"All right, now push against my hand."
[Werdende Kraft via wikimedia]

When learners do strength testing on my extremities, I often find myself confused by their instructions. Because learners often practice with each other, it means they practice with people who anticipate and act on what the learner intends, not what the learner has actually said. Plus, strength testing involves body positioning in a way where students are less likely to be mindful of physical autonomy.

I wrote about this a bit in "Neuro exam checklist," but it comes up frequently enough that I wanted to break it out into its own post. So this is the kind of feedback I give learners doing strength testing.

This is a living list. Last updated November 3, 2015

• Explain: Why are we doing strength testing, anyway? As a patient, it can look like a lot of work with no clear purpose, especially if the movements seem unrelated to my chief complaint.

• Stop talking: Learners frequently begin the test before they even finish telling me the instructions. So the test could be over before I even understand it has begun.

• Offer simple, clear instructions: I feel strongly that "Push against me" and "Pull against me" are far easier instructions for me to follow than "Resist my force." Or worse: "I'm going to push against you; don't let me." Framing things in the negative (ala "resist me") places a higher cognitive burden on me to figure out what the learner wants me to do to "resist." Plus, telling me to push/pull also makes it clear when the testing has begun, because I am in charge of the movement. If the learner is already pushing against me but I have not yet understood my counter move, it can give the learner a false positive.

• Let me move myself: During strength testing, learners may move my limbs into position while explaining the test, which makes me feel vulnerable. If learners allow me to move my arms or feet into position myself (including during reflex testing), I feel like I have some control over my own body.

• Indicate the end of the test: This can be as easy as saying "ok" or "thank you" (how polite!). Saying "great" or another filler can be awkward if I am clearly not doing well.

• Ease up on exit: When learners are eager to move on to the next test, they may let go while I am still exerting force, which drops my limb rapidly. When this tests neck muscles, this can be especially dangerous. But when learners are careful to ease pressure at the end of the test, I feel much more confident in their ability to be self-aware and treat me with respect.

Why "Is that okay?" is not okay

"I'd like to give you some hemlock. Is that okay?"
[Aristotle refusing the hemlock via wikimedia]

As an SP, I care a lot about consent. One of the things I think about is what constitutes true consent, where a patient feels informed & safe enough to make a decision. True consent is the keystone to patient autonomy.

One of the ways I see consent fail in scenarios is when a student doctor asks, "Is that OK?" For instance: "Is it OK if I take notes?" or "I'd like to do a heart exam; is that OK?"

It seems like asking permission would be the right thing to do. But I often hear this question as a ritualized social nicety rather than an invitation to participate, similar to "How are you today?".

More importantly, as a patient, I almost always agree -- even if I'm not sure I should. When someone in a position of authority asks for consent, technically the person has the power to refuse. But that hardly ever happens because it usually seems safer to agree than to challenge the authority, partly due to the power differential. This is especially true if the patient is particularly vulnerable or disadvantaged (elderly, facing language difficulties, in a lot of pain, etc.). As a patient, I don't want to jeopardize the care I need by disagreeing.

If the student-doctor has laid a lot of groundwork of empathy, trust and rapport, it helps smooth the sharp edges of consent. But I think it's more important to facilitate true consent to begin with. So here are some ways student-doctors can ask permission to promote better patient consent:

Wait: Student-doctors are frequently beginning the action while they are asking consent for it. As a patient, this immediately trains me to believe my consent is not important. I'd have to feel incredibly uncomfortable to refuse once something is already in motion.

Inform: Identify procedures before they happen. How can I consent to a heart exam if I don't know what's involved? As a patient, what I think I am agreeing to and what I am actually agreeing to are often quite different. For instance, as a patient I am often surprised to discover a heart exam involves touching four areas on my chest with a stethoscope on the skin. So when I agreed to a heart exam, I didn't understand I was also agreeing to ungowning. I didn't understand my breast tissue was going to be in the way. I didn't know the student-doctor was going to be listening in so many places! It makes me feel tricked and/or ignorant when this happens, neither of which enhances confidence and trust.

Use plain language: I feel frustrated and cautious when student-doctors use jargon when asking consent. "I'm going to palpate your thyroid, okay?" Palpate? Do I even know where my thyroid is? Using simple language is essential for consent, especially when student-doctors will be touching the patient. 

Offer legitimate choices: When I am asked if something is "okay" but I don't know what the alternative is, I feel trapped. "Would you like to lower your gown or would you prefer me to do it?" is a more understandable choice than "Would it be okay if you took your gown down?" Without understanding what the options are, I will probably agree because that seems to be my only option.

Determine comprehension: Consent without comprehension is not consent. I want student-doctors to keep inviting questions until I don't have any more. "What questions do you have?" is a classic, but once isn't enough. The best student-doctors follow up with "what other questions do you have?". The use of summary and teach back can also be really valuable ways to determine true comprehension.

Be prepared to hear no: When a student-doctor asks me "is it okay if..." I can tell they only expect me to say "yes." So why ask the question? Good student-doctors know what Plan B is if the patient refuses -- or don't ask questions where "yes" is the only right answer.

Ask open-ended questions: If "no" is not really an option, an open-ended question is more effective than a closed binary one. For instance, at the end of the encounter, instead of asking "Are you okay with that plan?" a more appropriate question is "How does that plan sound to you?" or "What do you think about that plan?"

Don't ask: Sometimes, asking a permission question which has an obvious answer signals to me the student-doctor feels unsure or uncertain. In some cases it may be better for the student-doctor to give a direction or offer information rather than ask permission -- then adjust if the patient reacts hesitantly. For instance, do I really need to be asked if the student-doctor can take notes? Unlikely.

Paying attention to how to best enable true consent is an impressive way to build trust and respect patient autonomy.

Homework:
In a week, observe how many times you agree to something you don't feel totally confident agreeing to. What keeps you from saying "no"?

Core value: Physical Autonomy

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.