What brings you in today? Each patient arrives with a chief complaint as well as personal stories and information, overt and hidden, that can be surfaced by an effective line of inquiry. This process of eliciting all one needs to know for diagnosis is in the service of healing. In contemporary medical education, the importance of understanding the feelings of others, voicing compassion, and establishing a good rapport with patients has led empathy to be regarded not only as an instinctive quality we gain through life experiences but also as a skill that can be fostered and assessed. Standardized Patients (SPs)—actors who portray patients in a simulated clinical environment—assist in this training by allowing students to practice their conversational and clinical skills firsthand.
Kerry Tribe’s Standardized Patient (2017) reflects on this phenomenon, exploring larger questions around empathy, communication, and performance. The artist learned about this specialist area of the acting profession from a relative who once worked as an SP. As Tribe observes, “It’s a performance for an audience of one, and it’s carefully scripted for ‘content,’ but the way an encounter unfolds is highly spontaneous. . . . I’m most interested in the unexpected, often awkward ways these strangers manage to connect in their encounters, and in the ways these connections can be missed or go awry.”
Tribe’s work often involves establishing collaborative dialogues with strangers. This new video installation builds upon her history of engaging individuals across disciplines. After observing Standardized Patient Programs at Stanford University and the University of Southern California (USC), the artist developed four case scenarios through close consultation with professional clinicians, communication experts, and SPs. Select USC staff participants, medical students, and SPs trained in portraying both patient and student roles were filmed at the university’s Keck School of Medicine. Tribe intercut these scenes with footage of the Stanford University School of Medicine’s Immersive Learning Center and unnerving simulation mannequins. Standardized Patient begins in a basement hallway with a row of students entering a series of fifteen-minute Objective Structured Clinical Examinations (OSCEs). They have been tasked with taking medical histories, telling their patients what they think is going on, and recommending next steps. “Nina Matthews” is a thirty-six-year-old following up on blood work for chest pains. “Judy Donaldson” is a seventy-two-year-old there to ask about her increasing forgetfulness at the urging of her daughter. “Samantha Reyes” is a teenager who came in to request oral contraceptives and agrees to be tested for STIs. An instructor and multiple students stand by the bedside of “Richard Bloom,” a sixty-eight-year-old man with end stage colon cancer, and take turns asking him about various aspects of his life, from his family to his spirituality. In such interactions the students are not only faced with physical symptoms but also asked to handle the complexity of these individuals, their attitudes, and their emotional responses to bad news. As author Leslie Jamison, a former SP, has observed: “Empathy isn’t just remembering to say that must be really hard—it’s figuring out how to bring difficulty into the light so it can be seen at all. Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to.”
Standardized Patient expands on the investigations of language, memory, and consciousness central to Tribe’s artistic practice. She has observed that “sometimes it takes the anomalies in the system to reveal how the system works.” Tribe’s interest in the use of SPs dovetails with her ongoing recent project on a communication disorder called aphasia. Resulting from cerebral traumas such as strokes, this condition reflects damage to the brain’s language centers and is experienced differently by every individual. After regularly attending weekly aphasia community support sessions at Cedars-Sinai Medical Center and gatherings of a spin-off group, The Aphasia Book Club, that began meeting in 2014 at the Echo Park Branch of the Los Angeles Public Library, Tribe produced a related body of work in video, sculpture, and photography. Presented in the solo exhibition The Loste Note in 2015, these works, which utilize the visual vocabulary of photo or film shoots, took the massive warehouse gallery space of 356 S. Mission Rd., Los Angeles, as the site of their creation and their reception, a context that resonates with the ways the disability can affect both the production and the understanding of language in its many forms.
While conducting research for this new project last spring, Tribe sat in on an acting class taught by H. Richard Greene, the SP who portrays cancer patient “Richard Bloom.” He told his students about an aphasic friend, a talented theater director, who had lost his ability to use words following a stroke but still managed to convey a huge range of feelings nonverbally. Coincidentally, Greene’s friend turned out to be one of the men Tribe had come to know well over the couple of years she spent with both aphasia groups. His suggestion that the book club begin reading poetry led her to title her related work The Aphasia Poetry Club (2015). In this three-channel video installation Tribe contends with how the difficulty of expression for aphasics problematizes the medium’s typical reliance on coherent narration by speaking subjects, replacing the standard “talking head” interview format with looser portraits of three individuals formed through associative relationships between their voiceover and her constructed imagery.
Tribe’s practice has involved actors in unconventional ways since the late 1990s, though she considers her work to be fundamentally documentary-based. For instance, in the early video Double (2001) she advertised in Los Angeles for actresses who shared her basic physical description. Shortly after meeting the artist for off-camera interviews, five performers interpreted her persona. The instability of their recall, coupled with their own improvisations, opens a space for fascinating, unrehearsed decisions that is similarly present in Standardized Patient. Tribe has also drawn from artists’ cinema, such as Hollis Frampton’s classic Critical Mass (1971). Frampton shot an explosive, improvised argument between a young couple in a single take, then diced it and spliced it together using a three steps-forward, one-step-back approach, with looped phrases, repeating shots, and moments of disjuncture between audio and images amplifying the characters’ emotional falling-out. In Tribe’s live reenactment of the same title, two actors precisely perform, cut by cut, the fragmented, fraught dialogue from memory—an endurance-based embodiment of all the rhythmic repetition and phasing of Frampton’s algorithmic editing.
Throughout Tribe’s work, there is a distinctive attention to the ways the physical form or apparatus of time-based media installations can mirror cognitive processes. Her installation H.M. (2009) recounts the famous story of “Patient H.M.,” who lost his episodic memory after undergoing experimental brain surgery for epilepsy in 1953: he would forget everything that happened to him within about twenty seconds. Tribe’s retelling not only relates this tale of severe memory impairment but also re-creates the experience of short-term memory loss by looping the single 16mm film through two projectors with a twenty-second delay between images. Her multifaceted project about aphasia is a continuation of this approach, describing the condition and also “producing” some aspect of the dissociation that characterizes the aphasic experience.
In Tribe’s New Work exhibition, an angled screen presents a progression of SP encounters on one side and a synchronized montage of supporting materials on the reverse. Fragments of the patients’ scripts, diagnostic flow charts, and textbook illustrations offer glimpses of the kinds of information that underlie the action. The encounter format, too, suggests that these performers inhabit a dual headspace—holding conversations while mentally tracking checklist items to be submitted afterward—an inversion of roles in which the “patients” are now the evaluators. The paradox of the SP exam lies in its artifice: both parties are acting while also being themselves. Yet there is the potential for medical student and actor to connect when both willingly suspend disbelief. Throughout Standardized Patient are details that underscore the aspect of time—shots of wall clocks, glances at watches, the interruption of a PA announcement—and the various recording and surveillance devices that signal the mediation involved in the elaborate exam staging. The neutral palette of this place for care and comfort cannot fully mask its strange details or conceal the fact that it is a charged environment no one wishes to spend much time in. Indeed, hospital anxiety is often amplified by the anticipated costs of care. Tribe’s Standardized Patient and her related work Rinse and Repeat were developed over the past year, a period of intense political debate and protest around access to affordable health care in the United States. As personal accounts of fear and outrage at the prospect of losing medical insurance flood news outlets and social media, there is perhaps no better moment to reflect on the need for greater public accountability and for empathy with the perspectives of others.
- Coined by Geoffrey Norman, PhD, the term “Standardized Patient” emphasizes the importance of presenting the same case in a standardized way. Other names used to describe this role include “Simulated Patient,” “Programmed Patient,” and “Patient Instructor.” The use of SPs at USC dates to 1963, when Dr. Howard S. Barrows employed the actress Rose McWilliams to work with students directly as paraplegic patient “Patty Dugger.” She had previously appeared in his short film demonstrations of a neurological exam. The use of actors was initially met with some skepticism within both the medical community and the press. See Peggy Wallace, PhD, “Following the Threads of an Innovation: The History of Standardized Patients in Medical Education,” in “Simulation in Medical Education,” ed. Howard S. Barrows, special issue, Caduceus: A Humanities Journal for Medicine and the Health Sciences 13, no. 2 (Autumn 1997): 5–28. Archived online at https://archive.org/details/caduceushuman1321997unse. Today a series of fifteen-minute encounters with SPs, known as the Step 2 Clinical Skills (Step 2 CS) portion of the United States Medical Licensing Examination (USMLE), is a required component of the American medical licensing process.
- Kerry Tribe in conversation with the author, “Examining Empathy with Kerry Tribe,” San Francisco Museum of Modern Art Member Magazine (Fall 2017): 24.
- Leslie Jamison, “The Empathy Exams,” in The Empathy Exams (Minneapolis: Graywolf Press, 2014), 5.
- Kerry Tribe quoted in Alex Teplitzky, “In Kerry Tribe’s Artworks, Forgetting Leads to Creating” (interview), Creative Capital Blog, April 7, 2015, http://blog.creative-capital .org/2015/04/in-kerry-tribes-artworks-forgetting-leads-to-creating/.
- Kerry Tribe, email to the author, March 29, 2017.
- For a representative excerpt from Tribe’s Critical Mass and other select works, see the artist’s website (www.kerrytribe.com) and Vimeo page (https://vimeo.com /user4461075).
- Tribe’s Rinse and Repeat, a single-channel video featuring related screen tests with actors discussing their work as SPs, was commissioned by REDCAT (Roy and Edna Disney/CalArts Theater), Los Angeles, for the group exhibition and performance series Chalk Circles, curated by Ruth Estévez and José Luis Blondet, June 17–August 20, 2017.