"All right, now push against my hand."
[Werdende Kraft via wikimedia]

When learners do strength testing on my extremities, I often find myself confused by their instructions. Because learners often practice with each other, it means they practice with people who anticipate and act on what the learner intends, not what the learner has actually said. Plus, strength testing involves body positioning in a way where students are less likely to be mindful of physical autonomy.

I wrote about this a bit in "Neuro exam checklist," but it comes up frequently enough that I wanted to break it out into its own post. So this is the kind of feedback I give learners doing strength testing.

This is a living list. Last updated November 3, 2015

• Explain: Why are we doing strength testing, anyway? As a patient, it can look like a lot of work with no clear purpose, especially if the movements seem unrelated to my chief complaint.

• Stop talking: Learners frequently begin the test before they even finish telling me the instructions. So the test could be over before I even understand it has begun.

• Offer simple, clear instructions: I feel strongly that "Push against me" and "Pull against me" are far easier instructions for me to follow than "Resist my force." Or worse: "I'm going to push against you; don't let me." Framing things in the negative (ala "resist me") places a higher cognitive burden on me to figure out what the learner wants me to do to "resist." Plus, telling me to push/pull also makes it clear when the testing has begun, because I am in charge of the movement. If the learner is already pushing against me but I have not yet understood my counter move, it can give the learner a false positive.

• Let me move myself: During strength testing, learners may move my limbs into position while explaining the test, which makes me feel vulnerable. If learners allow me to move my arms or feet into position myself (including during reflex testing), I feel like I have some control over my own body.

• Indicate the end of the test: This can be as easy as saying "ok" or "thank you" (how polite!). Saying "great" or another filler can be awkward if I am clearly not doing well.

• Ease up on exit: When learners are eager to move on to the next test, they may let go while I am still exerting force, which drops my limb rapidly. When this tests neck muscles, this can be especially dangerous. But when learners are careful to ease pressure at the end of the test, I feel much more confident in their ability to be self-aware and treat me with respect.

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.

HEENT checklist

An SP after a HEENT exam.
[Bartholin head transect via wikimedia]

The Head, Eyes, Ears, Nose & Throat exam is one of the most vulnerable exams for a patient because it uses pointy objects and bright lights near sensitive orifices. I don't know how SPs get used to this. I am pretty strict & consistent in my reactions during this exam because I want to remind students be especially considerate and careful in this region.

Here are some of the things I am looking for during an HEENT exam:

This is a living list. Last updated October 29, 2015.

Head

• Palpation: Careful of earrings and glasses when present. Use the word "touch" instead of palpation.

• Inspection: Verbalize inspection. When you do, don't use alarming words like "lesions."

 Eyes

• Reaching for my eyes is scary! Warn me before touching near them, ideally demonstrating on yourself.

• Conjunctiva: if you can, allow me to pull my own lower lids down and look up instead of doing it for me. This gives me more control in a vulnerable situation.

• Checking for pupillary reflex: tell me where to look. Otherwise, as a patient I am primed to look directly at the thing in front of my face, and when a bright light is suddenly flashed in my eye I may wince or blink or jerk in a way that gives you an incorrect finding.

• Ophthalmoscope/fundoscopic exam: tell me what you're doing before you do it. Tell me where to look. If you don't have to use the brightest light, I would appreciate it. If you're going to brace against me, warn me before you do. Don't, under any circumstances, brace yourself by placing your finger on my lip (I am surprised this happens as often as it does).

• Using a Snellen chart: if you ask me to "read the smallest line," I read the text on the bottom of the card. Be specific if it matters! 

• Checking visual fields: If you ask "Do you see my fingers?" I will turn my head to look at them. Yep, I see them. Tell me where to look if it matters! Also, sometimes students don't start far enough back (so I can always see the fingers) or come far enough forward (so I can never see the fingers despite that I can see the student shaking with the effort of trying to wiggle them). 

• Accommodation/convergence: tell me to keep my head still, or I am likely to move my head when I see a pen get too close too my face. Best practice: "I want to see how your eyes are moving. Please keep your eyes on this pen and your head still as I move it towards you."

• If I am wearing glasses and you ask me to take them off, especially for the ophthalmoscope exam, I will readily agree -- and then leave them on the table until you remember to tell me I can put them back on. Patients without their glasses can feel even more vulnerable while they aren't wearing them, so the sooner you tell me the better I feel about your awareness and consideration. Unfortunately, it is not unusual for me to have my glasses off for the rest of the encounter.

Ears

• Pointy things in my ears is one of the worst parts of being an SP. I've only had a handful of students cause pain, though. To achieve the highest standard, you must break the plane of my ears and use a cone.

Nose

• But pointy things in my nose is actually worse than pointy things in my ears. How you treat my ears is similar to the way you will treat my nose. To achieve the highest standard, you must break the plane of my nostrils and use a cone (it can be the same cone as my ear, but not vice versa!). 

• Sinus percussion: For heaven's sake, warn me before you start tapping on my face. It can be a very startling sensation if a patient doesn't know it's coming, and even more so in such a vulnerable area. Many patients don't understand what areas are involved when you invoke the word "sinus": if I think you're only going to examine my nose, reaching for my eyes will be a surprise. A better explanation: "I'm going to tap above and below your eyes; please tell me if it's tender." Demonstrate on yourself as your explain it. Always use the word "tap" instead of "percuss." 

• Ask me to tilt my head back rather than pushing it back yourself. I've had students push me back with a hand on my forehead or a finger under my nose, and both ways feel less respectful than asking me to move myself. 

•  SP Pro Tip: when the student inserts the speculum into your nose, hold your breath so the moisture doesn't fog the lens. The exam is quicker that way. 

 Throat

• If you ask me to open my mouth, I will, but I won't stick my tongue out until asked. If asked to say "Ah," I will try to do it without breathing directly into your faces if possible.

• Lymph node palpation: I prefer firm deliberate pressure as opposed to tiny tickling fingers underneath my chin.

• Thyroid palpation: Describe the exam before you put your hands around my neck. Since this exam is frequently done from behind and with a fairly firm pressure, it can otherwise feel alarming. 

• SP Pro Tip: If you are an SP in a school that includes a thyroid exam, I highly recommend beginning saliva production after the oral exam and only swallowing half of it when asked, in case the student requests another swallow.

Getting a clue

An SP giving a clue card to a student after a heart & lung exam.
[Detail from Card Players via wikimedia]

Obviously, most SPs do not match the physical findings of the cases they portray. There aren't enough of us to specially cast in cases which include findings like heart murmurs, abdominal masses, retinopathy, swollen lymph nodes, clubbing, etc. And despite the fascinating and helpful tips in "Training Standardized Patients To Have Physical Findings," it is almost impossible to simulate these findings, either.

So I usually give student doctors a card that explains the finding after they've finished an exam which might reveal it. Each school has a different method for doing this. Students are usually visibly triumphant when they receive a card, as if they have won a prize.

However, student doctors almost never share that finding with me as a patient. Once they get a card that describes the abnormal results of a tactile fremitus exam, for instance, they continue with the rest of the exam as if nothing had happened!

I find this tremendously frustrating as an SP because they lose out on the chance to practice giving findings that are not within normal limits without alarming patients. I want them to practice offering contextualization, risk or reassurance in these situations, to help me understand why the finding relates to my chief complaint. Without that practice, they will be behind the curve when it happens to them later.

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.

Ungowning instructions

SP awaiting a heart & lung exam.
[Madeleine dans le désert via wikimedia]

Actors are not generally modest. But most patients are. "There will be some patients who would sacrifice their health and lives in order to preserve their physical modesty."

So I care quite a lot about standardizing ungowning instructions because they have a huge effect on patient trust and confidence. Checklists often contain a question about appropriate draping, but it is rarely clear how SPs should score this except on a vague sense of personal taste. But again, that makes specific feedback difficult. So for me, good ungowning instructions have four parts:

First: confidence My discomfort rises in direct proportion to student discomfort. Being able to address vulnerable exams with confidence makes me feel less anxious. 

Second: expectations management Student doctors often assume I know that certain exams will require ungowning. As a patient, why would I know a heart or lung exam requires ungowning? When a student doctor tells me s/he is going to check my heart, as a patient I imagine a stethoscope will be used over my gown on what I think of as my heart: the left side of my chest above my breast tissue. So without further understanding, asking me to ungown at that point seems strange and awkward because I have no idea what's coming next. Best practice: "I'll be checking your heart and lungs in several places. To do that, I'll need to use the stethoscope on your skin." 

Third: simple, clear instructions Don't make me guess how far you want me to bring the gown down. When a student doctor tells me to lower the gown "a little," it makes me anxious: as a patient, I would be very embarrassed if I took my gown down too far and the doctor corrected me -- or if I didn't bring it down far enough and I had to keep guessing. Ambiguity is excruciating in vulnerable situations. Best practice for first year students: "Would you please untie your gown and lower it to your waist?" Adding the instruction to untie makes me have to think less about the order of steps, which makes the whole process more fluid and gives me more confidence in the student doctor. Don't forget to tell me when I can put my gown back up! 

Fourth: autonomy & consent Because I am at my most vulnerable, ungowning instructions require even more awareness of autonomy and consent than usual to make me feel safe and respected. Do not begin untying my gown without asking me. If you ask me to lower my gown, don't reach towards me before I complete the action. Allow me to be in control of the ungowning. If you notice I am having trouble untying the gown, offer to help me -- but do not reach for me without my consent.

Advanced studies:
By asking me to untie the gown, it generally becomes loose enough so that the exam can be performed by slipping the stethoscope under the gown, thereby preserving my modesty entirely (assuming the student learner tells me they are going under my gown, at any rate). In other cases, asking me to untie the gown and slipping an arm out is a better compromise than lowering my gown all the way to my waist.

Bonus points:
This all assumes the opening of the gown is in the back. I honestly can't think of a good reason to wear the opening in the front, because it feels so much more exposed and everything can be done by manipulating the gown. But some schools do, so I go along with it. However, if the gown opening is to the back, asking me to turn my opening to the front during the encounter is completely ridiculous. That requires me to get off the table and undress while the student's back is turned, all while eating precious encounter time. Not recommended.

SP encounters are not a substitute for medical care

I hear the GU exams feel sort of like this.
[Opisthotonus in a patient suffering from tetanus via wikimedia]

It's important to recognize satire when you see it:

Standardized Patient Suing Medical School After No One Detected Prostate Cancer

I probably get between 600-800 exams a year from various medical students. One of my favorite things about encounters that include physical exams is seeing the large range of findings between student doctors. My blood pressure is excellent but every student comes up with a different number. I have incredible reflexes if student doctors hit the right spot, but less than half of them do. Very few guess my age or weight correctly. I remember one group of students was once very concerned about something that turns out to be very normal in women.

One of the unanticipated side effects of this job is the constant battle against hypochondria: is it fatigue or is it CANCER? But because I have so many exams, I feel lured into a false sense of security. Even though I know these exams are cursory at best, I also haven't been to an actual doctor in... years. I need to change that.

Core value: Physical Autonomy

How I feel after a particularly disappointing physical exam.
[La Autopsia via wikimedia]

My first core value as an SP is "Empathy First." Many years of SP encounters have also led me to claim physical autonomy as a second core value. I firmly believe that autonomy is the key to respect. It is one of the things that is critical in reducing the power differential between doctors and patients.

Autonomy manifests most directly in an SP encounter during the physical exam. When a student doctor doesn't respect my physical autonomy, I feel vulnerable, helpless and insignificant.

When autonomy is not a core value for the student, my body feels like an object for the student to manipulate. Autonomy hinges on consent. There are several different levels of autonomy a student doctor can observe:

1. Move the object without explanation
2. Move the object with an explanation
3. Asking while moving the object
4. Asking before moving the object
5. Asking before moving the object and waiting for consent
6. Asking the object to move itself

Here's the thing: even if the student doctor is nice about 1-4, only numbers 5 and 6 are true autonomy. A student can be nice and still not respect my personal autonomy. Let's look at this more closely:

1. Move the object without explanation: the student doctor moves my arm out of the way and continues the exam without explanation. This makes me feel as if I am no longer a person to the student doctor, just in the way. This makes me feel resentful and cautious.
2. Move the object with an explanation: the student doctor moves my arm out of the way and explains why s/he is doing so. This makes me feel powerless.
3. Asking while moving the object: the student doctor asks "May I move your arm?" as the student doctor is moving my arm out of the way. Lots of students know they should ask a patient's permission, but many of them perform the action as they are asking for permission -- which makes me feel as if my consent doesn't matter.
4. Asking before moving the object: the student doctor asks "May I move your arm?" and waits for a beat. If I don't respond immediately in the affirmative, many students will move my arm anyway as if I had answered affirmatively! As a woman, I have been trained to be agreeable to implied consent, so it is difficult for me to offer any resistance to the student doctor's expectation when asked (especially if the student doctor is friendly). However, I don't immediately answer because I want to see what happens: when student doctors assume consent when there is none, this trains them badly for real patient encounters.
5. Asking before moving the object and waiting for consent: the student doctor asks "May I move your arm?" and waits for me to agree. This is an terrific way to reduce the power differential. I feel relieved, validated and grateful.
6. Asking the object to move itself: when the student doctor is conscientious enough to ask "Could you move your arm overhead, please?" I feel like cheering. Allowing patients the chance to move themselves into position allows them to feel in control in a vulnerable situation. I want medical education to rest on a strong foundation of patient control and consent.

Homework assignment:

Notice this week how many times you agree to something before the person has even finished making the request. Try not to agree in anticipation. How did that feel? How did the other person respond? Conversely, notice how many times you make a request and begin an action without waiting for a response.

Setting the standard:
An adequate standard would be one where student doctors ask permission before moving the patient and wait for the patient to respond. The student doctor would then continue to watch for verbal or non-verbal cues which indicate the patient feels more comfortable with assistance or does not need to provide continuous consent.

A better standard would be to find ways to allow patients to move themselves whenever possible. The student doctor would then watch for verbal or non-verbal cues to indicate the patient is having trouble understanding the instructions or unable to move themselves without assistance, at which point the student doctor would ask permission, as above.

Really quick

When I saw this (really quick!) video from Cooper Medical School, I thought, "YESSSS!" When students tell me they're going to do a "really quick" exam, it makes me feel rushed. If something is bothering me enough to make a doctor's appointment, I want a thorough exam, not a "really quick" one.

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.