These SPs don't understand why they're being fired.
[Adam et Ève wikimedia]

One of the worst parts about being an SP is that because SPs are often temporary or tentative contract workers, SPs can be dismissed for almost any or no reason at all.

But schools handle SP disciplinary issues in a variety of ways. Because these processes  -- and the rules it takes to invoke them -- are frequently unspecified when SPs are hired, it leaves us feeling both vulnerable and confused when an issue arises.

Based on my experience, there are several ways schools deal with SP disciplinary issues:

• No warning: Rarely, a school has an SP they know shouldn't be there, but the supervisor(s) never confront the SP due to a fear of conflict or a limited SP program. 

• No warning: More commonly, if a school decides there is an issue with an SP, they just stop scheduling the SP without directly addressing the issue. If the SP then contacts the school to inquire about work after a gap, it is considered an acceptable response to tell the SP s/he will be contacted when work is available -- but without saying it never will be. That misdirection is disrespectful and keeps the SP from finding another job.

• No warning: Sometimes a school fires an SP without communicating the complaint until the time of the firing. This means the SP is unable to remediate or improve performance for that -- or any -- school.

• 1 warning: Better schools directly address an issue of complaint with an SP at least once before firing them. The issue should be presented with kindness, clarity and an expectation of good intentions. If the SP does not improve, the SP knows they will be terminated. That's a lot of pressure to get it right.

• 2+ warnings: The best schools offer an initial warning about the behavior with concrete recommendations for change and a check-in process. If the SP does not improve immediately, one or more additional remediations may be required, each with a clear sense of changes and consequences, including possible termination.

• Infinite warnings: This is also unusual, but sometimes a school continues to give an SP feedback about an issue but the supervisor(s) never follow through with consequences. This can happen with a small SP pool where that particular SP's demographics are rare. But it is bad for learners and may erode standards for other SPs in the pool.

Since SPs are employed so precariously, the power differential means supervisors have a responsibility to act ethically despite the potential for uncomfortable conversations. Schools should role model the behaviors they expect SPs to exhibit to learners during difficult feedback.

As an SP, I want to clearly understand the process for termination for each school. In addition, I want schools to do more to help prevent SP issues from the start. Working in education creates a higher standard for educating employees. Because each school has different and even conflicting details (e.g.: does an SP give feedback about student appearance or not?), new SP training is crucial to keeping SPs from inadvertently breaking a rule they didn't know existed. Good event training (as opposed to irregular event training) would help set appropriate expectations for every SP, every time. And annual reviews would make sure each SP has a clear understanding of areas of improvement before they becomes crises.

Setting the standard:
Schools should offer new SPs training which includes clear expectations for SP behavior as well as the process for remediation and termination. Annual employee training should review those expectations. Individual event training should reinforce standards the school would find actionable. Once a problem is identified, a school should give at least two chances for SP remediation (though not infinite). The SP should be observed in future encounters and given concrete ways to improve performance. If the SP does not improve, the school can release the SP with a clean conscience.

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.

Case preparation

An SP prepares for a case.
[study for The Apotheosis of Homer via wikimedia]

Since I work for so many different schools, I've had to develop a case preparation method that is able handle as many different cases styles and expectations as possible.

Cases are often written poorly, with important information scattered or repeated in slightly different ways. Sometimes a case seems clear until a student begins asking questions, at which point you realize you're missing a key piece of information.

So here's how I analyze a case to prepare for an event at any event that follows an OSCE-like model:

• Apply heuristics: In the same way students memorize chunks of questions in order to routinize the asking of them, so do I. So regardless of how the case is written, I review it by looking at the elements categorically. Do I know the answers to the most common HPI questions? Do I know the answers to the basic questions for the patient's history, like... PMH: meds, allergies, surgeries, hospitalizations; FMH: parents, siblings, grandparents; SHx: tobacco, drugs, alcohol, diet, exercise, occupation, living situation. Because none of the schools I work with teach us these heuristics, it took me several years to be able to recognize the categorical details underlying most cases.

• Organize top to bottom: Often symptoms are not written in any particular order that I can see. This is made especially difficult if I need to track symptoms the character doesn't actually have but that students need to ask about for credit. So to help me memorize them, I re-organize them in order from top to bottom. Things like fever, dizziness, and headaches are at the top of the list, things like leg edema are at the bottom. Sometimes I may even draw a little person with appropriate markings to help me visualize the symptoms. I also do this for the PE.

• Create kinetic cues: When re-organizing symptoms, I will also create a gesture for each item. It's pretty easy to forget whether a student has asked about a particular symptom during a long encounter, or after several encounters. Performing a gesture at the same time as I answer the question helps me retain it longer. For instance, if a student asks if I have had a headache, regardless of the answer I may touch my temple. If the gesture is natural enough, the student won't notice it at all. If it's less natural, I may wait until the student is looking down at the clipboard. 

• Create a timeline: This is especially important for cases with a lot of past medical history or social history. It's so helpful to see the progression of things in a clear, logical order.

• Create acronyms: for schools that have social checklist items I tend to forget to watch for during the encounter, I create an acronym to review with myself periodically during the encounter. For instance, sometimes I forget to mentally check if the introduction is complete. So if I am at a school that wants me to track the introduction, empathy, rapport and whether the student used my name, the acronym might be ERIN (Empathy Rapport Intro Name).

• Rewrite: I frequently rewrite cases in ways that make more sense to me. For instance, I may rewrite a case using only positive findings, rather than trying to remember which findings are positive and which ones are negative. I frequently rewrite a case using only the heuristics and use that as my main case review. I may rewrite a case listing differences & similarities between characters if I am doing similar cases at different schools.

Discussion question:
What tricks do you have for preparing, organizing or memorizing a case?

Irregular standards: training

An SP with different trainers from different schools.
[In the Draper's Shop via wikimedia]

As I mentioned in Irregular standards: working at multiple schools, specific training for new SPs is often non-existent, leaving you to learn on your own how the training & standards at this school differ from other schools. But even for experienced SPs, different schools handle training in different ways:

For instance, as an SP you never know when you'll receive the case you are scheduled for before the event begins. In a couple of extreme cases, I have received a case on the day I was scheduled to perform it! But usually the range is anywhere between 3 weeks and 3 days before the event. 

Some schools pay for you to learn the case from home while others do not. If you are paid for home preparation, the amount can range anywhere from 2 hours to 30 minutes. 

Some events don't even offer training. Everything you glean from the case is what you will use to perform it. Sometimes you can send questions to the person who sent you the case, but they often go vaguely unanswered. In these events, I always feel like each event is an audition, not a role, and I feel like I'm holding my breath the whole time. 

Schools are inconsistent about when they offer training for cases. Sometimes you're trained on a case just once no matter how many times you do it again, but sometimes you're trained on a case every time no matter how many times you've done it. Sometimes a program that used to train SPs for a particular case stops training for it because they feel like everyone knows it -- but which means new SPs assigned the case are on their own. 

If training is scheduled, it can take a variety of different forms. Sometimes training is scheduled individually, sometimes in a group with others doing your case, sometimes in a group with everyone doing all the cases. Training can be anywhere between 2 hours and 15 minutes. It can be scheduled up to two weeks before the event or just before the event. Only rarely is training more than one session.

Training can include several items, not all of which happen at every school/event (even if they should):

• Contextual overview of case(s) or event in the school's curriculum
• Basic info about the event, like timing, what to do with linens, where to store materials, relevant policies/standards, etc.
• Reading of the case and/or checklist aloud
• Discussion of common pitfalls or issues
• Feedback training
• Physical demonstrations
• Role playing
• Quizzing SPs to check for memorization & consistency

Or it could be a free-for-all where SPs call out questions about their case(s) at random. This is my least favorite format. 

The trainer varies widely at institutions. Some events are trained by a faculty member, sometimes the SP manager, sometimes the head of the educational program, sometimes a Dean, sometimes a TA, sometimes a fellow SP, sometimes a dedicated program trainer.  

Similarly, the skill level of the trainer varies widely. Just like any other instructional event, some teachers are patient, prepared, accommodating and welcome questions. Others are brusque, impatient, or more clueless about the case than we are. Also, SPs can be quite a handful at training if you let them; keeping us on task can be quite a challenge and different people handle that better than others. 

Something most schools are missing, however, is follow through. What happens after the training/event? If the training happens several days/weeks before the event, I appreciate an email with training notes so I remember how the training may have affected my reading of the case. Also, most schools don't have a good feedback loop to make changes to the case after the event: it's nobody's job to compile SP questions and make edits so SPs don't ask the same questions every time. Also, if nobody makes changes to the case based on SP questions, then case drift becomes a real risk -- an invisible body of knowledge about those cases that is inaccessible to any new SP who learns the case.

Extra credit!
Many schools have one or two particular training formats for all their events -- so even if the training is different at each school, at least it's consistent at the school. But one school I work with is all over the map, with almost every possible permutation of the above factors. It's a bit dizzying.

Setting the standard:
My preferred training standard would be a case sent out at least a week ahead of time, with time for questions before the event. SPs would be paid for an hour of at-home prep. Questions would be responded to promptly and the answers coordinated for all at the training held at least an hour before the event. The trainer would be someone who knows how to teach well, and knows enough about the cases to answer most questions about it. The trainer would also be empowered to ask questions of an appropriate faculty member if something unexpected came up during training. SPs could contact the trainer during the event from inside the room to ask a question about the case or grading if necessary. After the event, SP questions would be consolidated and the cases edited before the next event.

Irregular standards: getting paid

Getting paid is always a gamble.
[His Station and Four Aces via wikimedia]

Every time I work in a new place, I feel like I have the same conversation over again, because every place does it differently and can't imagine other places don't do the same:

• Is prep time included?
• Is parking included?
• Does the time begin when the event begins or the time I am asked to arrive?
• Is training paid? Is it paid at the same rate as the event?
• Is a meal included?
• Is break time paid?
• Is the time paid between multiple events on the same day?
• Are there any additional discounts or benefits? (i.e., medical care, services, library access, network access, food?)

I keep a list of every place I work sorted by pay rate & perks so I know how to prioritize events.

Once that's been settled, every place has a different way of hiring and classifying SPs, which affects how I am paid, taxed & benefited:

• Am I considered a "real" employee? A temporary employee? A contract employee? 
• Am I paid through HR or the department? 
• Does someone track my time? Do I have to fill out a timesheet? Do I have to submit an invoice?
• Am I paid via check, direct deposit, gift card or cash? Many schools push direct deposit, but it's not always a requirement. 
• If I'm paid by check, is my check sent to me? Do I have to pick the check up? Am I sent a pay stub?
• Are taxes taken from my paycheck?
• Many places don't bother to tell SPs they have benefits, even if they do. I poke around on the school's HR site to see what's available to me based on the type of employee I am.

Every place has a different pay schedule, so keeping track of when I will be paid is a feat of mental gymnastics:

• Immediately after the event
• Two weeks after the event
• Once a month
• Twice a month
• An incomprehensible but supposedly regular schedule
• Whenever

Finally, if you're the kind of person who keeps track of your hours (and I am), it can be difficult to compare the hours per event with the hours actually paid. If you get a pay stub, some places combine your hours into one lump sum, making it harder to know whether you have been paid accurately for events that span multiple pay periods. I really love the places that pay per event because it's far easier to catch a discrepancy. I also like places that combine the events into one check but break out the hours per event on the paystub.

If I do discover a discrepancy, following up is never fun. It has to be at least a 2-3 hour discrepancy before I say anything, because nobody likes to look it up and track down the error. Anyway, it makes it interesting to do my taxes every year. Despite my best attempts, very few of the tax documents match my final totals.

Setting the standard:
An adequate standard would be one where SPs know ahead of time the answers to these sorts of questions without asking.

A better standard would make sure SPs are paid for prep time. Parking and an appropriate meal would be provided. SPs should be paid for the time they are scheduled, even if the event ends early. If the event runs over, the SP should be paid for the extra time. Break times should be paid, even if there is an awkward gap between events. Training should be paid at the same rate as the event.

A better standard would also inform SPs of the benefits they have as an employee, which means they need to be told what kind of employees they are being classified as. When possible, I would choose SPs to have as many benefits as other workers used in similar ways or with similar hours to other employees on campus.

Payment is a trickier standard because I know few programs have a lot of ability to control a process owned by HR. If the department does the payment, I would prefer to see SPs paid not more than two weeks from the event with an option for a mailed check or direct deposit. I would also prefer the department to track the time but to receive a paystub broken down by date or event to check against my own records.

If the SP program refers SPs for events to other departments, programs or institutions, there should be a clear way to be paid that does not require the SP to be responsible for figuring it out.

Irregular standards: working at multiple schools

If you ask two different schools, you'll get two different opinions.
[Line Infantry Officer & 2nd Standard Bearer via wikimedia]

Once I established myself at one school, I was proud and pleased to be hired at a second one. Working at a second school brought a major challenge, though: almost everything I thought I knew about being an SP was wrong.

One of the hardest lessons I had to learn as I expanded my network of SP jobs was that different schools have different standards for many similar exams. I remember the shock I had at my second school: That isn't how you test for Murphy's Sign! My estimation of the second school was damaged based on my experiences at the first school. So imagine my surprise when I was hired at a third school -- and they did some things differently than either of the other two schools!

So I had to learn to grade SP encounters based on the individual school standards rather than my own. This can be really hard to adapt to if you are a perfectionist like I am and want to believe in the One True Way. But the more schools I work for, the more I realize that while there are some basic general guidelines, as usual the devil is in the details.

And if you are responsible for grading students, the details matter. Because most schools don't compare their curriculum with other schools, there are a ton of built-in assumptions about How Things Work Here that you only discover through trial and error. This is why I ask so many clarifying questions during trainings: I don't want to mark a student down based on another school's standards.  Unfortunately, many programs don't want to have to standardize at that level, which can make it tricky to ask those questions without looking like a rigid rule-monger.

This is especially true for schools who use the same regular pool of actors, because that school's institutional cultural standards are assumed to have been transmitted via osmosis somehow. Those standards may (may!) have been discussed years ago, but they were rarely if ever reinforced, so after time nobody really remembers the details, including the trainers. The original SPs are likely to have experienced case drift, while newer SPs spend the first few events using past SP experiences to influence their current encounters.

So I really respect schools who are clear about their expectations for every encounter, every time. But knowing how different they all are, "Standardized" Patient seems like a bit of a misnomer.

Extra Credit!
You can spot an SP who has spent the bulk of their time at another school because they will always say, "But at [this other school] we did it like [that]!" during training.

Setting the standard:
Offer new SPs an extra 30-minute or 1-hour orientation to discuss your program, especially if your SPs have worked at other schools. Discuss the standards you have around grading and feedback, especially. Bonus points if you know enough about other schools to point out how your program differs from others. Also, check in with new SPs to see what questions they have after the first couple of events and/or observe their first few events to make sure they are following your standards. Never EVER say anything like, "Well, we all know about how [x] works, right?" when training a procedure or case.