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

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

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

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

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

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

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

Here's how I would categorize SP jobs:

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

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

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

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

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

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

Additional components that may affect SP modesty during encounters:

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

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

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

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

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"?