When I was in my 20s, my cervix got its first job. At $60 a pop, the gig was relatively straightforward, if a bit unorthodox: I had to allow a few ob-gyns to give me pelvic exams and practice placing a cervical cap — a relatively new form of birth control at the time.
The doctors could have honed their cap-placing skills on medical mannequins, but those cervixes would have been plastic and generic, with none of the variations in female anatomy that we real-life cervix models could offer.
Fast forward to today: Medical students have access to all manner of extraordinary virtual technologies that mimic the human body. Still, in terms of educational value, there’s no substitute for real human bodies, dead or alive.
Encounters with learners
When Cimarron Frazier isn’t performing in an opera, she’s pretending to have assorted aches and pains for the benefit of medical students at the University of Pennsylvania Medical School. Frazier’s side hustle is working as a standardized patient, also known as a standardized participant, or an SP.
The role of SPs is multifaceted. The concept was introduced in the 1960s by Harold Barrows, a neurologist and patient educator who identified the need for a comprehensive way to evaluate the clinical skills of medical students. Use of SPs has steadily increased over time. Today, it’s an integral practice in medical schools across the U.S. All SP programs are required to follow the guidelines outlined in the Association of Standardized Patient Educators Standards of Best Practices. The med students are called “learners,” and their interactions with the SPs are “encounters.” SPs, who are always paid, tend to be performing artists or retirees. And according to people who run these programs, it’s a sought-after gig. (Some medical schools also have more specialized SP programs that focus on teaching students to perform basic head-to-toe physical exams or gynecological exams. These may require additional training.)
In each encounter, a different student interacts with the same SP. Frazier typically spends three hours preparing for a given role, for which she has to memorize a script. She might be required to report specific symptoms to the learner, who will examine her and try to arrive at a diagnosis. Or she might play a patient receiving bad news from a doctor, giving the learner a chance to practice sensitivity and compassion. Afterward, the SPs give the learners feedback on what they did well or could have done better.
In the SP program at the University of Maryland Schools of Medicine and Nursing, learners include doctors, nurses, physical therapists, psychiatrists and even pharmacists, who might practice how to provide medication counseling or what to do if they suspect a customer is abusing opioids.
“The goal is for students to learn professionalism, empathy and partnering with the patient,” says Nancy Culpepper, director of the University of Maryland SP program. “Cultural sensitivity is also vital. Specific goals are always outlined on a checklist that standardized patients fill out after the encounter.”
Frazier recalls playing the role of a patient who had to share details about a traumatic event related to her physical symptoms. “The doctor was so focused on doing the exam that she wasn’t really listening,” she says. “Another time, the doctor explained that I had to undergo a procedure, but I left not understanding how long it was going to take or whether I had to check into the hospital or not.”
Frazier pointed out these gaffes during the debriefing sessions. “The students are always so grateful for the feedback,” she says. “I can count on one hand the number who responded defensively. They are being exposed to situations they will have to face in the real world.”
Culpepper adds, “It’s so rewarding when a student has an ‘aha’ moment, knowing that they have a toolbox to deal with difficult situations.”
Dissecting the dead
Interacting with a standardized patient can teach a doctor-in-training a lot about how to assess and diagnose a patient, as well as improve their bedside manner — but when it comes to understanding the finer points of human anatomy, nothing can beat a cadaver.
The Belgian anatomist Andreas Vesalius is credited with founding modern anatomy in the 16th century, using dead bodies retrieved from cemeteries and executions for study purposes. These days, patients generously donate their bodies to the cause.
Not surprisingly, cadaver dissection in medical schools is not as prevalent as it once was. On a practical level, cadavers are expensive. Even though the bodies are donated, there are still costs associated with shipping, embalming and storage. The recent advent of virtual cadavers has led some schools to ditch the skin-and-bone version altogether, but most use a combination of both.
A literature review published in a 2018 issue of Medical Principles and Practice set out to solve the obsolescence debate. The authors reviewed around 200 pieces of literature on the topic and concluded that cadaver dissection is still critical for medical practitioners, surgeons and anatomy teachers to become “competent professionals who can perform safe and satisfactory practices during their professional careers.”
“I can recall two patients that I had to intubate that likely would have died had I not been able to practice intubating on a cadaver,” says Mike Gnitecki, a paramedic in Texas. “It is very difficult to truly replicate a human airway for an intubation, or a human chest for a needle decompression.”
As with SP-based training, working with cadavers provides educational benefits that go beyond the purely physical. “A cadaver teaches more than just anatomy,” says Sakti Srivastava, chief of the division of clinical anatomy at Stanford University School of Medicine. Cadavers harbor what he calls a “hidden curriculum.”
“As students dissect, they’re reconstructing the story of an individual,” he says. “They learn empathy and a respect for the dead — things you will never get from a digital program.”
Yoo Jung Kim, a fourth-year student in Srivastava’s anatomy class, doesn’t whitewash over the gruesome aspects of the exercise. “Like most people, I had never seen a dead body before and I was anxious about that,” she says. “I will never forget the sensation of sawing through bone and the scent of the lingering bone dust. Our cadaver’s brain had the consistency of anchovy paste.”
But the value of it, she says, can’t be overstated: “You learn how physically fragile a body is and that there is a surprising degree of normal anatomical variations. This knowledge came in handy during my surgical rotations.”
A very intense and emotional connection often develops with the cadaver as well. “My fellow students and I were aware that we were putting our fingers through our cadaver’s former identity — the neural synapses that had codified this person’s memories, perhaps her high school graduation, her marriage, the birth of her first child, her inevitable cancer diagnosis.”
Srivastava points out that the opportunity to dissect is a privilege and a priceless experience. In the opening lecture, he says, the class observes a moment of silence to express gratitude to the people who chose to donate their bodies. Once the dissections are complete, the students often have an informal ceremony to recognize the lives of the donors. “This is not a requirement,” says Srivastava. “It comes entirely from the students. It’s very moving.”
He provides an analogy to sum up the value of the experience: “You can take a virtual tour of a beautiful place, or you can go to the place itself.”
In other words, Spotify is great, but there’s still nothing quite like vinyl.