How I feel after a particularly disappointing physical exam.
[La Autopsia via wikimedia]

My first core value as an SP is "Empathy First." Many years of SP encounters have also led me to claim physical autonomy as a second core value. I firmly believe that autonomy is the key to respect. It is one of the things that is critical in reducing the power differential between doctors and patients.

Autonomy manifests most directly in an SP encounter during the physical exam. When a student doctor doesn't respect my physical autonomy, I feel vulnerable, helpless and insignificant.

When autonomy is not a core value for the student, my body feels like an object for the student to manipulate. Autonomy hinges on consent. There are several different levels of autonomy a student doctor can observe:

1. Move the object without explanation
2. Move the object with an explanation
3. Asking while moving the object
4. Asking before moving the object
5. Asking before moving the object and waiting for consent
6. Asking the object to move itself

Here's the thing: even if the student doctor is nice about 1-4, only numbers 5 and 6 are true autonomy. A student can be nice and still not respect my personal autonomy. Let's look at this more closely:

1. Move the object without explanation: the student doctor moves my arm out of the way and continues the exam without explanation. This makes me feel as if I am no longer a person to the student doctor, just in the way. This makes me feel resentful and cautious.
2. Move the object with an explanation: the student doctor moves my arm out of the way and explains why s/he is doing so. This makes me feel powerless.
3. Asking while moving the object: the student doctor asks "May I move your arm?" as the student doctor is moving my arm out of the way. Lots of students know they should ask a patient's permission, but many of them perform the action as they are asking for permission -- which makes me feel as if my consent doesn't matter.
4. Asking before moving the object: the student doctor asks "May I move your arm?" and waits for a beat. If I don't respond immediately in the affirmative, many students will move my arm anyway as if I had answered affirmatively! As a woman, I have been trained to be agreeable to implied consent, so it is difficult for me to offer any resistance to the student doctor's expectation when asked (especially if the student doctor is friendly). However, I don't immediately answer because I want to see what happens: when student doctors assume consent when there is none, this trains them badly for real patient encounters.
5. Asking before moving the object and waiting for consent: the student doctor asks "May I move your arm?" and waits for me to agree. This is an terrific way to reduce the power differential. I feel relieved, validated and grateful.
6. Asking the object to move itself: when the student doctor is conscientious enough to ask "Could you move your arm overhead, please?" I feel like cheering. Allowing patients the chance to move themselves into position allows them to feel in control in a vulnerable situation. I want medical education to rest on a strong foundation of patient control and consent.

Homework assignment:

Notice this week how many times you agree to something before the person has even finished making the request. Try not to agree in anticipation. How did that feel? How did the other person respond? Conversely, notice how many times you make a request and begin an action without waiting for a response.

Setting the standard:
An adequate standard would be one where student doctors ask permission before moving the patient and wait for the patient to respond. The student doctor would then continue to watch for verbal or non-verbal cues which indicate the patient feels more comfortable with assistance or does not need to provide continuous consent.

A better standard would be to find ways to allow patients to move themselves whenever possible. The student doctor would then watch for verbal or non-verbal cues to indicate the patient is having trouble understanding the instructions or unable to move themselves without assistance, at which point the student doctor would ask permission, as above.

The Name Game

Banana fana fo-fatient, mi mi mo-matient
[Detail from the Babenberg Family Tree via wikimedia]

One of the hardest things about the first case in a series of SP encounters is during the introduction. "Hi, I'm Student Doctor Soandso, and you are...?" as they extend a hand.

For someone who can memorize 60-80 different checklist items for a character, when I am asked that question the first time, sometimes my mind just goes blank. And it's terrible because it's right at the beginning of the encounter: if I make an obvious mistake on MY NAME, something any real patient knows by heart, the student will have a much harder time engaging fully with the scenario.

Sometimes I play for time: "I'm sorry, what did you say? Oh, I thought you said 'your car'! Ha ha!" while thinking furiously. If I really can't remember, I make up a name and resolve to look up the real name between students. Getting the name right can be important because many cases are known not by the symptoms but by the character name, e.g. the "Andrea" case.

Some cases don't include names at all, so you get to make them up. I have a series of names I remember based on age bracket, which is especially useful if I have multiple cases in a day. (I finally have a use for all the mistaken names people have called me over the years!) Then I use an historic family surname. So if I'm stuck, one of these names readily pops to mind. I also have a consistent series of names and ages for a combination of up to 5 children, grandchildren, spouses, and pets. I think it is distasteful when SPs (or even faculty members) create names that are punny or based on celebrity/character names. It makes it harder for the student to take the case seriously.

One school I work with has a policy of introducing the patient by both first and last name so that the student is prompted to ask what the patient prefers to be called. But otherwise I just introduce myself by whatever I think the patient would use, which is usually the first name unless the patient in this case would be older or more formal for some reason. However, if a students enters and asks if I am "Mrs. Smith" when the case has not specified I am married (or has specifically specified I am divorced), then I call them on that gendered/social assumption.

I prefer case names when they are gender neutral. Even so there are some names that students assume are a particular gender and they are surprised when they open the door to find I am not the expected gender. Once, a student was so flustered by that he said he was going to complain! "They'll be hearing from me about THAT!" he declared.

Extra credit #1:
I always feel better when students use my name in a scenario: it gives them a boost in the "rapport" category. Transitions are great places to use a patient's name: between the history and the physical exam, between the physical and the conclusion, or during a summary statement.

Extra credit #2:
If a case doesn't include a birthdate, just an age, it's always a good idea to create one because many times student doctors will ask (and I can't do that calculation on the fly). That's also something patients know by heart, so any hesitation grinds the scenario to a halt. That can require tricky math depending on the current month vs the birthmonth, so I almost always pick a birthdate in early January so simply subtracting the age from the current year works out.

Really quick

When I saw this (really quick!) video from Cooper Medical School, I thought, "YESSSS!" When students tell me they're going to do a "really quick" exam, it makes me feel rushed. If something is bothering me enough to make a doctor's appointment, I want a thorough exam, not a "really quick" one.

Role reversal

Who is the student and who is the master?
[A Teacher and his Pupil via wikimedia]

Adam Bitterman proposes a "reverse" SP scenario where actors pretend to be doctors and students pretend to be patients as a way to enhance student empathy and etiquette. How fun would that be? I would start by creating five encounters with different types of doctors and a very simple history for students, so that the student experiences the way different doctors can affect the same patient with the same case.

I can imagine many ways it could be enlightening. I also see some ways that medical students would still have trouble empathizing with the experience of most patients. For instance, technical jargon wouldn't make students feel stupid. Students would still likely anticipate the exams being performed, and so never experience the frustration of unclear instructions. Students are unlikely to feel as nervous or ashamed of their bodies as patients do when being exposed or asked personal questions.

Still, it seems like a worthwhile experiment to reinforce good habits, especially paired with some self-analysis exercises. In what ways do the students resemble or respect the Standardized Doctor in the scenario? What did the SD do that caused them to be uncomfortable? I would love to see a checklist of SD communication skills that the student "patients" fill out.