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.

Summertime

A lazy June day lying over the educational horizon.
[June Day via wikimedia]

Ah, it's the end of the school year. As an SP it is bittersweet in many ways:

• We see such a small slice of students' lives. I often see students more than once, but if they are Y2 students, they can suddenly be ready to graduate, moving onto other programs and cities. When I think about how much they've had to master in such a short time, I am nostalgic and impressed.

• The end of the year changes my feedback sometimes. For instance, during the last OSCE of Y2, I know the students won't go through another OSCE (except for schools who do occasional 3rd year or resident events). So for schools with open feedback, my tone is more informal and summative, more broadly applicable: Congratulations! What have you learned? What are you still struggling with? What specialty are you planning? These skills will help you with that [in a specific way]!

• Summer is when my income plunges. Very few schools have summer events. So I watch my monthly average drop with trepidation and am almost giddy when a random summer job comes my way. When the regular fall schedules start up in August, I'll be ready to jump back in.

• Conversely, summer is when I have the most free time. So I plan my major travels & adventures around this time when possible to reduce the opportunity cost of missing a job during the school year. I'll get to write more, think more. Maybe I'll even get around to reading the Empathy Exams like I said I'd do in January! Yes, I'm looking forward to reading on the porch, drinking homemade iced chai.

Discussion question:
What are your summer plans?

The gendering of imaginary medical professionals

Because women are always nurses, right?
[Train to be a Nurse via wikimedia]

As an actor and a conscientious person, I am interested in our habitual language choices, especially relating to intrinsic human qualities like sex, gender, race, etc.

For instance, there are times during an encounter when a student may refer to my PCP or someone treating me for a particular condition in the case. And almost invariably, the gender of this doctor who doesn't even exist is male. This is true even if the student asking is a woman.

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"

So I am surprised when, even after all these years, I fall into the same trap:

student: "When did you last see your doctor?"
SP: "I saw him last month."

When I use a masculine pronoun by default, I have to let it go because I don't want to do anything to derail the scenario. But I mentally wince when I hear myself say it.

However, if the student defaults to a masculine pronoun, I can choose to ignore it or challenge it, depending on what feels best for that interaction. For example:

student: "Have you seen a doctor for this condition?"
SP: "Oh, yes."
student: "What did he tell you was going on?"
SP: "She told me to come back for more tests next month."

As an SP, I find I don't even need to add emphasis to "she" or act offended in any way. Just changing the pronoun is enough to change the dynamic and get the student's attention.

It takes a lot of concentration to flip the model and not just go along with it, especially when I'm concentrating on the rest of the encounter requirements, which is why I don't remember to do this as often as I would like. But when I do I feel like I'm helping to create the kind of world I want to live in.

Bonus points:
Other gendered professions in scenarios (a living list): apparently social workers are female, too.

Extra credit:
If a student-doctor uses the term "lady doctor," please call them out on it either in character during the scenario or gently during feedback. (Yes! I've heard it!)

Setting the Standard:
Women can be doctors, too. In fact, nationwide almost 50% of students in medical school are women. I recommend using a feminine pronoun for all imaginary medical professionals to reinforce that possibility and offset the default gendering of medical professionals.

1 year!

Happy birthday, blog!
[Strawberries and cakes via wikimedia]

It's now been a year since I began Setting the Standard. One of my very favorite things to do is to create pattern from chaos, so I have loved writing about this job in very detailed ways. I am very pleased to write concretely about the largely invisible and intangible relationship skills which have such a large impact on patients, like empathy, power differential, consent, physical autonomy, etc. Compiling the differences between institutions feels like I have a particularly unique view on something that initially seems simple. It is also very satisfying to get internal checklists standards and jargon out of my head and onto the "page" to use as a reference when called for.

In my second year I hope to find other SPs engaged in the online community: writing, thinking, feeling, training, and discussing this strange and wonderful work. As I wrote on my "About" page: "The only thing that would make this work more fulfilling is a stronger SP culture... I want to raise our standards. I want an SP culture that is both curious and dedicated to self-improvement." Student and SP management opinions are also welcomed! SP work shouldn't be lonely work, especially if we are in the business of analyzing and addressing communication skills. We're in this together.

I still have so much more to write about, and many more scenarios to perform with many different kinds of institutions. I am terribly glad to be an SP, so grateful for these brief windows into the lives of others who are also ever myself. So as long as I am an SP, I will continue learning, playing, and writing.

Extra credit
I wish I felt comfortable writing about scenarios in the way Tom does, because I appreciate their perspective and poetry. But my thin veneer of anonymity is more important to me. So thanks for writing what needs to be written, Tom! Have a cupcake.

Joyeux Noël

An SP singing at the holiday party.
[A Christmas Carol via wikimedia]

Whatever you celebrate, may your holidays be both merry and bright.

Applied skills: communications breakdown

Not a good time for feedback.
[Fighting horses via wikimedia]

One of the ironic things about what I do is that I am paid to evaluate communication skills -- but in a way that is generally unsupported outside the confines of an SP encounter.

I have been trained to observe things like eye contact, body posture, tone. I notice empathy and rapport skills. I am keenly aware of power dynamics and language that contributes to subtle coercion. I am attuned to actions that indicate engagement and responsiveness.

So when I experience difficult situations outside the exam room, situations in which a lack of communication skills is contributing to a negative situation, I don't know what to do.

I now have language to describe why I am uncomfortable to myself. Honestly, this is a hugely useful tool. Awareness of what makes me uncomfortable and why can sometimes be enough to ride out a difficult encounter.

However, most of those situations don't allow me to communicate my distress without negative consequences. During typical SP feedback, there is a willing suspension of defensiveness which makes constructive comments possible. Of course that is a fragile balance and can easily be upset with the wrong approach. But where else in life do you get the chance to comment on how to improve a difficult encounter?

I wish there were more opportunities for that, because observing the behavior without being able to comment on or resolve it makes me feel helpless sometimes.

Hand wash

Lady Macbeth could teach us a few things about hand washing.
[Ellen Terry as Lady Macbeth via wikimeda]

One of the things I have become more aware of since becoming an SP is how hard it is to stay healthy in the health profession! Students generally can't make up scenario events, and so they enter my room in various stages of illness and fever.

So now I am much more aware of handwashing -- both theirs and mine. Since I shake so many student hands, I try to wash them between students. I am more careful about rubbing my eyes. I use a paper towel to open the bathroom door after I've washed my hands. I use the back of my wrist to shut off the water. When I handle pens or my phone I want to wash my hands. Sometimes I sanitize the keyboard I am using for checklists.  I even use the sanitizing gel more than I used to, though I primarily prefer soap & water.

When we are in flu season, my handwashing urge kicks into overdrive. But it must be working, because it's been a while since I got the flu, despite persistent contact with potentially infected students.

Discussion question
Does your school have a checklist item for "Student washed hands"? If so, what are the criteria for full credit? Can students use hand gel? Do they have to wash their hands in front of you or outside the room? Do they have to wash their hands immediately before beginning a physical exam? Etc.

Extra credit!
I once had a student in a group setting who refused to use hand gel because she claimed to be allergic to it. In this location there was no access to water. So I allowed her do the physical exam but it made me squirm. Only afterwards did I realize I should have asked her to use gloves instead.