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.

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.