A patient completing a student feedback survey.
[Portrait of Nicholas Thérèse Benôit Frochot via wikimedia]

Medical students at the University of Pittsburgh are developing a patient feedback app: "The app allows both patients and students to rate how they think an appointment went. Patients also can give feedback on how the student performed."

Honest feedback from patients is a noble goal. I would love to contribute to a system where patients felt they could offer honest feedback and know they had been heard.

Some issues I see:

• Data without plans for followup, development, training and/or mentorship is useless. Don't bother collecting data until you have plans to do something with it. (I feel this way about SP checklists, too.)

• It's very difficult for a patient, who has a huge emotional investment in the experience and the outcome, to step back and offer kind, trustworthy, respectful feedback to learners. Even SPs often have trouble doing this, and we're only pretending to have the experience!

• Patients can be expected to ignore the parts of the feedback they don't care much about to focus on the thing that really bothered them. That makes the data less useful. (This is true for SPs, too.)

• When is the survey administered? Feedback about any encounter should happen as soon after an encounter as possible, so that both parties remember the details. If the patient is asked to do it at home, after the encounter and after the patient has seen several other medical professionals, the patient is going to give less reliable feedback.

• If the app is something a patient is expected to download and use on their own phones, that will further reduce the usefulness of the survey. Plus, a smartphone app only reaches those who can afford smartphones. I hope the system can be adapted so those who don't use smartphones can still have a say.

Also: "Students already get feedback from what are called standardized patients — actors who are assigned a specific situation and medical illness. But according to Patel, that feedback is mostly objective: Did they wash their hands and avoid medical jargon? Students are often left with a lot of unanswered questions."

That may be true at the University of Pittsburgh, but it's not true everywhere. In fact, I would say that limiting SPs to objective feedback limits the full potential of SPs. However, the subjective feedback must be very capable to be effective. To do it well, SP must be trained to articulate their experiences in ways patients cannot (due to things like the power differential as well as a general lack of constructive feedback training or emotional analysis).

Also, more SP encounters could help. Many schools only offer end-of-the year testing. In high-stakes exams most students are focused on the outcomes, not the feedback. The advantage of the app is that students would ideally be receiving a consistent stream of feedback throughout their clinical experiences, which gives them more opportunities to notice patterns and make changes. Imagine what could happen if students saw more SPs over the course of a year!

Using students in invasive exams

A student on her way to a transvaginal probe.
[Captives via wikimedia]

This situation at Valencia State College makes me extremely angry: Students sue Florida college for alleged forced vaginal probes. "Two female college students said they were forced to endure almost weekly vaginal probes as part of a medical diagnostic sonography class at a Florida community college, according to a civil rights lawsuit filed in federal court."

This violates at least three values that are very important to me as an SP:

• Power differential: Students should not even be in a position to refuse something like this. It's ridiculous. "The complaint states that the clinical and laboratory co-ordinator initially told the students that the probes were voluntary." Even if that is true, when someone has control over your grades and future, the power differential makes it very difficult to refuse. In addition, this communicates to students that the institution values cooperation over modesty/comfort. When those students graduate, I guarantee they will carry that attitude over to patients when they are the ones in power.

• Consent: If a student refuses a transvaginal probe, that's it. Full stop. No coercion, no harassment, no threats. But based on my experiences as an SP, I don't doubt this claim:"When the women protested they were told they could find a different school, would be blacklisted from local hospital jobs and their grades would be reduced."

• Respect: This? Is the opposite of respect: “Plaintiffs endured these invasive probes without a modicum of privacy. Plaintiffs would disrobe in a restroom, drape themselves in towels, and traverse the sonography classroom in full view of instructors and other students.” So is this: "It also claims Ball made inappropriate comments during the procedures. According to the lawsuit, Ball told a student undergoing the procedure that she was “sexy” and that she should be an “escort girl”." Honestly, even colleges that do hire SPs for these exams are sometimes not as respectful as I'd like them to be. To subject students to this is infuriating.

So yeah, students used to practice invasive exams on each other. As an old-time faculty member once told me, "You never knew whether to pick a partner you liked -- or one you didn't."

But very few schools still practice this for reasons that should be extremely obvious. In fact, schools have used SP models as "gynecological teaching associates" since 1968. The VCA spokesperson states "using volunteers, including students, for medical sonography training [is] a nationally accepted practice." If true, then apparently sonography programs need to get their act together and adopt the more rigorous and respectful standard that the medical community has been using for aeons. If not, then the college is being deliberately disingenuous. Neither of these things gives me confidence in the strength of their educational program.

I suspect the college uses students because GTAs are expensive, and rightfully so. But they are worth every penny, not the least because it avoids this outrageous and uncomfortable tangle between students, peers & faculty.

Extra credit
Relatedly, I cringed when I recently read this from The Naturopathic Diaries: "It was not uncommon for students to perform prostate and gynecological exams on each other in order to complete the required examination for competency. And in fact, the instructor of our advanced gynecology class (an elective course) asked the female students taking the course to act as standardized patients. When I learned this, I was happy that I did not register for the weekend elective course. The lack of actual patients to practice examinations significantly hinders naturopathic clinical training." I know this is not true for all naturopathic colleges, but I imagine it's true for many. Argh!

Setting the Standard:

Students should never have to be put in a position to refuse an invasive exam. Instead, schools should always hire male and female models for those exams. When they do, they should be paid well and treated respectfully.