[Portrait of Robert Louis Stevenson via wikimedia]

"Our business in life is not to succeed, 
but to continue to fail in good spirits."

Robert Louis Stevenson

This was obviously not written about the concept of SP work, but it could have been. On the best of days, our job is to allow students to fail in good spirits. That's where the learning happens.

Overstepping one's bounds

An SP about to demonstrate her medical knowledge.
[Queen Victoria via wikimedia]

One of the things I keep reminding myself is that SPs are not medical professionals. For instance, no matter how many times we do a gall bladder case, we are not qualified to diagnose cholecystitis.

In fact, I think it's dangerous for SPs to give advice to medical students about anything beyond what they experienced in the encounter unless expressly directed to do so at the event. I cringe when I hear SPs discuss medical feedback they've given students because "I've had a lot of experience with nurses and I know how they do things" or because the SP has experience with the condition s/he is portraying.

This is especially true given our inconsistent training. But it is also in large part because during feedback the power differential is flipped: SPs become the authority, and our words carry a lot of weight, especially with students earlier in the program. But that balance is fragile. If what the SP says conflicts with what students are being taught, all SPs become untrustworthy. We are part of their education but rarely have any actual insight into what they are being taught beyond what we know about our case. Standards and procedures differ at each school, program, hospital, clinic, specialty, etc. And teaching changes all the time, so there is real risk of delivering outdated information.

I also think this attitude is disrespectful to students. Even though SPs should be respected and appreciated for what we have to offer medical students, it's ridiculous to think we are medical experts when the amount students have to learn -- and have already learned -- is so stupendous. Many first-year medical students probably know more about general medicine than most SPs, even those who work several cases a month. Medical students, by and large, are dedicated and bright. We need to make sure we are honoring their educational journey by refraining from the need to prove what we think we know. Of course, some SPs have been or are medical professionals. But I still feel just as strongly that they should not be speaking to students in that role for all the same reasons.

I feel the strength of SPs lies within our ability to focus our comments on the communication skills of the students, not the medical skills. With limited feedback time, I would hope SPs would choose to focus on the details of the interaction rather than medical feedback.

Setting the standard:
At the very least, SPs must identify when they are offering feedback based on their personal medical knowledge, never giving the impression they are speaking on behalf of the program.

Better schools ask SPs to refer students to their lead instructor if there is a conflict between the way the SP thinks a PE should be done or if an HPI question should be asked that isn't on our checklist.

The best schools reinforce this standard and review to make sure SPs are staying within good feedback guidelines.

Alphabet soup

Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

History lesson

A senior faculty member observing an SP encounter.
[Man Holding a Caduceus via wikimedia]

Happy New Year! For Christmas this year I got several SP books, so expect to see quotes/reviews in the future from such thrillers as "Coaching Standardized Patients, "Training Standardized Patients To Have Physical Findings," "Objective Structured Clinical Exams," as well as the new SP classic "The Empathy Exams."

But first I wanted to direct your attention to an article by the esteemed Peggy Wallace: "Following The Threads Of An Innovation: The History Of Standardized Patients In Medical Education" published in 1997. How delightful! I appreciate having an authoritative source to refer to. Here's a brief summary:

"Today, as we enter the new millennium, the standardized patient has become one of the most pervasive and highly talented of the new methodologies in medical education. It was certainly not always so. The standardized patient was anything but welcome and readily excepted educational tool, especially in the early days." Though the use of SPs began in 1963, it was not until 1985 that the traditional OSCE begin to integrate SPs, and even then its dissemination was slow. National boards (USMLE Step2) didn't incorporate SPs until after the article was published!

There were 3 primary contributors to the standardized patient field:

* Howard S. Barrows was the first to use SPs at USC. "Almost never was there a student whose clinical skills were evaluated as unsatisfactory because the faculty almost never directly observed the student with patients. In fact until the advent of standardized patients, there was no objective clinical measure by which to evaluate students." It's fascinating to learn that Barrows went on to teach at McMaster University, which has similarly transformed medical applicant interviews through the MMI. While at McMaster he developed the small group format and the use of USPs. He developed ways of simulating difficult findings on SPs like bruits and pneumothorax. He was the first to develop encounters with difficult patients: seductive, angry, inquisitive, etc. 

* Paula Stillman created specific checklists at the University of Arizona. For instance, what does "examine the eye" mean, really? Stillman could tell you 20 things a student should do to examine an eye that nobody had bothered to standardize before. In addition to using SPs as a body and an evaluator, she also used SPs to teach those skills: "They knew nothing about medicine. They were strictly process people." And yet still effective, I imagine, with the appropriate training! She was the first to begin working with patients with actual physical findings (only one school here does that). 

* Robert Kretzschmar began using SP models as "gynecological teaching associates" in 1968. At first they were just bodies with a sheet obscuring their face and without commentary or feedback, but Kretzschmar expanded the teaching & communication roles for GTAs in 1972.

Things which did not come to pass:

* "The 'patient instructor' might become a necessity rather than a luxury --  and Standardized Patients might be even more extensively needed for clinical learning and self-assessment as the pool of teaching faculty dwindles." (Not without better training!) 

* "And what about the practicing physician, or the one who has lost his license to practice? Might not the standardized patient be able to support the physician in new learning... [making] it possible for the physicians-in-trouble to relearn?" (While I would love to see more of this, I only know of one program that works with physicians-in-trouble and it's a very small, closed group.) 

* One of the interesting skills that seems to have been lost over the years is the use of "stimulated recall" after the encounter. SP feedback can be great, but I imagine reviewing a video of the encounter with an expert guide to ask you questions at specific points would be incredibly effective. (I try to do something similar in my feedback -- e.g. "What were you thinking when X happened or when you asked X?" -- but I'd like it to be a standard tool for schools to use when appropriate.)

Thank you, Peggy Wallace, and thank you, Barrows, Stillman & Kretzschmar! As Wallace concludes, "May that golden rod, now firmly planted, continue to inspire winged ideals in the midst of the inevitable conflict of the opinons that will create the fertile soil for sustaining educational efforts as the search goes on for a better way to support the healers of today – and nurture those of tomorrow."