An elderly patient patiently waits for her appointment.
[Portrait of an Old Woman via wikimedia]

Some people still say you can't practice empathy, that people either have this as a skill or they don't.  I disagree, which is why I like these elderly simulations in Poland:

Medical student Ludwika Wodyk fumbles her way slowly down the stairs, her movements encumbered by heavy strapping around her limbs and body, her vision distorted by special goggles. She is one of a group of medical students in Poland being given the chance to experience first-hand how it can feel to be an aging patient.

Empathy is something that can be taught, or at the very least, experienced. For many people, empathy is highly contextual, so direct experience with a problem can often give them insight into the barriers or complications of a particular population. This brings benefits like understanding, tolerance, and more creative problem-solving when the same circumstances arise again.

Elderly simulations can also be found in Britain and at MIT.

Extra credit:
When I roleplay older patients, I usually focus on the visual aspects. In future scenarios I want to pay more attention to the physical aspects and give feedback from the perspective of a person who might also have mobility, sight and hearing challenges as well.

Bedside Manner

Yes, I want to see more cross-pollination and artistic collaborations like Bedside Manner!

From the artist's website: "Bedside Manner is a series of photographs and an 18-minute video that explores the little-known world of standardized patient simulations. Standardized patients (SPs) are professional medical actors who are trained to present particular sets of symptoms in order to help medical students improve their diagnostic skills and bedside manner. Routinely, SP encounters are filmed and evaluated by medical professors who observe the interaction of student and medical actor through a one-way mirror."

I am delighted Corinne May Botz got permission for this series. Botz is also the author/photographer of "The Nutshell Studies of Unexplained Death," which explored the groundbreaking crime scene dioramas of Frances Gleaner Lee in the 40s and 50s.

I really wish I could watch the video, which doesn't appear to be available on her site or linked from the New Yorker. According to Botz, the video "deconstructs a real-life standardized patient simulation. It also creates a complex portrait of the neurologist Dr. Alice Flaherty, who plays herself as a doctor, standardized patient and real patient." Intriguing!

I think I am most interested in exploring this further: "...acting and staged representations inform the interaction between patients and doctors in important ways. In order to express their suffering, real patients must learn how to act in doctors' offices." This is very insightful. Reminding learners that patients are "acting," too, may be of use to them. The more learners are able to demonstrate empathy, validation, confidence, respect and autonomy, the less likely patients are to feel the need to "perform" to demonstrate their distress.

In fact, I am strongly reminded of a blog post called "Performance Anxiety" about how an obese patient feels the need to be "terrifically cheerful" in order to receive adequate care. "...being cheerful and upbeat simply works to get a better quality of care in almost every instance. But it’s also enormously taxing, because it is, after all, a performance. Going in for my ultrasound appointment, I was nervous as hell, but I also knew that as soon as I met with the wand-wielder I’d have to push all that worry away and take on a lighthearted, friendly, cheerful persona if I wanted to be certain I’d be treated like a whole person... this pressure to perform under what are at best extremely uncomfortable circumstances does add an additional layer of stress... I resent having to put this happy-fat-lady caricature on. But it’s the most reliable method I know for securing good customer service when I’m meeting a specialist or any new-to-me medical professional for the first time."

Computer simulations vs SPs

Choose your own adventure!
[La Vérendrye via wikimedia]

I don't know whether to be excited about or skeptical of SIMmersion. A little from Column A, a little from Column B, I guess.

I love technology. I love giving students more chances to practice difficult conversations. As an additional tool in the toolbox, this looks stellar. I can totally see learners using this to practice before an SP encounter.

But then I read things in their press release like:

"A computer screen might not be better for teaching the physical examination of a human, but interacting with a well-designed system is better for teaching students how to talk with a patient [than interacting with SPs]."

If they truly feel this way, and if this is the way they are marketing the product, then the whole foundation is suspect.

I actually went through their sample Motivational Interviewing scenario. Engaging with a computer is fun, and including the MI curriculum as a preview before and as a guide during the encounter is very effective.

But the timing and emotional range is all wrong. Learners, especially beginning ones, struggle with a number of things that can adversely affect patient interactions, like word choices and nonverbal cues. This is especially true in the context of a fast-paced encounter. It's much easier to pick the right statement when you have a limited number of options and as much time as you want to think about it.

Also, there is no verbal feedback in SIMmersions. I strongly believe immediate feedback/debrief with an experienced facilitator featuring student self-reflection is an incredibly effective component of learning. Instead, SIMmersions features a woman in the bottom corner of the screen who responds with appropriate body language based on your response, and offers suggestions for the most effective thing to say next.

I see the usefulness of SIMmersion primarily as an early part of skill acquisition. In my ideal curriculum, learners would develop a new skill like this: beginning with a lecture/introduction, then independent reading/videos, then observation, then SIMmersions, then group work, then SP work with timeouts and a facilitator, then a solo SP.

However, this whole things makes me think we're not far off from The Diamond Age's prediction of "ractors," who are essentially crowd-sourced, on-demand scenario actors able to perform anywhere. Wouldn't that be fun?

Inside the Simulation Studio

An SP shows us the inside of his studio.
[Self-Portrait (In the new studio) via wikimedia]

Oh, HELLO! Has anyone heard of the free "Inside the Simulation Studio" conference for SPs?  This sounds absolutely delightful!

Unfortunately, I can't find any recent info on it. Most of the information I can find is from 2013. But happily someone has posted videos from all the speakers! They include a wide range of diverse presentations including traditional power point, creative writing, music, roleplaying, films, recorded encounters, etc. The topics also span a wide range: the future of SPs, how to approach specific encounters, case development, active listening, feedback, mannequins, the scope of SP opportunities, etc.

I love the opportunity to watch other SPs talk and do what they love. But one of the things that really makes my heart sing is the specific emphasis on SPs and their creativity. Yes, I am analytical by nature, but the magic of SPs is the combination of heart, head and hand. So I am excited to see a group not only tolerate that combination, but embrace it.

All in all it's funny, informative and heartwarming. I hope they offer it again sometime. Check out the videos for yourself!

https://vimeo.com/channels/644246/82072169

Mind The Gap

The majestic horror of an on-call schedule.
[Grand Canyon of the Yellowstone via wikimedia]

SP schedules are highly unpredictable and mutable.

This instability is one of the reasons why we should be compensated well. As I wrote in Herding Cats, "SP work is meant to be flexible, but in reality many schools maintain a pool of 'reliable' (by which they mean 'available') SPs. If you are unavailable too often it can count against you. I think this is a bit unfair for a profession that offers no benefits, security or regular work."

So articles like this one about The Gap, which is rejecting an even worse on-call approach, are of great interest to me.

Irregular standards: SP discipline

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.

Actor Seeks Role

All I can think of when I watch the SP-inspired "Actor Seeks Role" is how ironic it is that we work in the health industry but have so little access to health care:

This short film is much funnier and more tragic than when I wrote: "SP encounters are not a substitute for medical care." It's so easy to forget that SPs are considered temporary workers at best, and not eligible for the kinds of benefits other employees receive. Only one school I work with allows SPs to access medical care at their institution (which is, quite honestly, a big reason why SPs work at that school).

The Affordable Care Act really made a big difference in my ability to continue to contribute as an SP without living in constant fear of debilitating medical bills. I sure would like it better if schools were willing to include us on their health plans, though, or access to their care at a reduced rate.

Extra credit:
Of course, it's also charming to see how another SP studies, performs, and grapples with how to be a serious actor while being paid to be a pretend patient. Even while obviously exaggerated, it's certainly more realistic than that Seinfeld episode.

There's an app for that

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

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

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

Some issues I see:

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

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

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

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

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

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

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

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

Maintaining the Mask

A glimpse of the SP under the patient mask.
[Self-portrait with Mask via wikimedia]

When learners feel particularly self-conscious in a scenario, they often break character. This could be because the scenario is new, they're not confident in their abilities, or because a subject is particularly uncomfortable (e.g.: sexual history).

When a learner breaks character, they may talk to themselves, ask the SP a direct question rather than the patient, or make a guess about what they think is supposed to happen in the scenario. It is often accompanied by an expression of appeal towards the SP to get the SP to break character, too. Sometimes they smile to indicate they're in on the joke. I think learners do this because it gives them some control & power in a situation where they feel insecure.

As an SP, it takes a tremendous amount of will to resist or deflect this. So if a learner asks me a direct question like, "So am I supposed to examine your heart?," I have to react like a patient: "I don't know? I guess? I mean, you're the doctor, ha ha!" Or I have to keep a straight face while the learner is clearly looking for more information but hasn't asked for it yet.

Sometimes that's enough pushback for the learner to realize they really do have to pretend to be a medical professional for this encounter. And so we move on.

Sometimes it's not, though. A scenario is a fascinating place that only works when everyone involved agrees to create a shared fantasy. If one person isn't into it, the whole thing limps along until time is called.

That can lead to awkward feedback. In a scenario like that, if I try to give feedback about what I observed, the learner is often defensive. So instead I try to talk with them about why the s/he had trouble taking the encounter seriously. Sometimes we talk about the purpose of scenarios. Even if it doesn't feel real to them, it feels real to me. So the more seriously they treat the encounter, the better feedback I can give.

The Silent Curriculum

Flinching from the silent curriculum.
[Susanna and the Elders via wikimedia]

I love "The Silent Curriculum" so, so, so much. It's powerful and true and brave. Go read it. Go!

I referenced similar issues in my "Beyond the classroom" post:

"SPs are only one tiny influence in a medical student's education. What school students pick, what attitudes they arrive with, who their mentors are, their internships, their residencies, the laws they practice under, and the insurance industry all influence the kinds of medical professionals they become. Almost all of these things are outside their control, and certainly outside of mine. So yes, to be effective, medical educators should be role models. I would feel better if I knew the skills SPs teach students were being reinforced at all levels."

I think one of the things Katherine Brooks writes that is particularly important is this: "I allowed myself to participate in the unconsented care of patients and prioritized my learning, evaluations, and reputation over my values."

I know when faced with personal self-preservation, I am not always the advocate I should be. I am sensitive to explicit vs. implicit rules; that's part of what makes me a good SP. But I feel at my most helpless when faced with bureaucracy where the culture does not match the mission and I have no safe way to express it.

It also makes me realize that while I love the traditional 15-minutes-in-a-room-with-a-student-doctor, the scenarios and schools I am really impressed with are the ones that focus on interdisciplinary & team scenarios. How medical professionals treat each other very much affects how they treat patients. Core values like power differential and consent are ten times worse when working within an institutional infrastructure. How can we expect people to treat patients better than they themselves are treated? While some may be able to do so in the short term through sheer force of empathy, it is not sustainable in the long term, and the medical profession suffers for it.

So the first time I was in a scenario which specifically requested students to challenge each other, my heart almost burst with happiness. I hope to see more of these kinds of events as time goes on. As learners are encouraged to practice challenging and accepting challenges to authority, I hope to contribute to a culture that values a spectrum of diverse voices and views.

Setting the Standard:
Create scenarios to help learners make decisions in teams in ways that encourage challenging each other or gracefully accepting criticism. Reinforce these aspects of scenarios even when they are not the primary objectives. These skills can and should be practiced in safe spaces where grades, jobs or professional relationships are not at risk.

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?

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.

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.

SP community site?

An SP looking skeptical but intrigued.
[The Detective via wikimedia]

Well, hello, there! Does anyone know anything about http://www.standardized-patient.org/ ? It's exactly what I've been looking for for years but it doesn't quite feel right and I can't put my finger on why.  Maybe: "All content becomes property of the website"? Maybe: one of the most active members seems to be a spammer? Maybe: I can't tell what school or consortium is behind it? (I'd feel more comfortable if a legitimate organization like ASPE was behind it.) Where did it come from? Why is it here? So many questions, not enough answers -- or activity.

[updated 02/28: most of the members have been removed. Hmmmm. Updated 03/09: many more new members, all of whom seem to be spammers. Dang it!]

Quote of the Day

[Portrait of Robert Louis Stevenson via wikimedia]

"Our business in life is not to succeed, 
but to continue to fail in good spirits."

Robert Louis Stevenson

This was obviously not written about the concept of SP work, but it could have been. On the best of days, our job is to allow students to fail in good spirits. That's where the learning happens.

Overstepping one's bounds

An SP about to demonstrate her medical knowledge.
[Queen Victoria via wikimedia]

One of the things I keep reminding myself is that SPs are not medical professionals. For instance, no matter how many times we do a gall bladder case, we are not qualified to diagnose cholecystitis.

In fact, I think it's dangerous for SPs to give advice to medical students about anything beyond what they experienced in the encounter unless expressly directed to do so at the event. I cringe when I hear SPs discuss medical feedback they've given students because "I've had a lot of experience with nurses and I know how they do things" or because the SP has experience with the condition s/he is portraying.

This is especially true given our inconsistent training. But it is also in large part because during feedback the power differential is flipped: SPs become the authority, and our words carry a lot of weight, especially with students earlier in the program. But that balance is fragile. If what the SP says conflicts with what students are being taught, all SPs become untrustworthy. We are part of their education but rarely have any actual insight into what they are being taught beyond what we know about our case. Standards and procedures differ at each school, program, hospital, clinic, specialty, etc. And teaching changes all the time, so there is real risk of delivering outdated information.

I also think this attitude is disrespectful to students. Even though SPs should be respected and appreciated for what we have to offer medical students, it's ridiculous to think we are medical experts when the amount students have to learn -- and have already learned -- is so stupendous. Many first-year medical students probably know more about general medicine than most SPs, even those who work several cases a month. Medical students, by and large, are dedicated and bright. We need to make sure we are honoring their educational journey by refraining from the need to prove what we think we know. Of course, some SPs have been or are medical professionals. But I still feel just as strongly that they should not be speaking to students in that role for all the same reasons.

I feel the strength of SPs lies within our ability to focus our comments on the communication skills of the students, not the medical skills. With limited feedback time, I would hope SPs would choose to focus on the details of the interaction rather than medical feedback.

Setting the standard:
At the very least, SPs must identify when they are offering feedback based on their personal medical knowledge, never giving the impression they are speaking on behalf of the program.

Better schools ask SPs to refer students to their lead instructor if there is a conflict between the way the SP thinks a PE should be done or if an HPI question should be asked that isn't on our checklist.

The best schools reinforce this standard and review to make sure SPs are staying within good feedback guidelines.

Alphabet soup

Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

History lesson

A senior faculty member observing an SP encounter.
[Man Holding a Caduceus via wikimedia]

Happy New Year! For Christmas this year I got several SP books, so expect to see quotes/reviews in the future from such thrillers as "Coaching Standardized Patients, "Training Standardized Patients To Have Physical Findings," "Objective Structured Clinical Exams," as well as the new SP classic "The Empathy Exams."

But first I wanted to direct your attention to an article by the esteemed Peggy Wallace: "Following The Threads Of An Innovation: The History Of Standardized Patients In Medical Education" published in 1997. How delightful! I appreciate having an authoritative source to refer to. Here's a brief summary:

"Today, as we enter the new millennium, the standardized patient has become one of the most pervasive and highly talented of the new methodologies in medical education. It was certainly not always so. The standardized patient was anything but welcome and readily excepted educational tool, especially in the early days." Though the use of SPs began in 1963, it was not until 1985 that the traditional OSCE begin to integrate SPs, and even then its dissemination was slow. National boards (USMLE Step2) didn't incorporate SPs until after the article was published!

There were 3 primary contributors to the standardized patient field:

* Howard S. Barrows was the first to use SPs at USC. "Almost never was there a student whose clinical skills were evaluated as unsatisfactory because the faculty almost never directly observed the student with patients. In fact until the advent of standardized patients, there was no objective clinical measure by which to evaluate students." It's fascinating to learn that Barrows went on to teach at McMaster University, which has similarly transformed medical applicant interviews through the MMI. While at McMaster he developed the small group format and the use of USPs. He developed ways of simulating difficult findings on SPs like bruits and pneumothorax. He was the first to develop encounters with difficult patients: seductive, angry, inquisitive, etc. 

* Paula Stillman created specific checklists at the University of Arizona. For instance, what does "examine the eye" mean, really? Stillman could tell you 20 things a student should do to examine an eye that nobody had bothered to standardize before. In addition to using SPs as a body and an evaluator, she also used SPs to teach those skills: "They knew nothing about medicine. They were strictly process people." And yet still effective, I imagine, with the appropriate training! She was the first to begin working with patients with actual physical findings (only one school here does that). 

* Robert Kretzschmar began using SP models as "gynecological teaching associates" in 1968. At first they were just bodies with a sheet obscuring their face and without commentary or feedback, but Kretzschmar expanded the teaching & communication roles for GTAs in 1972.

Things which did not come to pass:

* "The 'patient instructor' might become a necessity rather than a luxury --  and Standardized Patients might be even more extensively needed for clinical learning and self-assessment as the pool of teaching faculty dwindles." (Not without better training!) 

* "And what about the practicing physician, or the one who has lost his license to practice? Might not the standardized patient be able to support the physician in new learning... [making] it possible for the physicians-in-trouble to relearn?" (While I would love to see more of this, I only know of one program that works with physicians-in-trouble and it's a very small, closed group.) 

* One of the interesting skills that seems to have been lost over the years is the use of "stimulated recall" after the encounter. SP feedback can be great, but I imagine reviewing a video of the encounter with an expert guide to ask you questions at specific points would be incredibly effective. (I try to do something similar in my feedback -- e.g. "What were you thinking when X happened or when you asked X?" -- but I'd like it to be a standard tool for schools to use when appropriate.)

Thank you, Peggy Wallace, and thank you, Barrows, Stillman & Kretzschmar! As Wallace concludes, "May that golden rod, now firmly planted, continue to inspire winged ideals in the midst of the inevitable conflict of the opinons that will create the fertile soil for sustaining educational efforts as the search goes on for a better way to support the healers of today – and nurture those of tomorrow."

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.

Quote of the day

[Portrait of Pablo Picasso via wikimedia]

"Art is a lie which makes us realize the truth."

Pablo Picasso

Now replace "Art" with "A scenario." Discuss.