An SP tries to remain covered during an invasive exam.
[The Invasion via wikimedia]

Acting (or at the very least, memorization) is an important component to being an SP. But also important is self-awareness and comfort for varying levels of exposure & contact during an encounter. Generally speaking, if you want to be an SP, there are three kinds of exams you could be a part of:

• Interview: the student doctor asks history questions, counseling, etc. but does not perform a physical exam.

• Physical: the student doctor examines one or more body systems using hands and/or tools. This may or may not involve wearing a gown.

• Invasive: primarily breasts, pelvic & rectal exams. These are paid at a higher rate than the first two categories (though the rate widely varies across the US).

Some schools are explicit in these designations, while others do not bother to distinguish between the first two categories.

But these categories are pretty broad. For true ethical transparency, I think the categories should be even more nuanced. For instance, some of the physical scenarios can be invasive and uncomfortably intimate for some SPs who are modest, rightfully nervous of pointy things in their ears, or easily triggered.

Here's how I would categorize SP jobs:

• History Interview: student doctors ask questions about the patient's chief compliant, medical history, family medical history and/or social history. Relatively straightforward, without major revelations.

• Psych interview: Any interview that includes a major social or emotional component, as these require such different affects, reactions and feedback. Different SPs find different kinds of psych encounters draining. Some find depression exhausting, while others find mania exhausting.

• Basic physical exam: the student doctor examines one or more visible body systems using hands, eyes and tools. Neuro exams and mental status exams would qualify, too.

• Mildly invasive physical exam: anything that involves ungowning instructions would probably qualify for this category. Exposing the abdomen or chest is a modesty issue for some SPs, so heart and lung exams can be uncomfortable for them. Exams that require the SP (or the student) to move breast tissue would be part of this category, as would attaching leads. 

• Moderately invasive physical exam: I don't understand why there isn't more consideration and expectations management around HEENT exams, which involve sharp pointy cones in sensitive orifices like noses and ears. I know SPs who have been harmed in these exams. Eye exams, too, can qualify here, especially ones that involve students pulling on an SP's eyelids or pushing on the eyes in some way (neuro exams, looking for conjunctivitis, etc.). Checking for the liver and spleen can be pretty invasive & intimate depending on the school, as the student hooks his/her hands under an SP's ribs. And if a school wants students to check the inguinal nodes, SPs had better be aware of that and consent to it beforehand. Nobody wants a surprise inguinal exam.

• Majorly invasive physical exam: In addition to breast, pelvic, and rectal exams, I would include blood draws & biopsies in this category.

Additional components that may affect SP modesty during encounters:

• What is the level of undress required for each role even if the SP is in a gown? For instance: can the SP wear pants, or bike shorts? Can the SP wear tank tops or bras? 

• Who will be observing? SPs may feel more or less comfortable in group encounters, with peer observers, with faculty observers in the room, with faculty observers outside the room, with staff observation, or with video review after the event.

Extra credit:
I once worked for a school that wanted women to remove their bras for the event since students would be performing heart/lung exams. The school didn't think it was fair for the students who had female SPs to have to struggle with this complication when students who had male SPs did not. This is generally not acceptable, but even worse is that this was mentioned on the day of the exam. What SP was going to refuse at that point? That felt disrespectful (and frankly, sexist).

Setting the standard:
I think having knowledge of these categories is an important tool for SPs to choose the kinds of jobs they are comfortable with, especially when first starting out. For every event, make it clear what is expected of the SP before the SP accepts the job. Do not penalize SPs for refusing jobs outside their comfort level.

Abdominal exam checklist

Open wide!
[Bartholin abdominal anatomy via wikimedia]

When I do a case that requires an abdominal exam, I am simultaneously relieved and apprehensive. I am relieved because the exam is a simple one to evaluate (unlike the neuro exam). I am apprehensive because I never know how I'll feel after a day of belly poking.

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

This is a living list. Last updated February 01, 2015.

• Draping technique: Very much like ungowning instructions, draping requires confidence, clear expectations/instructions, and a willingness to give as much control as possible to the patient. Best practice: "I'm going to lay this sheet over your legs. Please lie back and lift your gown to just below your breasts so I can examine your stomach." The drape should cover my pelvic bones (at the very least; I actually prefer my belly button) as I pull my gown up, and then be rolled back later. If the student turns his/her head away after the drape is lowered, it makes me feel like s/he respects my modesty. If a student doctor needs a clearer view of the lower quadrants, the student doctor should ask me to roll down my shorts -- the student should never try to roll it down for me or slip the stethoscope underneath. Both of those things feel very intimate and violating.
• Inspection: Verbalization is crucial for SPs (otherwise, how do we know students are looking for anything?), but I think it's a good idea for patients, too. If a student doctor uses words like "lesions" or "masses," as a patient I start to get nervous even if the findings are negative.
• Auscultation: Listening must happen in all four quadrants. I grade tough on the lower quadrants, so even if student doctors put the stethoscope down four times, if all contacts are above or at the belly button, I don't given them credit. Similarly, listening should happen on the skin, not on the drape. As always, student doctors should announce their intentions before performing auscultation. Use the word "listen" rather than "auscultate."
• Percussion: like auscultation, percussion is only valid in all four quadrants and should be on the skin. Unlike auscultation, it is crucial for the student-doctor to warn me about percussion before it happens because it is such an alarming, unexpected feeling otherwise. When warning me, "tap" is a word that makes more sense to me as a patient than "percuss." This is also true for the liver exam.
• Palpation: like auscultation & percussion, palpation is only valid in all four quadrants and should be on the skin. Like percussion, it is crucial for the student doctor to warn me about palpation, especially that one round will be light and another round will be deep. When warning me, use the word "press" rather than "palpate." Palpation tends to be the most variable aspect of the SP exam: many student are unwilling to press firmly in a scenario. So while my stomach feel less pummeled at the end of the day, I don't feel I can grade as effectively. And those student doctors who do push hard, push haaard. Can't there be something in between?
• Rebound tenderness: make it clear this is a rebound test, not another form of palpation. Push and hold for a couple of seconds, then suddenly release. Be sure to ask if it hurts more pushing down or coming up. If there is pain, be sure to ask where the pain is located: the palpated side or elsewhere?
• Abdominal aorta: the abdominal aorta exam tends to be pretty uncomfortable, even more so than deep palpation. I appreciate student doctors when they tell me that and when they tell me what they're looking for or it just seems like more random pushing on my abdomen.
• Liver/spleen: having someone hook their hands under your ribs can be both uncomfortable and intimate, so it's very important to explain before the exam. When a student doctor percusses the liver, I feel more comfortable when I know how large the area will be beforehand -- many patients have no idea how large their organs are.
• Obturator & Psoas: If I don't know why you're asking me to move my legs, I don't feel as if you understand my abdominal pain.
• Neutral hand positioning: brushing or resting your hand near my pubis or thigh during this exam is very alarming, especially if the student is of the opposite sex.
• Clear instructions & informed consent: "May I palpate your stomach?" How can I consent if I don't know what "palpate" means? How can I consent to a liver, spleen or gall bladder exam if I don't know where they are? As a patient I will say "yes" because I assume the consequences of saying "no" are worse.
• Closing: when a student doctor summarizes the findings, that helps me understand the exam is over. When a student doctor offers to help me up, I feel grateful even if I refuse the help.

Extra credit!
I did not know Saint Erasmus "is venerated as the patron saint of sailors and abdominal pain" until just now. I will think of him at my next abdominal exam.