The clinic examination room was painted in cool shades of white and gray. In front of me sat a 65-year-old female patient in mild acute distress, complaining of chest pain that had progressed over the past week. The chest pain was now preventing her from doing all the things she enjoyed doing, such as exercising, and driving her car, and going to work. Her activities of daily living, in short, were adversely impacted. As I sat on my stool across from her in my white coat, I could respond with only one thing.

“I’m sorry to hear that.”

I winced. I regretted the words immediately as they left my mouth. They felt inauthentic, as if belonging to a prewritten script that dictated the clinical encounter. A forced statement of empathy. Deep down, I knew that I was not sorry for her and her condition. I couldn’t care less.

Instead of caring, I was performing. Performing a script that I had enacted multiple times before and memorized. After all, none of this was real.

The patient was not a real patient with chest pain but in fact a standardized patient mimicking chest pain. The examination room was not a real examination room in a hospital or clinic but in fact a room built to resemble an examination room. And outside this room I would type up my SOAP note within a strict 15-minute time limit. Outside this room, there was no camera on the ceiling recording my every move. There was no clinical simulation between patient and student doctor.  

“It’s all just acting,” one of my peers vented to me earlier that day. “Just follow the criteria, say all the things they want you to say, blahblahblah. Follow the checklist and you’ll be fine.”

I nodded my head in silence. All I had to do was take a comprehensive history, complete an accurate and thorough physical exam, and, most importantly, exhibit empathy. I had to fulfill these requirements to get a decent grade and pass the course. But with this rigid script to follow, where was the opportunity to be spontaneous and real? Perhaps there was no room for anything of the sort in a clinical simulation.

Simulation-based learning has become the cornerstone of modern medical education — not just for future physicians, but also nurses, physician assistants, and pharmacists. Within these controlled environments, students of all disciplines can attain personal confidence as well as individualized feedback before heading out to do the “real thing” in the “real world.” Simulation-based education can come in a variety of permutations, allowing students to become more accustomed to history taking and physical examination (during encounters involving standardized patients) and practice more hands-on diagnostic skills, procedures, and treatments (during cases with manikins).

Nevertheless, simulation-based education comes with its own drawbacks. Scenarios involving both standardized patients and manikins are entirely fictitious, with role-playing that requires a certain amount of performance. Medical students themselves recognize and acknowledge these limitations, especially when it comes to the demonstration of empathy. A 2020 study that thematically analyzed letters and group discussions between medical students, for example, determined that students are acutely aware of the “fake empathy” that must be employed during simulation training in order to “tick the empathy box.” In these required performances, empathy is not practiced as an art — rather, it is employed as artifice.

This verisimilitude encourages students to become what medical educators have termed “simulation doctors,” or physicians “who act out a good relationship to their patients but have no authentic connection with them.” If standardized patients are actors who are specially trained to follow an illness script, then medical students are no different. We, too, are nothing more than actors trained to follow a clinical script. We pass and move forward if our performances are believable; we stay behind and remediate if our performances are not up to par.

By its very nature, medicine is a performative profession. Physicians perform a physical exam, physicians perform a surgery or operative procedure, physicians perform empathy. This performative aspect is intensified during simulation-based education, encounters which are usually video recorded and later analyzed by faculty to evaluate students’ clinical competencies and identify their strengths and weaknesses. All of this is a necessary preamble to prepare students for real patients instead of standardized patients, real people who bring their real hopes, fears, and pains with them into the clinical space. We tell ourselves to fake it till we make it, till one day it becomes real — but, I fear, what if it never does? Maybe simulation-based education offers nothing more than a few rehearsals before opening night, a pre-performance before another performance. Maybe we all are stuck in pantomime, waiting for a reality that will never arrive.

After I had completed my SOAP note in the hallway outside, I reentered the clinic examination room — not for another encounter with the standardized patient, but for a debrief with the actor. The simulation was finally over, the camera on the ceiling no longer recording our play-acting. These post-simulation sessions allowed us students to reflect on the experience with our respective actors and receive their feedback.

When I opened the door, I was surprised to discover that my standardized patient was no longer wearing her costume. She had traded in her wrinkled patient gown for her real clothes: a comfy sweater and jeans. I, on the other hand, was still wearing my white coat.

“So,” she began, “what did you think of today’s encounter?”

“It was alright,” I replied as I sat down. “I felt a bit off today… My mind has been a bit fuzzy lately.” I still hadn’t recovered from last week’s exams, and now keeping up appearances in this simulation had drained me even further.

The woman smiled behind her mask, but I couldn’t tell for sure. As I rearranged the mask that covered my own face, I realized I didn’t even know her real name.

Maybe now, I thought. Maybe now that we were out of the simulation, we could have a genuine encounter. A moment of real connection. Something authentic.

The woman nodded her head before speaking.

“I’m sorry to hear that.”

What do you think of simulated patient examinations and their impact on teaching empathy? Share your thoughts in the comments.

Saljooq Asif, MS is a second-year medical student at New York Institute of Technology College of Osteopathic Medicine. He is also a Lecturer in the Program in Narrative Medicine at Columbia University, where his scholarship focuses on the broader health humanities in relation to narrative ethics, racial justice, popular culture, and more. He is a 2021-2022 Doximity Op-Med Fellow.

Illustration by Diana Connolly