An SP looking skeptical but intrigued.
[The Detective via wikimedia]

Well, hello, there! Does anyone know anything about http://www.standardized-patient.org/ ? It's exactly what I've been looking for for years but it doesn't quite feel right and I can't put my finger on why.  Maybe: "All content becomes property of the website"? Maybe: one of the most active members seems to be a spammer? Maybe: I can't tell what school or consortium is behind it? (I'd feel more comfortable if a legitimate organization like ASPE was behind it.) Where did it come from? Why is it here? So many questions, not enough answers -- or activity.

[updated 02/28: most of the members have been removed. Hmmmm. Updated 03/09: many more new members, all of whom seem to be spammers. Dang it!]

Answering open-ended questions

An SP attempts to answer an open-ended question.
[The Open Door via wikimedia]

Ideally, student doctors should ask SPs open-ended questions at the beginning of the encounter and then move to more focused ones. For instance, after introductions, a student doctor should ask something like, "So what brings you in today?" to elicit the patient's chief complaint.

In real life, a patient is very likely to spend the next 18 seconds describing their chief complaint. However, SPs are usually given a pretty simple opening line, like "My eye hurts" or "I passed out" or even something like "I haven't felt like myself lately" for psych cases. This opening line is meant to minimize and standardize the amount of information SPs initially give to students. It usually prompts students to move into close-ended HPI questions like "When did that start?" or "Can you show me exactly where it hurts?"

Sometimes, though, a particularly astute student will ask another open-ended question: "What's been going on?" or "Can you tell me more about that?" I have rarely received a script that includes how to answer that question. It seems simple, but there are two tricky parts:

• At programs that use a checklist for evaluation, as an SP you can't use any of the checklist items to answer that question! A real patient might say, "Well, I'm having really sharp pain behind my right eye that's been going on for four days now." Which means a student wouldn't need to ask about Onset, Quality and Location then. You can't evaluate a student on questions they already have information about, so the student would receive credit for those items.

• It is unlikely multiple SPs will answer that question in the same way, meaning some students will get more or less information about the chief complaint at the beginning of the encounter.

This conundrum has followed me for years and I have rarely felt like I have a satisfactory answer that remains vague enough while maintaining the momentum and realism of the scenario.

So instead of answering that second open-ended question by giving away checklist items, my new standardized answer for most cases is a response about my emotional affect and why I finally came to see the doctor today. For instance:

Student: "What brings you in today?"
SP: "My eye hurts."
Student: "Oh, I'm sorry to hear that. Tell me what's been going on."
SP: "Well, I was hoping it would go away but it hasn't, so I came in because I can't stand it anymore. I'm kind of worried."
Student: "Well, I'm glad you came in! When did this start?"

This kind of response works for a wide range of cases and severities. It gives away no checklist items and offers the student another bid for empathy if they haven't already responded empathetically to the chief complaint. It's an answer that doesn't need to be standardized amongst SPs. And because the student hasn't received any HPI info, they are prompted to ask close-ended questions. And then on we go!

Rejection

An SP flees after an unsatisfactory experience with a student-doctor.
[Sita Bhumi Pravesh via wikimedia]

This Atlantic article is written from the perspective of marriage, but it helps crystalize a particular (dis)connection dynamic I experience with some students:

"Throughout the day, partners would make requests for connection, what Gottman calls "bids." For example, say that the husband is a bird enthusiast and notices a goldfinch fly across the yard. He might say to his wife, "Look at that beautiful bird outside!" He's not just commenting on the bird here: he's requesting a response from his wife -- a sign of interest or support -- hoping they’ll connect, however momentarily, over the bird. 

The wife now has a choice. She can respond by either "turning toward" or "turning away" from her husband, as Gottman puts it. Though the bird-bid might seem minor and silly, it can actually reveal a lot about the health of the relationship. The husband thought the bird was important enough to bring it up in conversation and the question is whether his wife recognizes and respects that. 

People who turned toward their partners in the study responded by engaging the bidder, showing interest and support in the bid. Those who didn’t—those who turned away—would not respond or respond minimally and continue doing whatever they were doing, like watching TV or reading the paper. Sometimes they would respond with overt hostility, saying something like, "Stop interrupting me, I’m reading.""

Students rarely respond with hostility, of course. But when they don't engage when I make a "bid," that makes me feel as if the student-doctor doesn't care about me as a patient. For instance, if I talk about my pain and the the student moves onto the next question without acknowledging it, s/he has rejected my bid. If I talk about my kids, my job, or a funny thing that happened to me but the student doesn't engage with it, s/he has rejected my bid.

Ignoring my request for connection (or responding insincerely) is very likely to affect the student's empathy and/or rapport scores.

HEENT checklist

An SP after a HEENT exam.
[Bartholin head transect via wikimedia]

The Head, Eyes, Ears, Nose & Throat exam is one of the most vulnerable exams for a patient because it uses pointy objects and bright lights near sensitive orifices. I don't know how SPs get used to this. I am pretty strict & consistent in my reactions during this exam because I want to remind students be especially considerate and careful in this region.

Here are some of the things I am looking for during an HEENT exam:

This is a living list. Last updated October 29, 2015.

Head

• Palpation: Careful of earrings and glasses when present. Use the word "touch" instead of palpation.

• Inspection: Verbalize inspection. When you do, don't use alarming words like "lesions."

 Eyes

• Reaching for my eyes is scary! Warn me before touching near them, ideally demonstrating on yourself.

• Conjunctiva: if you can, allow me to pull my own lower lids down and look up instead of doing it for me. This gives me more control in a vulnerable situation.

• Checking for pupillary reflex: tell me where to look. Otherwise, as a patient I am primed to look directly at the thing in front of my face, and when a bright light is suddenly flashed in my eye I may wince or blink or jerk in a way that gives you an incorrect finding.

• Ophthalmoscope/fundoscopic exam: tell me what you're doing before you do it. Tell me where to look. If you don't have to use the brightest light, I would appreciate it. If you're going to brace against me, warn me before you do. Don't, under any circumstances, brace yourself by placing your finger on my lip (I am surprised this happens as often as it does).

• Using a Snellen chart: if you ask me to "read the smallest line," I read the text on the bottom of the card. Be specific if it matters! 

• Checking visual fields: If you ask "Do you see my fingers?" I will turn my head to look at them. Yep, I see them. Tell me where to look if it matters! Also, sometimes students don't start far enough back (so I can always see the fingers) or come far enough forward (so I can never see the fingers despite that I can see the student shaking with the effort of trying to wiggle them). 

• Accommodation/convergence: tell me to keep my head still, or I am likely to move my head when I see a pen get too close too my face. Best practice: "I want to see how your eyes are moving. Please keep your eyes on this pen and your head still as I move it towards you."

• If I am wearing glasses and you ask me to take them off, especially for the ophthalmoscope exam, I will readily agree -- and then leave them on the table until you remember to tell me I can put them back on. Patients without their glasses can feel even more vulnerable while they aren't wearing them, so the sooner you tell me the better I feel about your awareness and consideration. Unfortunately, it is not unusual for me to have my glasses off for the rest of the encounter.

Ears

• Pointy things in my ears is one of the worst parts of being an SP. I've only had a handful of students cause pain, though. To achieve the highest standard, you must break the plane of my ears and use a cone.

Nose

• But pointy things in my nose is actually worse than pointy things in my ears. How you treat my ears is similar to the way you will treat my nose. To achieve the highest standard, you must break the plane of my nostrils and use a cone (it can be the same cone as my ear, but not vice versa!). 

• Sinus percussion: For heaven's sake, warn me before you start tapping on my face. It can be a very startling sensation if a patient doesn't know it's coming, and even more so in such a vulnerable area. Many patients don't understand what areas are involved when you invoke the word "sinus": if I think you're only going to examine my nose, reaching for my eyes will be a surprise. A better explanation: "I'm going to tap above and below your eyes; please tell me if it's tender." Demonstrate on yourself as your explain it. Always use the word "tap" instead of "percuss." 

• Ask me to tilt my head back rather than pushing it back yourself. I've had students push me back with a hand on my forehead or a finger under my nose, and both ways feel less respectful than asking me to move myself. 

•  SP Pro Tip: when the student inserts the speculum into your nose, hold your breath so the moisture doesn't fog the lens. The exam is quicker that way. 

 Throat

• If you ask me to open my mouth, I will, but I won't stick my tongue out until asked. If asked to say "Ah," I will try to do it without breathing directly into your faces if possible.

• Lymph node palpation: I prefer firm deliberate pressure as opposed to tiny tickling fingers underneath my chin.

• Thyroid palpation: Describe the exam before you put your hands around my neck. Since this exam is frequently done from behind and with a fairly firm pressure, it can otherwise feel alarming. 

• SP Pro Tip: If you are an SP in a school that includes a thyroid exam, I highly recommend beginning saliva production after the oral exam and only swallowing half of it when asked, in case the student requests another swallow.