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.

Modesty & invasiveness in SP encounters

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.

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.