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!