An SP and a learner collaborate together.
[The Duet via wikimedia]

Collaboration is a tool learners can use to reduce the power differential and invite the patient into the conversation.

Collaboration engages the patient with questions that explicitly offer the patient input into treatment, insight into the illness, or the ability to set the agenda or control their own experiences. Learners can always collaborate with the patient even in simple encounters:

• What else did you want to talk about at today's visit?
• What/why do you think this is happening?
• What do you think about [X]?
• What questions do you have so far (not just as a wrap-up question)
• Is there anything else I should know about your condition?
• We can stop the physical exam at any time.
• How does that plan sound?

Collaboration is especially vital in lifestyle modification discussions, and open-ended questions are the most effective.

• How could you improve your diet?
• How could you add more vegetables to your diet?
• How could you get more exercise in your day?
• What activities are most interesting to you?

However, a collaborative statement is not a supportive statement. So if the learner says "We'll do this together" or that "I'll be here every step of the way," that's nice and an effective use of reassurance/support, but it's not collaboration. And as I've written before, "Is that OK?" is not a collaborative (or good) question.

Here's an example of how to classify statements that could occur in a smoking cessation case, for example:

• Statement: I tell my patient to start slow, just one cigarette a day.
• Statement: That's something you could do.
• Closed collaboration: Will that work for you?
• Open collaboration: How does that sound?
• Open collaboration: What questions do you have about those recommendations?
• Open concrete collaboration: How many cigarettes do you think you would like to try cutting back on per day?
• Supportive: We'll do this together. We have lots of resources to keep you on track.

Homework:
Keep an ear out for collaborative statements in your next encounter. What could the learner do to invite you into the conversation?

Delivering a diagnosis

A learner explains a diagnosis to an SP.
[Girolamo Mercuriali via wikimedia]

When learners try to give me a diagnosis, I often feel unsatisfied because the explanation is missing one or more key components that will help my understanding.

When I go to the doctor I want to know these things in this order:

• How has this conclusion been reached? Without a summary of findings or history, I have less ability to relate the diagnosis to my chief complaint. Transparency allows me to trust the diagnosis when it comes.

• What is it? The diagnosis should include the medical term and the layman term if there is one. For instance, if the diagnosis is "Non-Hodgkins Disease" or a "lymphoma," I may not understand the learner is telling me I have cancer. If it is a serious diagnosis, I ask learners to leave a beat at this point so I have a chance to process it before continuing with the other parts.

• What does the patient know about it? After the diagnosis has been named and I know how the doctor has reached that conclusion, it is very effective if the student-doctor opens up the conversation with, "What do you know about [X]?" This allows the patient to lead the conversation and it gives the opportunity for the student-doctor to clear up any misunderstandings or praise the patient for their knowledge.

• How serious is it? Regardless of the diagnosis, there is always a range of outcomes and consequences. I will likely leap to the worst-case scenario unless I know what the range is. My perception may also change based on any previous experiences I've had (directly or indirectly) with the diagnosis. If I'm not going to die immediately, hearing, "X% of people with this diagnosis have Y happen to them" is really helpful. This is especially true if I am hearing the results of a screening test as opposed to a true diagnosis. 

• How long will this affect me? Knowing whether the diagnosis will affect me for three days or three years shapes my ability to understand the scope and impact of the diagnosis. Sometimes learners tell me they will "treat" my condition for a period of time: when I hear this, as a patient I think they mean they will cure it. So I want learners to be clear whether this is a treatment meant to prolong my life, or whether my condition is something that will resolve after treatment.

• What's the next step? And equally importantly, what's my next step? Even if my next step is "wait until the test results come back in 2-3 days," I still know what to do.

Plain language, reassurance, validation, empathy, teach back, collaboration, etc. are good tools to use within this framework, too, but they can't be used to replace one of these steps.

For example:

"Based on your coughing & fever, and those sounds I heard in your lungs, I think you probably have pneumonia, which is a lung infection that causes fluid to build up in your lungs. You're young and healthy so I'm not too concerned right now, but I'm glad you came in so we can treat it before it gets worse. Fortunately, it will probably get better in a couple of weeks after we begin treatment. I'm going to recommend a chest X-ray and a test of what you're coughing up so we know for sure it's pneumonia and so we know what kinds of medications to give you. How does that sound?"

Learners are of course welcome to elaborate on these points if the patient indicates they want more information or clarity. Otherwise, each of these steps should be no more than 1-2 sentences each.

You're going to be OK

A student-doctor reassures an SP.
[Hope in a Prison of Despair via wikimedia]

When a learner attempts to reassure me during an encounter by saying, "You're going to be OK," I smile on the inside even though I still look worried on the outside. Because I know the urge to comfort a concerned patient is almost overwhelming, and I can't fault them for the impulse.

But it's impossible to guarantee a patient will be OK. If I believe it and it turns out to be wrong, I am going to feel betrayed by and mistrustful of the person who said it. During feedback with learners, most wished they could take back that statement as soon as they said it. But they didn't know what to say instead. So here's the structure I recommend:

• Validate the emotion: sincerely acknowledging an emotion almost always de-escalates it. It makes me feel heard and like the student-doctor is attentive to my non-verbal communication.

• Next steps: of course, defusing the emotion is only the first step. Without further steps, the de-escalation will act as a pause button, but then my anxiety will continue to rise until I know what the student-doctor plans to do about it. The plans don't have to be in great detail, but anything student-doctors are able to do to manage my expectations will cause me to feel more confident in their abilities and less distressed.

• Reassurance: this is generally what "You're going to be OK" is meant to do, but it's hard for it to seem sincere on its own, which is why the other elements help to support it. An expression that indicates care and responsiveness is all that's needed here.

Here's an example of how this could work even in a first-year encounter:

SP: Am I having a heart attack?! 

Student-doctor: I can see why you'd be concerned about that. I'm going to do a heart exam and then check in with my supervisor so we can take care of you as quickly as possible.

Discussion question:
What other reassuring statements could the student-doctor make using this format?

Teach back

Doves & cherubim are not strictly required for successful teach back.
[L'Annonciation de 1644 via wikimedia]

I love the "teach back" technique. Teach back is a way to verify shared understanding by asking someone to explain their understanding of the instructions and/or event.

Done well, this can keep patients from skating out the door just by smiling and nodding at the provider, even though they didn't understand anything the provider said. When I am asked to do teach back, I find it often prompts me to ask questions I didn't have when asked "do you have any questions?" I might realize I zoned out during the encounter. It forces me to pay closer attention. It also lets the provider know if I've truly understood key details, like how many times to take a medicine per day, what the next step in my diagnosis is, or what will keep the rash from returning.

However, the two most common way most learners employ teach back is  at the end of the encounter:

1. "I just want to make sure you understand everything correctly, so will you please tell me what I've just told you?" 

2. "So, sometimes I am unclear and use big words when I am talking to patients. To make sure I was clear, will you please tell me what you understand of our conversation today?"

Both of these framings are incredibly awkward. As one student told me in feedback, "It's like I have to choose between calling the patient stupid or calling myself incompetent."

So here's the best way I know how to use teach back with patients:

• Start with a summary of the history and physical exam findings. Summaries are awesome in general because they give both the learner and me a last chance to verify/update inaccurate information. But a summary also primes me for teach back because it helps me focus on the things the learner finds important, making it more likely I will recall and retain that information.

• "What questions do you have?" after the summary helps make sure that all questions are resolved before moving to teach back. No new info should be introduced during teach back. Resummarize after all questions have been answered if possible.

• Identify the patient's most relevant support network. Sometimes that information has already been obtained through the social history, but if not, questions like "Who brought you in today?" or "Who are you going to call when you get home?" or "Are you going to need to contact work?" et cetera can be helpful. The student-doctor can ask more than one question to help identify the person I am most likely to discuss my condition with. These questions should be approached with a transitionary tone rather than come across as a complete non-sequiter.

• Now do teach back! "What are you going to tell [person identified in Step 3] about [the next step/your medicines/what we talked about today]? The learner can continue to prompt me in this way about any of the key details they want to ensure I understand. 

For example:

Student-doctor: So let me sum up: You’ve had a rash for a week, and when I looked at your leg I saw circular black dots. So I'm going to prescribe some cream you'll use twice a day. How does all that sound to you? 

SP: Yeah, great. 

Student-doctor: OK. What questions do you have? 

SP: I can't think of any. 

Student-doctor: OK, then we're good. So who brought you into the clinic today? 

SP: My husband. 

Student-doctor: Great, so on the way home, what are you going to tell him about your condition?

There can be lots of nuance here depending on how the patient answers. But this basic structure makes me feel as if the learner is preparing me for a conversation I'm going to have rather than giving me a pop quiz. And because the learner seems like s/he is interested in my life and support network, it enhances our rapport.

Discussion question:

Does your school practice the teach back method? I'd love to see more examples of how to introduce teach back well, or other resources that talk about the concept. Everything I've found doesn't explain it as well as I'd like, hence the generic Wikipedia link.

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.

Does that make sense?

Sure, sure, that makes sense.
[La Lecture via wikimedia]

One of the things I hear from learners during encounters that makes me wince is this:

"Does that make sense?"

This question is problematic in part because it often seems like a formality, like How are you today? or Is that OK? As a binary closed question, there is really only one right answer to keep things moving: yes.

Also, admitting uncertainty is a difficult thing for patients to do. "Does that make sense?" places the burden on the listener for understanding rather than on the speaker for clarity.

"Does this make sense?" can also cast doubt on the confidence of the speaker, as if the speaker is asking for validation instead of confirmation.

I hear this phrase a lot in trainings, too, and as an SP or workshop participant I am unlikely to say "no." In a group, "Does that make sense?" is often met with silence, but silence doesn't actually indicate comprehension.

If someone wants to assess my understanding, the use of open questions like "What questions do you have?" or "What do you think?" is a much better method. Teach back is an effective tool, too. If what you've said doesn't make sense, my response will make that clear.

Bonus points
Other phrases which discourage questions:

• "That's pretty self-explanatory, right?"
• "We all know..."/"I'm sure you all know [x], so..."

Using Google Glass

Earliest known depiction of a student using Google Glass.
[The "Glasses Apostle" via wikimedia]

I was going to scoff when I ran across this report preview:

Recording Medical Students’ Encounters with Standardized Patients Using Google Glass: Providing End-of-Life Clinical Education

Until I read "traditional wall-mounted cameras...provide a limited view of key nonverbal communication behaviors during clinical encounters."

Ah! Yes! That is totally true. When I review video encounters, without a good look at the student's face, grading things like eye contact & sincerity becomes much more difficult.

"Next steps include a larger, more rigorous comparison of Google Glass versus traditional videos and expanded use of this technology in other aspects of the clinical skills training program."

Indeed. I am thinking of the cost-benefit ratio, though. The results have higher fidelity, but do they justify the cost and cognitive dissonance during their use? I guess that depends on what the program uses the resulting videos for. Data without analysis is a waste of resources.

Bonus points (added August 2015)

• I've now been in an event that includes these glasses! I don't know what happens with the video, but the glasses just looked like safety goggles, the kind you might wear to protect your eyes from bodily fluids. In the context of this particular event, it wasn't that incongruous, though it probably would have been in a traditional patient room.

• I've also been at events that use Go Pro cameras attached to the learner, which also seems like an interesting strategy.

Quote of the Day

[Portrait of Henry Ford via wikimedia]

"You can't build a reputation on what you are going to do."

Henry Ford

When I give students feedback about empathy or rapport, sometimes they respond by saying, "Oh, I'm so much better in clinic" or "I'm different with real patients" or "I don't do well when I'm being observed." But I can't give feedback on skills I don't observe.

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"?

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.

Core value: Consent

Drink this. You don't need to know what it is.
[Self-Portrait with Dr Arrieta via wikimedia]

I have written about physical autonomy as a core value before. As an SP, feedback about treating patients with physical respect seems like the very least I can do. But full autonomy is about respecting the whole patient. Either way, consent is a requirement.

Consent is only consent if it is informed consent. But informed consent is not a ham-handed attempt to shock and awe. No, informed consent is a delicate and nuanced thing. Rather than an intimidating stack of papers as thick as a brick, informed consent is a beautiful waltz of informer and informed. Rather than a mad chaos of anxiety and pressure, informed consent can be a quiet and deliberate Sunday morning. Informed consent invites inquiry and empathy rather than blame and scrutiny. Informed consent should relieve ambiguity and bolster confidence. Informed consent should ideally take as long as it damn well needs to. That's why asking "Do you have any questions?" or "Is that OK?" isn't enough.

Of course, all of that's often not possible in the constraints of an SP encounter, even the long-form scenarios. But when a student genuinely tries to include consent in an encounter, I am relieved and delighted.

A student who excels in consent:

• Identifies procedures before they happen
• Asks permission
• Waits for recognition/response
• Uses simple language to describe complex topics (e.g. AGUS, screening vs. diagnostic)
• Keeps inviting questions until I don't have any more. Consent without comprehension isn't consent. 
• Asks questions that have more than one possible answer: how can I say truly say yes if i don't know what no will mean? As a patient I will say "yes" because I assume the consequences of saying "no" are worse.
• Does not ask leading questions (e.g.: "You don’t mind if I’m touching you like this, do you?")
• Tells me the range of options, not just the worst or best one
• Confirms my understanding using "teach back" or other concrete methods

Extra credit!
I was recently asked to sign things in a hospital. I was asked to sign them without having read them first or know what I was signing for. One was for HIPAA. When I asked to read it, I was told, "It's the same thing you sign everywhere. You've been signing it since 1996 or something." In other words, "You give me permission to do everything on this piece of paper that I’m not going to let you read, right?" This is a poor, but appallingly common, example of respecting patient autonomy.

Discussion question: 
Consent can lean towards coercion when a power differential is involved. Why is that?

Getting a clue

An SP giving a clue card to a student after a heart & lung exam.
[Detail from Card Players via wikimedia]

Obviously, most SPs do not match the physical findings of the cases they portray. There aren't enough of us to specially cast in cases which include findings like heart murmurs, abdominal masses, retinopathy, swollen lymph nodes, clubbing, etc. And despite the fascinating and helpful tips in "Training Standardized Patients To Have Physical Findings," it is almost impossible to simulate these findings, either.

So I usually give student doctors a card that explains the finding after they've finished an exam which might reveal it. Each school has a different method for doing this. Students are usually visibly triumphant when they receive a card, as if they have won a prize.

However, student doctors almost never share that finding with me as a patient. Once they get a card that describes the abnormal results of a tactile fremitus exam, for instance, they continue with the rest of the exam as if nothing had happened!

I find this tremendously frustrating as an SP because they lose out on the chance to practice giving findings that are not within normal limits without alarming patients. I want them to practice offering contextualization, risk or reassurance in these situations, to help me understand why the finding relates to my chief complaint. Without that practice, they will be behind the curve when it happens to them later.

How are you today?

"Oh, I'm fine..."
[Allegorical Portrait of Elizabeth I via wikimedia]

One of the questions that makes me cringe is frequently the very first question asked in an SP encounter. The student doctor walks into the room, smiles, and says, "How are you today?"

I cringe because as a patient, I have two choices:

1. "Fine." Which is totally not true, because why would I have come to the doctor if I was fine? But as a patient, I know this is the only socially acceptable answer and the one the doctor is expecting to hear. So I assume the student doctor values social courtesies more than the truth, which makes me feel anxious. I may also assume the doctor is not sensitive, empathic or present.

2. Tell something closer to the truth: "Well, not so great. That's why I'm here." A student doctor's response to this will tell me a lot about how safe I will feel for the rest of the encounter. In many cases, this mild challenge really throws them for a loop and the reaction is almost defensive. A better student doctor will acknowledge the bind of that question, which will leave me feeling relieved and safer to challenge the doctor if the need arises again.

"How are you?" is a habitual phrase that is completely unnecessary to communicate rapport or respect. In fact, because of the power differential, it does more harm than good by requiring patients to either lie  to seem like a "good" patient, or to challenge the doctor and deal with the possible stigma of being a difficult patient.

The first few minutes of any encounter are crucial to setting a sense of safety and honesty. Asking questions that only have one acceptable answer trains patients to lie. In this case, a small lie, to be sure. But lies of any kind undermine a patient's trust and may lead to self-censure.

A better opening: A proper introduction followed by either "What brings you in today?" or "I see you're here for X. I'm sorry to hear that. Can you tell me more about what's going on?"

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."

Feedback hierarchy

Rising to the challenge.
[Monte Cristallo via wikimedia]

SP events have very different methods for student feedback. In places where I can give written or verbal feedback, I have developed a feedback hierarchy to prioritize the limited time I have. Developing a hierarchy allows me to succinctly provide feedback that is both individualized for that particular student and yet consistently reflects my most important values.

This list is ordered in a way which increasingly incorporates more awareness of patient needs at each level. Beginning students are most likely to hear the feedback at the first levels, while advanced students can discuss the higher-level items. If I find a student is defensive in feedback, I often find those students respond better to items lower in the hierarchy.

This is a living list. Last updated January 14, 2015.

Level 1: Domain knowledge
Some schools want you to talk to students about items on the checklist, but some don't. I prefer to spend limited feedback time on communication skills further on in the hierarchy. But if student doctors make mistakes in the history or physical exam to a degree which would be noticeable to a patient, it dramatically affects patient trust and confidence. For instance, if a student doctor hurts me during a physical exam, this is the most important feedback to give. If I feel nervous about how a student doctor handles vulnerable areas like my ears, eyes, or nose, it doesn't matter how empathetic they are. If a student doctor is very disorganized or hesitant when gathering history, as a patient I will feel dubious about their competence. If a student doctor touches me in what a patient could interpret as inappropriate, that's the most important feedback to give (e.g.: a student's knees between my legs, a coat cuff brushing against my breast, etc.).

Level 2: Rapport
Many checklists have a "rapport" item, but nobody ever really talks about what that means. For most SPs, it seems to be a catchall category for "I liked the student doctor" or "The student doctor seemed friendly." But I need more specific guidelines for myself so I can give specific feedback to students. So for me, rapport is about establishing a personal connection with the patient. So when I give feedback about rapport, I comment on posture, tone, eye contact, active listening skills, the use of open-ended questions, using my name, matching my energy, jargon, and communicating sincerity. These things help me feel as if the student doctor is paying attention to me and my nonverbal cues. In addition, if a student attempts to learn/respond to anything about me that isn't medically necessary for them to know (or if they tell me something about themselves), I count that as rapport.

Level 3: Empathy
I always say "empathy first" in encounters, but if students have serious deficiencies in the first two levels, I usually address them in feedback first. To be honest, so few people use empathy regularly that many patients/SPs don't even know it's missing. So empathy is the first of the nuanced skills -- those skills which begin to sort the excellent students from the less adept students. For me, responding to a patient's emotional state is the key to empathy. So when I am looking for empathy, I am looking for student doctors to:

• acknowledge the patient's pain: during the chief complaint, when the patient describes the quality of the pain, when the patient rates the pain, or during a physical exam.
• acknowledge sensitivity for awkward or sensitive questions.
• acknowledge loss or grief: for instance, if family members have died while taking the family health history; if the patient or someone close to the patient has lost a job, etc.
• acknowledge fear or confusion: for instance, during a diagnosis or when the student uses overly technical language.

Level 4: Respect
Respect and rapport are often conflated, but I think you can have rapport without respect and vice versa. Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. The power differential really comes into play here. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race.

Level 5: Autonomy
This is one of the things I value most highly. Student doctors who promote patient autonomy prove themselves as trustworthy and make me feel safe. Unfortunately, this is the hardest category for most students because almost everything in medical school (and society at large) rewards the exact opposite of autonomy. I am especially interested in how to facilitate true consent, one where patients feel they have the understanding to make the right decision for themselves and the ability to safely refuse without compromising care. This can be as simple as asking permission to touch a patient and as complex as signing surgical consent forms. So when I give feedback about autonomy, I often comment on the basic tools of summarization and expectations management. In addition, I especially esteem student doctors who go so far as to ask my opinion or invite collaboration. But influencing the way student doctors ask questions is one of my most effective ways to improve autonomy: I want them to ask questions in ways that don't inherently limit the acceptable answers, wait for consent, and keep inviting questions until I am satisfied. Checklists don't usually have a category that would apply to this, so I often lump it into Respect. But I think it is so much bigger than that. You can respect someone but not support their autonomy.

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.

Really quick

When I saw this (really quick!) video from Cooper Medical School, I thought, "YESSSS!" When students tell me they're going to do a "really quick" exam, it makes me feel rushed. If something is bothering me enough to make a doctor's appointment, I want a thorough exam, not a "really quick" one.

The power of the power differential

Everything looks so... small from up here.
[Jupiter Weighing the Fate of Man via wikimedia]

When we go to the doctor we are at our most vulnerable. We are vulnerable because we are sick and we are vulnerable because we are at a loss for medical domain knowledge. This gap between knowledge and helplessness is the power differential between doctors and patients. The more pain a patient is in, the larger the gap.

The emotional heart of power differential is fear. As a patient, I have a huge incentive to say things which make the doctor think well of me for fear I might jeopardize the care I need otherwise. If I worry about being judged, I won't feel safe. Some patients will respond to the power differential with deference, while others will be defensive. Either way, doctors who are willing to examine their own power dynamics will enhance security, honesty and shared understanding with their patients. So when I give feedback to students about communication skills, I frequently focus on things that reduce power differential.

This is a living list. Last updated June 29, 2014.

What increases power differential:

• Technical language: As a patient, if I can't understand the student, I will feel ashamed and stupid. In response I can attempt a reasonable guess, let it slide, or ask a question. Because patients often see doctors as authority figures, asking a question can feel confrontational. Comprehension (and the desire for confrontation) fails at a rate directly proportional to pain.
• Body language: Formal body language and sitting far away enhances the power differential between us. A clipboard can sometimes feel like a shield if the student has a death grip on it or spends more time looking at the notes than at me. Some students, in order to demonstrate active listening skills, lean forward too aggressively, making me feel scrutinized instead of supported.
• Taboo topics: when students assume they can ask sensitive questions without appropriate framing, they are taking advantage of the power differential. Topics include sex (cheating, STIs, abortion), alcoholism, depression, etc. For some patients, this can even include topics like urine and bowel movements. The more taboo the topic, the more important it is that the student doctor communicates safety and acceptance.
• Physical exam: The power differential is at its most obvious during the physical exam, especially if any part of my body is ungowned. Bodily autonomy is, in my opinion, a primary and absolute right. When students move me without asking me, or when they don't tell me what they are going to do before they do it, or when they give me unclear instructions (and then show surprise when I don't do what they expect), that makes me feel violated and frustrated. Compassion should not end when the physical exam begins.
• Command language: When students ask if I have been "compliant" with prior instructions during an encounter, I immediately feel judged and unworthy. Even in feedback, when I hear that my character was "non-compliant," I flinch. Compliance has power differential built into the word itself: the doctor gives orders, the patient obeys. Similarly, when a student doctor refers to my "complaint," the word implies a value judgement and I worry the student doctor isn't taking my concern seriously. The same is true if the student doctor at some point mentions "denies [pain, loss of consciousness, past medical history]." To hear that I have "denied" something sounds as if the student doctor doesn't believe me.
• Unbalanced speaking ratio: when the provider speaks much more than the patient does, that's a reflection of the power differential.
  
  
  

What decreases power differential:

• Empathy: When a student offers empathy at the pain I am currently experiencing, I can stop worrying about whether the student thinks my issue is serious enough to merit attention.
• Validation: When a student validates my choice to come in, I feel recognized and empowered.
• Normalization: When a student normalizes my concerns, I feel less alone and more accepted. Without empathy first, though, it can feel dismissive.
• Body language: open and relaxed postures help decrease the power differential, but being too familiar can have the opposite effect. A good rule of thumb is to sit close enough so that if we both reached out an arm we could touch.
• Rapport: when a student wants to know something about me that isn't medically necessary, that makes me feel like more of a person. When a student remarks on something we have in common, then I feel more connected. Being too familiar with a patient too quickly it can have the opposite effect, but a good rule of thumb is 1-2 remarks per case in which the patient is a new patient.
• Autonomy: When a student gives me a choice, I feel respected. Whenever a student specifically acknowledges that I am a person who might have her own needs, expectations and feelings, I am relieved and feel more in control.
• Manners: using "please" and "thank you," especially during the physical exam, makes me feel respected.
• Reflective language: When a student uses the same words and terms I use, I feel we are sharing the same reality.
• Summarization: When a student summarizes what s/he has heard at the end of the history and asks me to verify it, I feels as if my opinion about my own history matters. This sounds obvious, but as a patient it can too often feel as if my words fall into a black box and I have no idea if what I'm saying is actually what's being heard. Being specifically invited to correct the doctor is a very simple and elegant way for a doctor to redistribute power. Transparency also helps even the power dynamic, and summarization is one of the best ways to demonstrate it within the context of the encounter.
• Accommodation: whether the student doctor asks my preferred name or whether I want the lights dimmed when I have a headache, accommodation demonstrates a willingness to adapt to the patient's needs. Accommodation also means physical self-awareness: if it hurts to turn my neck, the student doctor should sit where I can see him or her comfortably. If I have to adjust myself to accommodate the doctor, that reinforces the power differential.
• Ownership: when I am allowed or expected to contribute to the treatment plan, I am able to more fully integrate it to fit my actual life, making it more likely I will follow the recommendations.
• Asking permission: when I am asked permission to be touched, especially in painful, vulnerable or private areas, I feel more respected and safe.

Basically, reducing power differential is a way to reduce vulnerability, fear and shame in patients. Reducing power differential enhances trust, confidence and respect.

Extra credit! 
Power is different than authority: discuss.

Words to watch: a list

Making a list. Checking it twice.
[Porträt des Erasmus von Rotterdam via wikimedia]

I  care a lot about the use of plain language in SP encounters. Here are some words I feel are taken for granted in a typical encounter.

This is a living list. Last updated July 28, 2017.

History:

• Quality: "Can you describe the quality of the pain?" I maintain patients have never encountered this use of the word "quality," instead equating it to the value of something. So I might say, "I don't know. Pretty high quality, I guess?" Better: "How would you describe the pain you're feeling?"
• Radiate: "Does the pain radiate?" Radiation is not a word I would have ever associated with pain before I became an SP. Does radiation mean radioactive? Does it mean it's warm like a radiator? Does it mean it radiates outward a certain distance? Better: "Where else do you feel the pain?"
• Chronic: "Do you have any chronic conditions I should be aware of?" As a patient, I have no idea what doctors consider to be a "chronic condition" that s/he should "be aware of." Following with examples is better, but I still think it's best to ask the question more clearly to begin with. Better: "What ongoing health problems do you have?" Minus a million points if I hazard a guess like "Does chicken pox count?" or "I twisted my knee in college" and the student waves a hand: "Oh, no, I meant something more serious like...". As a patient, you've just trained me to keep my mouth closed next time you ask something I'm not sure I understand.
• Immunizations: As a patient, when I hear "Are your immunizations up to date?" I think, "Um, I guess so? Is there something I was supposed to get other than what I got for school?" And then I say "yes" or "I think so?" Better: "What immunizations have you had?" is a more open-ended question. I might not know the answer because few patients have any idea what they were required to be immunized for. However, telling a doctor "Whatever I got for school, I guess" is better than a "yes" which really means "I don't know."
• Trauma: "Have you experienced any trauma lately?" For patients, "trauma" almost certainly means emotional trauma, not physical trauma. If left unspecified, as a patient I will feel very confused as to why this question has anything to do with the pain I came in with. Better:  "Have you had any accidents or injuries lately/to that area?"
• Discharge (noun): I think a doctor could use this word and as a patient I would probably know what it means, but it feels very clinical. As an SP I would never use it unless required in a case quote because I don't think most patients would use that word on their own. "I have some stuff coming out of my eyes/ears/nose/down there," I might say instead. If a student hears me say this and feels compelled to say, "So you're experiencing some discharge?" I might say, "Sure, I guess?" But that will add to our power differential because the student is unwilling to use the language that I am using.
• Complications: When a student asks "did you have any complications after surgery?" or mentions "complications of diabetes," as a patient I have no idea what they are talking about. If this is meant to be an open-ended question, then follow with specifics. If it's shorthand for a wide range of possible issues, then mention some of the most alarming or common ones so I don't shrug and say "I don't think so" with some uncertainty.
• Fatigue: please just ask if I've been tired.
• Bilateral: say "on both sides."
• Hypertension: please just ask if I have high blood pressure.
• Inflammation: please use words like red, swollen, irritated, etc.
• Palpitations: Has my heart been fluttering? Have I felt it skip a beat? Have I felt it beating out of my chest? Any of these things are more understandable to patients than the word "palpitations".
• Extremities: ask about my arms and legs or hands and feet.
• Ulcers, lesions: ask if I have sores.
• Cardiovascular: tell me about my heart and lungs instead.
• Siblings: ask if I have any brothers or sisters instead.

Physical exam:

• Auscultate: Just tell me you're listening, or listening with the stethoscope.
• Palpate: If a students tells me "I'm going to palpate now," as a patient I have no idea what s/he is about to do. If left unexplained, I will often react with mild surprise when the student palpates. Better: "I'm going to examine [body part] now."
• Percuss: If a students tells me "I'm going to percuss," as a patient I have no idea what s/he is about to do. If left unexplained, I will often react with moderate surprise when the student percusses me because percussion can be a startling sensation when you don't expect it. Also, while as a patient I can understand why you would want to palpate, percussion can seem like a pretty puzzling procedure to patients. Better: "I'm going to tap on [body part] so I can [reason]."
• Drape: to patients, drapes are things that hang on their windows. If a student hands me a paper drape and says, "Here's a drape" as if I'm supposed to know what to do with it, I pause and give a quizzical look. Better: "Please use this to cover your legs." If you have to call it something, you could call it a sheet. But please please please do not call a gown a drape. Please.
• Positive: If a student provokes pain in a physical exam and tells me "Well, that's a positive sign," as a patient I think "No, it's not!" It keeps me from feeling as if the doctor understands my pain and furthers the gap in our realities.

Treatment:

• Abortive: Women, especially, may have a hard time hearing this word as part of a treatment plan. Just say, "to stop X" or "to prevent X".
• Prophylactic: Similarly, describing a medicine or practice as something meant to prevent  a specific result is more understandable than the word "prophylactic."
• Discharge (verb): just say, "when you leave the hospital."
• Test names: As a patient, I smile and nod when tests are recommended like a CBC panel, MRI, CT scan, etc. because I am not often given an explanation of those tests, and yet I am often asked if I consent to those tests as part of the treatment plan. What is "imaging," anyway? What will the patient experience? Some patients may know, of course, in which case asking "What do you know about X test?" can be a nice open-ended way to make sure the patient truly understands the recommendation before launching into an explanation the patient may not need.
• Attending, Preceptor, etc. That level of granularity may be useful to other professionals, but is confusing for patients. "Your doctor," "my supervisor" or "my boss" are much more understandable labels.

Extra Credit!

• Language that learners think sounds neutral but actually sounds very scary to patients: lesion, masses, etc.

Setting the standard:

An adequate standard would include a list of potential jargon words for every case that required jargon as a checklist item.

A better standard would be a consistent list of words (like this one) applied as broadly as possible for that program's events. Even if the student is not being specifically evaluated for jargon, SPs could still give feedback about it. Additional words could be added based on particular cases if needed.