as replication of published results in behavioral research, few of which have been fully addressed. Yet it seems that standardized patients, and more generally, the arts in medical education, are here to stay.

And the Past

The idea of bringing artistic experiences to medical education may seem novel. Certainly there was precious little of that kind of thing in the school I attended in the mid-70s. But maybe, at base, the idea is not so new after all. Recall the words of the Hippocratic oath, history’s first exposition of medical ethics. Fledgling doctors have been taking that oath for more than two thousand years. In it, the physician promises, among other things, “To hold my teacher in this art equal to my own parents…” If medicine is indeed an art, as most would likely concede, then perhaps Dr. Anderson and his colleagues are bringing medicine back to its roots.