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.

Answering open-ended questions

An SP attempts to answer an open-ended question.
[The Open Door via wikimedia]

Ideally, student doctors should ask SPs open-ended questions at the beginning of the encounter and then move to more focused ones. For instance, after introductions, a student doctor should ask something like, "So what brings you in today?" to elicit the patient's chief complaint.

In real life, a patient is very likely to spend the next 18 seconds describing their chief complaint. However, SPs are usually given a pretty simple opening line, like "My eye hurts" or "I passed out" or even something like "I haven't felt like myself lately" for psych cases. This opening line is meant to minimize and standardize the amount of information SPs initially give to students. It usually prompts students to move into close-ended HPI questions like "When did that start?" or "Can you show me exactly where it hurts?"

Sometimes, though, a particularly astute student will ask another open-ended question: "What's been going on?" or "Can you tell me more about that?" I have rarely received a script that includes how to answer that question. It seems simple, but there are two tricky parts:

• At programs that use a checklist for evaluation, as an SP you can't use any of the checklist items to answer that question! A real patient might say, "Well, I'm having really sharp pain behind my right eye that's been going on for four days now." Which means a student wouldn't need to ask about Onset, Quality and Location then. You can't evaluate a student on questions they already have information about, so the student would receive credit for those items.

• It is unlikely multiple SPs will answer that question in the same way, meaning some students will get more or less information about the chief complaint at the beginning of the encounter.

This conundrum has followed me for years and I have rarely felt like I have a satisfactory answer that remains vague enough while maintaining the momentum and realism of the scenario.

So instead of answering that second open-ended question by giving away checklist items, my new standardized answer for most cases is a response about my emotional affect and why I finally came to see the doctor today. For instance:

Student: "What brings you in today?"
SP: "My eye hurts."
Student: "Oh, I'm sorry to hear that. Tell me what's been going on."
SP: "Well, I was hoping it would go away but it hasn't, so I came in because I can't stand it anymore. I'm kind of worried."
Student: "Well, I'm glad you came in! When did this start?"

This kind of response works for a wide range of cases and severities. It gives away no checklist items and offers the student another bid for empathy if they haven't already responded empathetically to the chief complaint. It's an answer that doesn't need to be standardized amongst SPs. And because the student hasn't received any HPI info, they are prompted to ask close-ended questions. And then on we go!

Alphabet soup

Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

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.

Pain scales

Ideally, when I am portraying a patient in pain, my portrayal will give student doctors a clue as to how much pain I am in. But students are also trained to ask the classic question: "Can you rate your pain for me?"

Classic universal pain scale via nshealth.ca.
[click to embiggen]

Above is the classic pain scale. However, instead of saying "zero being no pain and 10 being the worst pain possible" students often say, "where 0 is no pain at all and 10 is the worst pain you've ever felt." I always think this is a little limiting, because the scale could change for each patient depending on how much pain a patient has experienced in a lifetime. For instance, a patient who has given birth may rate an ankle sprain at a 6, whereas someone who has sprained an ankle may rate it a 10 if nothing else worse has happened to them. Cases are written so that all patients give the same rating, but when the question is asked this way, as an SP I always have to think about it: what is the worst pain I've ever felt? (Pulmonary embolism, in case you're wondering.)

Sometimes, student doctors will simply ask "Can you rate your pain on a scale of 1-10" and I have learned to ask "Is 10 bad or is 10 good?" to remind them they haven't given the patient a complete scale. Because outside of the simulation, if a doctor doesn't clarify, the patient may give what s/he considered to be a reasonable guess, and the doctor may get incorrect information.

Badly written cases will often only have one pain rating attached even though the pain has changed over time. So if  student doctors ask questions like "What did the pain start at?" or "How long has it been at a 4?" as an SP I always wince and guess. The rule of responding to cases that don't have a definitive answer to a student question is that the answer is either "no," "I don't know," or that the answer won't affect the case. But I certainly feel like a better SP and more standardized when I know the answers to good questions.

I say our affect should be an indicator to the patient's pain level, but only one school I work with attempts to standardize SPs to portray pain based on the case rating -- and then usually only for the really important cases that could affect a student continuing with the program. This can make it more difficult for student doctors to interpret my pain, because other SPs may portray a 6 less seriously than I do. Some students may feel I am "overacting" if I portray a 6 with a "wrinkled nose, raised upper lip, rapid breathing," even though that's the official pain scale.

However, my favorite pain scale is from Hyperbole and a Half:

0:  Hi.  I am not experiencing any pain at all.  I don't know why I'm even here.
1:  I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.
2:  I probably just need a Band Aid.
3:  This is distressing.  I don't want this to be happening to me at all.
4:  My pain is not fucking around.
5:  Why is this happening to me??
6:  Ow.  Okay, my pain is super legit now.

7:  I see Jesus coming for me and I'm scared.
8:  I am experiencing a disturbing amount of pain.  I might actually be dying.  Please help.
9:  I am almost definitely dying.
10:  I am actively being mauled by a bear.
11: Blood is going to explode out of my face at any moment.
Too Serious For Numbers:  You probably have ebola.  It appears that you may also be suffering from Stigmata and/or pinkeye.

This scale is the one that most closely matches how I actually feel about pain in my own life. Honestly, if I rate something as a 9, I want the doctor to know I feel I am almost definitely dying. Few people go to the doctor unless the pain is at least a 3 or more. So even though a 3 is considered "mild" pain in the classic scale, it's significant enough to drive the patient to see a doctor. In other words, the pain is bad enough for someone to miss work and/or pay a lot of money to address it. At that point, no pain is "mild" pain, in my opinion. As a patient, one of my biggest fears is that the doctor won't take my pain seriously. I worry they may think a 6 is mild, even though, as the Better Pain Chart shows, I feel like "my pain is super legit now."

Sometimes, students describe the pain scale "where 0 is no pain at all and 10 is the worst pain imaginable." When they do, I smile to myself and think of this xkcd comic:

[click to embiggen]

I can imagine a LOT of pain. Cases always have pain ratings attached to them that won't fluctuate based on how students ask this question, but when the scale is described to me this way I think, if I were a real patient, I would drastically revise my estimate downward.

Extra credit!
If students ask about the ADL scale right after the pain scale, it can be very confusing for patients because the scale is reversed. When that happens, I think it's better to ask about it as a percentage than a single number.

Further reading:
McSweeny's has a delightful article about SPs being trained to simulate pain. Wish more schools did this!

Postscript (Jun01.2020): 

When the coronavirus devastated the profession, this pain scale felt especially appropriate:

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.

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.

Lost in translation: using plain language

Where jargon must have been invented.
[The Tower of Babel, via wikimedia]

One of the things I really care about as an SP is the use of accessible language. It's very easy for SPs to become accustomed to medical terms and concepts that a "real" patient would be uncertain of or that are different in the patient's daily context. I believe addressing health literacy makes a positive impact on the relationship between doctors and patients and provides better outcomes for patients.

My advice to learners is to use "living room language," or language targeted to a 3rd-grade reading level. How would they explain this to a 10-year-old? A patient will usually give clear cues if they feel they can handle more complex language.

At this point most students I work with know better than to use abbreviations or really ridiculous medical jargon. But there are still words students use as if they are common knowledge. Some patients might be able to understand them in context. But even if they do, every time a patient has to spend mental energy interpreting a doctor's question, that reinforces the power differential between them. The greater the power differential, the more difficult it is to establish trust and safety. More importantly, a patient may not actually understand what a doctor has asked -- but attempts a reasonable guess so s/he doesn't look stupid, and then the doctor mistakenly believes they share an understanding when they really don't.

So when a student uses a word I think a patient might have trouble immediately understanding, I have a few ways to respond while still staying in character depending on the school, the student, or the scenario:

•  a slight pause before I answer
• a questioning look
• an ambiguous answer based on the more common meaning of the word
• "What does that mean?" or "What do you mean?"
• "I don't know what that means."
• "You mean [restates question in a patient-centered way]...?"
• "Well, I don't know what that means, but [answers question as if student had asked it in a more accessible way]

Some schools don't want SPs to react when a student uses technical language for a variety of reasons: because they're being taught to use precise language like that, because it eats up precious time in a short encounter, etc. And because SPs are inconsistent in reacting to technical language, if you are the SP who looks confused when the student keeps insisting on using the word "palpation," students may think you are deliberately playing dumb.

But I feel like to best prepare students to communicate with their patients, students need to practice translating the language they are learning into a language patients understand. My job is to remember what it was like the first time I encountered an odd word and react in a similar way for all encounters afterwards. Allowing students to shortcut this skill in SP encounters sets them up badly when they encounter patients in clinics.