"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.

Uptalk?

I'm not sure? If this is serious?
[Sibilla via wikimedia]

"Did the student seem confident?" is one of those subjective questions SPs are often asked to answer on checklists. So when student-doctors frequently end their sentences as if they are questions?  I often advise learners to limit their use of "uptalk" during feedback.

As a patient, excessive uptalk causes me to lose confidence in the student-doctor because it can come across as if s/he is uncertain or seeking validation. This is especially true if the uptalk is paired with other signs of deference, like cocking his/her head to one side.

Nonverbal cues strongly affect patient trust & confidence. Learners often expressive gratitude when given feedback about things like tone & posture because they are often invisible things learners can change which have real impacts on patients.

Uptalk can be controversial, however. I recognize it is often gendered: I give women this feedback more than men, and women are more often socialized with habits that undermine their authority. But learning to project respectful authority & appropriate confidence are keys to navigating the power differential between doctors and patients. So when I give feedback to learners about uptalk, I try to keep it as neutral as possible. Sometimes we replay and reframe sentences that stood out during the encounter. I don't expect to change a lifetime of vocal inflection in one session, but awareness is always the first step.

Do you have heart disease?

Not for the faint of heart.
[Heart diagram from Grey's Anatomy via wikimedia]

The other day a medical professional was taking my medical history and asked, "Do you have heart disease?" And as I always do when a learner asks me that question during a scenario, I thought, What does that mean?

"Heart disease" is such a broad category, and patients rarely refer to their own experiences that way. Patients who have had heart attacks, high blood pressure or high cholesterol may not include those items when asked about "heart disease."

"Disease" is a big part of the problem here, too, I think. As a patient, I wouldn't think to include palpitations when asked this. Or a pulmonary embolism. Does a stroke count? What if I've been told I have HBP or high cholesterol but am not being actively treated for it?

It is especially important to be clear when asking a string of questions to which the answers are usually no. Because as a patient, it is much easier to say "no" than it is to stop the flow to ask a clarifying question.

Extra credit

The term "cardiovascular disease" is even worse. Plain language is important!

Setting the standard

If learners at your school ask broadly about "heart disease," train SPs how to respond realistically and in a standardized way, because otherwise they are almost certainly all giving different answers. Better yet, train learners to ask a broad question about health history first, then to follow up with specific examples based on chief complaint, case and/or presentation.

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.

Communicating sincerity

A student-doctor demonstrating sincerity during an encounter.
[Sterne and Grisette via wikimedia]

I feel strongly that feedback is most effective when it rests on a foundation of observable behavior and offers a concrete way for the student to attempt to fix it.

This can be especially difficult for vague skills like empathy, rapport and respect. Because even if a student doctor knows to say the right thing -- "I'm sorry to hear that" to express empathy, for example -- sometimes it doesn't sound sincere.

So what does that mean? Without concrete observations and recommendations, it's not very helpful to say to a student, "When you said 'I'm sorry to hear that,' it didn't seem sincere" and leave it at that. But it's taken me a long time to really feel like I can describe what sincerity looks like in a helpful way.

So for me, sincerity is when verbal and nonverbal cues match. There are several cues I look for when gaging sincerity:

Eye contact: Does the student maintain or engage eye contact when speaking? If the student is looking away while speaking, or abruptly looks down right after or even while speaking, I will feel as if the student doctor is not sincere. However, if the student looks up and engages eye contact with me while speaking, I am more likely to feel they are sincere. 

Tone: When speaking, did the student's tone change? If the student offers an empathetic statement with the same tone as they use to ask about past medical history, I will feel as if the student doctor is not sincere. 

Expression: Did the student's expression change? Did they raise/lower their eyebrows, blink, tilt their head? Are they smiling or frowning? If the student's expression doesn't change when delivering bad news, expressing empathy, or attempting rapport, I will feel the student doctor is not sincere. For instance, if the student-doctor smiles widely while saying "That's terrible!" I will not feel s/he is sincere.

Rate: Does the student doctor pause for a moment after expressing empathy, or barrel right onto the next question without a breath? Does s/he rattle off "I'm-sorry-to-hear-that" all as one word? If so, that will feel less sincere.

Non-verbal vocal expression: Does the student add a non-verbal vocal expression like "ohhhh", a tongue ticking against teeth, or a sharp inhalation when offering empathy? Do they say "mmm-hmmmm" when attempting rapport or engaging in active listening skills? Those are signals that indicate sincerity.

Posture & Movements: Does the student's posture & movements match what they are trying to communicate? For instance, if we are having a personal discussion, is s/he all the way across the room? Checking their watch? Did they shake their head or nod appropriately? If the student is trying to communicate something serious but is slouching on the stool or leaning against the wall, I will feel the student doctor is not sincere. 

Energy: Is the student matching the patient's level of concern? Are they using a similar rate, volume, emphasis as I am? If the student seems much more upset than I am at a parent's passing, for instance, I will feel the student doctor is not sincere.

Setting the standard:
If the checklist asks me to grade a student on skills like empathy, rapport or respect, I prefer to give them full credit only when they seem sincere.

Hand wash

Lady Macbeth could teach us a few things about hand washing.
[Ellen Terry as Lady Macbeth via wikimeda]

One of the things I have become more aware of since becoming an SP is how hard it is to stay healthy in the health profession! Students generally can't make up scenario events, and so they enter my room in various stages of illness and fever.

So now I am much more aware of handwashing -- both theirs and mine. Since I shake so many student hands, I try to wash them between students. I am more careful about rubbing my eyes. I use a paper towel to open the bathroom door after I've washed my hands. I use the back of my wrist to shut off the water. When I handle pens or my phone I want to wash my hands. Sometimes I sanitize the keyboard I am using for checklists.  I even use the sanitizing gel more than I used to, though I primarily prefer soap & water.

When we are in flu season, my handwashing urge kicks into overdrive. But it must be working, because it's been a while since I got the flu, despite persistent contact with potentially infected students.

Discussion question
Does your school have a checklist item for "Student washed hands"? If so, what are the criteria for full credit? Can students use hand gel? Do they have to wash their hands in front of you or outside the room? Do they have to wash their hands immediately before beginning a physical exam? Etc.

Extra credit!
I once had a student in a group setting who refused to use hand gel because she claimed to be allergic to it. In this location there was no access to water. So I allowed her do the physical exam but it made me squirm. Only afterwards did I realize I should have asked her to use gloves instead.

Would you see this doctor again?

Just one glass of wine won't affect the SP's rating, right?
[The Doctor's Visit via wikimedia]

Many checklists contain a question like this: Would you see this doctor again? No pressure!

This question works best when the evaluation is more than a Yes/No question. With a binary scale I feel compelled to mark "Yes" in all but the most egregious encounters.

But honestly, the answer is usually a little more nuanced. As a patient, I am likely to see a doctor again even if I had a pretty mediocre experience. The trouble of finding a new doctor doesn't seem worth it unless it was truly a terrible experience. So "Yes, but..." would probably be a more realistic answer for most of my patients.

Some schools offer a scale that looks more like Definitely Yes, Probably, Maybe/Not Sure, Probably Not, and Definitely Not. That feels a bit easier to pick an option that feels true for that encounter. When I use that scale, most of my students are rated Probably or Maybe. Exceptional students rise to Definitely Yes and difficult encounters, mercifully few, sink to Probably Not. Have I ever used a Definitely Not? If I'm not sure, I probably haven't, because the encounter would be undoubtably seared into my brain.

The big question is: who sees the results of this question? Would you see this doctor again is a much trickier question to answer if you know the student will see the rating directly, because who wants to be rated "No" or even "Maybe"? Fortunately, most schools I work with spare the students this ego-crushing rating. Instead, they filter it through the faculty, who can see the ratings in aggregate and compare other SP ratings for that student to see if there are any red flags they should be watching for. But I didn't know that when I was first starting out, so it seemed like the student's delicate sense of self hung in the balance between my keyboard and mouse.

Extra credit!
Some SPs mark this from the perspective of an SP, which I think is unfair. Given the SP's understanding of the case, they may mark a student down for not having done a particular medical procedure or asked a particular question they consider crucial to the case -- but I feel that the student has already been marked down elsewhere on the checklist, if so. So I only respond based on how I feel the patient I am playing would have answered the question.

Setting the standard:
If this question is asked, it should be at least a 3-point scale: Yes, Maybe, No. It should include a place for comments. Students should probably not see these directly. SPs should be aware of the outcome of this evaluative statement.

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.

Wrapping up

Ah, I see we're almost done here.
[A Lady in a Fur Wrap via wikimedia]

We've talked about a proper introduction, but what is a proper conclusion, anyway? As soon as I realize a student doctor is wrapping up, these are the things I am looking for:

Summaries:

• A summarization of HPI
• A summarization of relevant physical exam findings

Answers to these 3 questions in this order using plain language (even if the answer is "I don't think so" or "I don't know yet.")

• How serious is it?
• How long will I feel like this?
• What is the next step?

And finally:

• Teach back
• "What questions do you have?"
• Validation & empathy
• Farewell

Ungowning instructions

SP awaiting a heart & lung exam.
[Madeleine dans le désert via wikimedia]

Actors are not generally modest. But most patients are. "There will be some patients who would sacrifice their health and lives in order to preserve their physical modesty."

So I care quite a lot about standardizing ungowning instructions because they have a huge effect on patient trust and confidence. Checklists often contain a question about appropriate draping, but it is rarely clear how SPs should score this except on a vague sense of personal taste. But again, that makes specific feedback difficult. So for me, good ungowning instructions have four parts:

First: confidence My discomfort rises in direct proportion to student discomfort. Being able to address vulnerable exams with confidence makes me feel less anxious. 

Second: expectations management Student doctors often assume I know that certain exams will require ungowning. As a patient, why would I know a heart or lung exam requires ungowning? When a student doctor tells me s/he is going to check my heart, as a patient I imagine a stethoscope will be used over my gown on what I think of as my heart: the left side of my chest above my breast tissue. So without further understanding, asking me to ungown at that point seems strange and awkward because I have no idea what's coming next. Best practice: "I'll be checking your heart and lungs in several places. To do that, I'll need to use the stethoscope on your skin." 

Third: simple, clear instructions Don't make me guess how far you want me to bring the gown down. When a student doctor tells me to lower the gown "a little," it makes me anxious: as a patient, I would be very embarrassed if I took my gown down too far and the doctor corrected me -- or if I didn't bring it down far enough and I had to keep guessing. Ambiguity is excruciating in vulnerable situations. Best practice for first year students: "Would you please untie your gown and lower it to your waist?" Adding the instruction to untie makes me have to think less about the order of steps, which makes the whole process more fluid and gives me more confidence in the student doctor. Don't forget to tell me when I can put my gown back up! 

Fourth: autonomy & consent Because I am at my most vulnerable, ungowning instructions require even more awareness of autonomy and consent than usual to make me feel safe and respected. Do not begin untying my gown without asking me. If you ask me to lower my gown, don't reach towards me before I complete the action. Allow me to be in control of the ungowning. If you notice I am having trouble untying the gown, offer to help me -- but do not reach for me without my consent.

Advanced studies:
By asking me to untie the gown, it generally becomes loose enough so that the exam can be performed by slipping the stethoscope under the gown, thereby preserving my modesty entirely (assuming the student learner tells me they are going under my gown, at any rate). In other cases, asking me to untie the gown and slipping an arm out is a better compromise than lowering my gown all the way to my waist.

Bonus points:
This all assumes the opening of the gown is in the back. I honestly can't think of a good reason to wear the opening in the front, because it feels so much more exposed and everything can be done by manipulating the gown. But some schools do, so I go along with it. However, if the gown opening is to the back, asking me to turn my opening to the front during the encounter is completely ridiculous. That requires me to get off the table and undress while the student's back is turned, all while eating precious encounter time. Not recommended.

A proper introduction

Sadly, students never introduce themselves like this.
[The Introduction via wikimedia]

Many, many checklists have an item in the communication skills section worded something like this: "Did the doctor introduce themselves appropriately?"

Well, what does that mean? How do I know whether a student deserves credit for an "appropriate" introduction? Different schools train their students to default to a particular greeting. But this form of greeting is hardly ever required, so it makes it more difficult for me to know if the introduction is "appropriate." So in the face of a non-existent standard, it means this question is almost always answered "yes" if the student says anything at all.

My personal standard for an "appropriate" introduction includes the student's first name, last name, and title: "Hi, I'm Dr. Amy Basil."

Here are some other ways student doctors have introduced themselves that would not pass that standard:

1. "Hi, I'm Amy."
2. "Hi, I'm Amy Basil."
3. "Hi, I'm Dr. Amy."
4. "Hi, I'm Dr. Basil."

It seems like such a small thing, but when you're grading 60 students over the course of a week, having a simple assessment for an "appropriate" introduction reduces cognitive overhead for SPs and makes us all standardized for the event. And without concrete standards, how can you suggest improvements in feedback?

Extra credit!
If a student doctor follows the introduction by describing his/her role in my health care before launching into questions, I feel immediately more trusting and secure in our interaction. E.g.:
"I'm a doctor here at the clinic."
"I'm your husband's doctor."
"I'm a health coach. Your doctor will be here shortly."
"I'm a member of the health care team working with you today."

Neuro exam checklist

Looks pretty simple, doesn't it?
[from Bell's Explaining the Course of the Nerves via wikimedia]

In the "classic" SP encounter, I am tasked to memorize a case, act it with the students, keep track of what the student is or isn't doing while in the encounter, complete a checklist after the student leaves, and then give feedback to the student after the checklist is complete. Wash, rinse, repeat up to 20 times a day.

Of those types of cases, the hardest one is the neuro case, because the neuro exam has so many things to remember. Most physical exams have a limited number of discrete actions on a small segment of the body. The neuro exam, however, is literally head to toe. A complete neuro exam can include as many as 40 items -- on top of memorizing the history and communication checklists!

And for patients, the neuro exam is often the most obtuse exam. The other exams are generally pretty obvious: if I come with stomach pain, I expect the student to do an abdominal exam. But neuro exams can be used for several cases, including headaches, seizures, palsy, strokes, hypertentions, stress, cardio, confusion, etc.

So when students don't explain what they are looking for, parts of the neuro exam can feel like complete nonsense. My doctor wants me to do what? And what does it have to do with the problem I came in for? Without appropriate expectations management, this can erode my trust and confidence in the student doctor. Plus, since students primarily practice on each other, they anticipate the next step in the process and forget the patient doesn't know it. So when I give feedback after neuro exams, it's primarily focused on expectations management, autonomy and consent.

Here are some of the things I am looking for during a neuro encounter:

This is a living list. Last updated Apr09, 2014.

• Associated symptoms: When students ask only about associated symptoms, I have learned to say "Like what?" so that I don't inadvertently give something away. When students ask about "auras" without explanation, as a patient I find that really confusing, and I may suddenly wonder if I am visiting a New Age doctor instead of an MD. When students ask about "visual changes" I don't know how to answer unless they give examples.
• Eye movement: students almost always forget to tell me to follow the movement of the pen with my eyes only. If they tell me to follow the pen, I move my whole head and wait to see if they notice. Some don't -- which means I can't give them credit for doing an H exam. Most do, and when they stop to give me clearer instructions without apologizing, as a patient I often feel both embarrassed and annoyed.
• Checking visual fields: If a student asks "Do you see my fingers?" I turn my head to look at them. Yep, I see them. Tell me where to look if it matters!
• Shining a light in my eyes: tell me where to look. If you don't have to use the very brightest setting, please don't.
• Examining eyes with ophthalmoscope: tell me where to look. Also, tell me you're going to get so close to me before you do, or I might start backing away. Never touch my lips with your finger to brace yourself. If you're going to use my forehead to brace yourself, warn or ask me before you do it. If you're going to lift my eyelid up, definitely warn me -- but I recommend checking without lifting first to see if you can get what you need in the most minimally invasive way.
• Using a Snellen chart: if a student asks me to "read the smallest line" I read the text on the bottom of the card. Be specific if it matters!
• Checking hearing: I feel more comfortable if I am able to cover my ear rather than the student doctor doing it. If I can see the student doctor's hands while they rub their fingers together, that can affect the outcome of the exam. If a student doctor rubs their fingers together but doesn't ask me if I hear it, I do not respond. I really appreciate when students use words like "taco" or "raspberry" during the whisper tests rather than "ABC" or "123." I feel more comfortable during the Weber or Rinne tests when the student doctor clearly explains why and how they are using the tuning fork.
• Facial expressions: This is the part of the exam where I feel like I'm on Candid Camera. Tell me why you want me to make funny faces for you. Do not use the words "innervate" when you do. Some variation of this is fine: "I'd like to test some nerves in your face, so I'm going to ask you to make a few funny expressions. Can you [smiles/frown/etc]?" If the student-doctor does it with me, I don't feel quite as ridiculous. If the student-doctor asks me to puff out my cheeks but does not tell me to keep them puffed as they push them, I will let them collapse -- which sometimes leads students to believe there is a finding when there isn't.
• Opening eyes against resistance: Quite often, students ask me to close my eyes and then try to open them without warning me. As a patient this Freaks. Me. Out. Feeling fingers against my closed eyes is very alarming because eyes are so vulnerable. But here's what's worse: opening my eyes as the student is reaching for them because as a patient I didn't know there was more to the test beyond closing my eyes. Either way, as a patient I WILL flinch. If done inadequately, this test can make me feel extremely vulnerable and unsafe with the student doctor. If it has been prefaced by other tests that have affected my trust, this one has an even bigger impact.
• Checking for sensation: "Can you feel this?" is not the same as "Does this feel the same on both sides?" And if you just ask "Does this feel the same?" I am likely to say, "The same as what?" unless you've specified comparison on both sides. When student doctors don't warn me before checking for sensation on my arms/legs, it can feel a little creepy, especially when the person is of the opposite gender. When checking for facial sensation, if a student reached towards my eyes before telling me about the facial sensation test, I will often move my head because as a patient I have no idea why they are reaching for a vulnerable area.
• Tongue deviation: "Stick your tongue out" can feel weird unless the student explains why (hopefully as part of the facial expressions). If you want me to open my mouth, tell me. Also, "Wiggle your tongue around" is not the same as "Move your tongue from side to side."
• Gag reflex: Schools have a lot of different policies on this. Some specifically ask student not to do it, some ask the SPs to fake a gag reflex as soon as it is clear that's what the student is testing for. And sadly, some actually want their students to actually test the gag reflex. I have a lot of tolerance for internal exams, but when that happens I fake the gag reflex immediately.
• Resistance tests: I feel very strongly that all resistance tests should be framed simply as "Push/pull against me" rather than "So I'm going to try to put your [body part] into [a position]. Don't let me." or "Resist me." The negative instruction makes me spend an extra second or two trying to figure out what the student doctor wants me to do. Additionally, it makes it much harder to when the actual test begins, because students are generally already holding my body in the position they want me to resist before they finish the instruction. It's as complicated to write as it is to work it all out on the table.
• Shoulder/neck resistance: With shoulder resistance, students often start by pushing down on my shoulders and when I don't automatically push up, they then have to explain the test. Sometimes they will tell me to lift my shoulders up and then push down on them -- without telling me to resist, so I let them push me down. Some students interpret this as a positive sign. The easiest way to perform this test is for the student to push down on my shoulder and say, "Please shrug your shoulders." Relatedly, if a student asks me to "Turn your head into my hand," as a patient I don't know whether they want me to rotate my head or tilt it towards my shoulder.
• Leg resistance: Don't ask me to push up both thighs against resistance at same time. Seriously, have you ever tried that? Do one at a time.
• Sharp/dull testing: For goodness sake, demonstrate sharp/dull testing once on my arm before going through the whole thing so I know what to expect. This is a million times more important if you're going to do it on my face. Also, do not be surprised when different parts of my body are more sensitive than others. That does not indicate a positive finding -- it just means jabbing me on the top of my foot with the same force as the outside of my thigh hurts more because the nerves are closer to the surface of the skin. If you are too tentative with your sharps, though, you may get false dull patches -- as an SP I am dying to tell you when that happens, but as a patient I just assume that's part of the test. If, as a patient, I have findings during a sharp/dull test, I often act surprised unless the patient has already observed it in the case history. That often prompts students to check again -- and if I give them an answer they expect, they cannot resist saying "yes, that's right." If the school has the student use a safety pin (?!!!) and the student has not shown it to me but I see it after the test, as a patient I will feel alarmed and betrayed. If my hand is not in the right position and a student moves it into position without asking while my eyes are closed, I will feel especially vulnerable.
• Reflexes: The thing I hate most about reflex testing is that almost every student grabs my arm without asking me or telling me why -- and I hate it even more so when they grab my hands (thumbs up). Moving a patient without their consent violates bodily autonomy, and as a patient it teaches me you do not value my consent. It is SO EASY and vastly more respectful to ask "Could you please place your arm here [indicating their own arm and waiting]? Okay, now relax your arm." Also, as an SP I have excellent reflexes (in both upper & lower extremities), so it is disheartening to discover lots of students are not able to elicit my reflexes correctly.
• Point-to-point and Rapid alternating movement: When students don't explain rapid alternating movement, I feel like I'm playing a child's game. This is especially true for the finger-to-nose test: as a patient, I wonder if the student doctor think I'm drunk.
• Orientation questions: When students ask me orientation questions without explanation, it seems unnecessarily ominous and obscure. Some are at least aware enough to say, "I'm going to ask you some silly questions." But rarely do they say why. Try "...to rule out anything serious." Afterwards, I would feel relieved if I was jokingly congratulated for passing this most obvious of exams.
• Gait and balance: "Hop off the table" seems a bit too informal for my tastes. Clear instructions about how to walk and how far to walk and why make me feel more comfortable.

Extra credit!
Because the neuro exam has so many items, students often feel rushed. That makes me feel anxious. As the exam progresses, the accumulation of abrupt and opaque exams can foster distrust -- which makes me feel even more anxious and cautious. And the more time student have to spend explaining or re-explaining the tests, the more rushed they feel. So the more students can pre-invest in finding simple ways to explain and manage the neuro exam for SPs, the faster and easier it will be for everyone, including the patients they see later in their careers.