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!

Awkward handwashing techniques

An SP waits for the student doctor to finish washing her hands.
[The Sisters via wikimedia]

The introduction sets the tone for the rest of the encounter. When a school requires hand washing for credit, there are two potential moments of awkwardness depending on how the student chooses to wash their hands:

1. If the student uses sanitizing gel, they almost always use too much. Then they either spend a lot of time trying to rub it in, or they shake my hand with their slimy hand. With the first, I lose confidence in the student in the same way as I do when a student uses a tool incorrectly. With the second, I lose trust because shaking a slimy hand is disgusting and it makes me feel that either the student doesn't know that -- or doesn't care about my discomfort. 

2. If the student washes their hands in the sink, there is frequently a long pause while the student says nothing and has their back turned away from me. That makes me feel disengaged. If the student attempts to fill that gap with rapport building, an overview of the encounter, or a review of the doorway information/chief complaint, I feel that time is being put to better use and I have more confidence in the student.

Setting the standard:
To limit awkwardness at the beginning of the encounter, I highly recommend students practice how much hand gel to use to be both clean and efficient. If washing hands in the sink, I highly recommend students practice the ability to talk and wash at the same time.

How are you today?

"Oh, I'm fine..."
[Allegorical Portrait of Elizabeth I via wikimedia]

One of the questions that makes me cringe is frequently the very first question asked in an SP encounter. The student doctor walks into the room, smiles, and says, "How are you today?"

I cringe because as a patient, I have two choices:

1. "Fine." Which is totally not true, because why would I have come to the doctor if I was fine? But as a patient, I know this is the only socially acceptable answer and the one the doctor is expecting to hear. So I assume the student doctor values social courtesies more than the truth, which makes me feel anxious. I may also assume the doctor is not sensitive, empathic or present.

2. Tell something closer to the truth: "Well, not so great. That's why I'm here." A student doctor's response to this will tell me a lot about how safe I will feel for the rest of the encounter. In many cases, this mild challenge really throws them for a loop and the reaction is almost defensive. A better student doctor will acknowledge the bind of that question, which will leave me feeling relieved and safer to challenge the doctor if the need arises again.

"How are you?" is a habitual phrase that is completely unnecessary to communicate rapport or respect. In fact, because of the power differential, it does more harm than good by requiring patients to either lie  to seem like a "good" patient, or to challenge the doctor and deal with the possible stigma of being a difficult patient.

The first few minutes of any encounter are crucial to setting a sense of safety and honesty. Asking questions that only have one acceptable answer trains patients to lie. In this case, a small lie, to be sure. But lies of any kind undermine a patient's trust and may lead to self-censure.

A better opening: A proper introduction followed by either "What brings you in today?" or "I see you're here for X. I'm sorry to hear that. Can you tell me more about what's going on?"

A proper introduction

Sadly, students never introduce themselves like this.
[The Introduction via wikimedia]

Many, many checklists have an item in the communication skills section worded something like this: "Did the doctor introduce themselves appropriately?"

Well, what does that mean? How do I know whether a student deserves credit for an "appropriate" introduction? Different schools train their students to default to a particular greeting. But this form of greeting is hardly ever required, so it makes it more difficult for me to know if the introduction is "appropriate." So in the face of a non-existent standard, it means this question is almost always answered "yes" if the student says anything at all.

My personal standard for an "appropriate" introduction includes the student's first name, last name, and title: "Hi, I'm Dr. Amy Basil."

Here are some other ways student doctors have introduced themselves that would not pass that standard:

1. "Hi, I'm Amy."
2. "Hi, I'm Amy Basil."
3. "Hi, I'm Dr. Amy."
4. "Hi, I'm Dr. Basil."

It seems like such a small thing, but when you're grading 60 students over the course of a week, having a simple assessment for an "appropriate" introduction reduces cognitive overhead for SPs and makes us all standardized for the event. And without concrete standards, how can you suggest improvements in feedback?

Extra credit!
If a student doctor follows the introduction by describing his/her role in my health care before launching into questions, I feel immediately more trusting and secure in our interaction. E.g.:
"I'm a doctor here at the clinic."
"I'm your husband's doctor."
"I'm a health coach. Your doctor will be here shortly."
"I'm a member of the health care team working with you today."

The Name Game

Banana fana fo-fatient, mi mi mo-matient
[Detail from the Babenberg Family Tree via wikimedia]

One of the hardest things about the first case in a series of SP encounters is during the introduction. "Hi, I'm Student Doctor Soandso, and you are...?" as they extend a hand.

For someone who can memorize 60-80 different checklist items for a character, when I am asked that question the first time, sometimes my mind just goes blank. And it's terrible because it's right at the beginning of the encounter: if I make an obvious mistake on MY NAME, something any real patient knows by heart, the student will have a much harder time engaging fully with the scenario.

Sometimes I play for time: "I'm sorry, what did you say? Oh, I thought you said 'your car'! Ha ha!" while thinking furiously. If I really can't remember, I make up a name and resolve to look up the real name between students. Getting the name right can be important because many cases are known not by the symptoms but by the character name, e.g. the "Andrea" case.

Some cases don't include names at all, so you get to make them up. I have a series of names I remember based on age bracket, which is especially useful if I have multiple cases in a day. (I finally have a use for all the mistaken names people have called me over the years!) Then I use an historic family surname. So if I'm stuck, one of these names readily pops to mind. I also have a consistent series of names and ages for a combination of up to 5 children, grandchildren, spouses, and pets. I think it is distasteful when SPs (or even faculty members) create names that are punny or based on celebrity/character names. It makes it harder for the student to take the case seriously.

One school I work with has a policy of introducing the patient by both first and last name so that the student is prompted to ask what the patient prefers to be called. But otherwise I just introduce myself by whatever I think the patient would use, which is usually the first name unless the patient in this case would be older or more formal for some reason. However, if a students enters and asks if I am "Mrs. Smith" when the case has not specified I am married (or has specifically specified I am divorced), then I call them on that gendered/social assumption.

I prefer case names when they are gender neutral. Even so there are some names that students assume are a particular gender and they are surprised when they open the door to find I am not the expected gender. Once, a student was so flustered by that he said he was going to complain! "They'll be hearing from me about THAT!" he declared.

Extra credit #1:
I always feel better when students use my name in a scenario: it gives them a boost in the "rapport" category. Transitions are great places to use a patient's name: between the history and the physical exam, between the physical and the conclusion, or during a summary statement.

Extra credit #2:
If a case doesn't include a birthdate, just an age, it's always a good idea to create one because many times student doctors will ask (and I can't do that calculation on the fly). That's also something patients know by heart, so any hesitation grinds the scenario to a halt. That can require tricky math depending on the current month vs the birthmonth, so I almost always pick a birthdate in early January so simply subtracting the age from the current year works out.

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.

Empathy first

Show me yours and I'll show you mine.
[Maria mit flammendem Herz, via wikimedia]

If I could teach medical students only one thing as an SP, it would be to provide empathy first. Nothing makes me feel more heard and understood than empathy right at the beginning of the encounter.

What usually happens:

student: "What brings you in today?"

SP: "I have chest pain/this weird rash/trouble sleeping."

student: "When did that start?"

What would make me feel ten times better:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. So when did that start?"

Extra credit! Add validation:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. I'm glad you came in. So when did that start?"

Doctors have the most ability to influence patient trust within the first few minutes of the encounter. As soon as the doctor has offered me empathy for my current pain and validation for coming in, I feel like the doctor has heard my concern and is taking it seriously. At that point, I can feel myself relax.

Setting the standard:
If a checklist item asks the SP to evaluate empathy, that empathy should be some sort of verbal statement about the pain the patient is currently experiencing within the first minute of the encounter.