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

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

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

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

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

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

Irregular standards: getting paid

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Beyond the classroom

A medical student in the midst of medical education. SPs are the third wave from the left.
[The South Ledges, Appledore via wikimedia]

I feel bad when I read articles like "5 Simple Habits Can Help Doctors Connect With Patients" because of quotes like this:

"Our medical teachers put a premium on accuracy and efficiency, which became conflated with speed. Everything had to be fast. In 2014, doctors still value speed and technical accuracy, but we also do more to consider the quality of care we give and whether patients are satisfied with it."

As much as I love what I do and how much I value communication skills, when I read this I feel like we ask doctors to do more and more with less and less. In many medical school scenarios we have between 12-15 minutes for each scenario. What sort of meaningful connection can be made in that time? In practice, doctors can't take much more time than that or they risk disrupting an already overbooked schedule.

Also:

"Medical educators should be role models for these common courtesies... Trainees take their cues from us. These behaviors are what constitute 'bedside manner.'"

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.

Unannounced SPs

USPs arrive at a clinic evaluation.
[Unexpected Visitors via wikimedia]

I loved the specificity and the intent in this study published April 2014: "Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system" by Sondra Zabar, Kathleen Hanley, David Stevens, Jessica Murphy, Angela Burgess, Adina Kalet and Colleen Gillespie. (whew!)

"Implementing a USP assessment can help clinical settings move beyond patient satisfaction as a measure of performance and focus more on targeted assessments of the quality of care provided."

Oh, my, yes! I would love to be a USP. SPs are especially qualified to offer real-life quality assurance in a variety of settings: "USPs can be trained to be consistent and accurate raters of clinical performance and clinic functioning through the use of highly specific, behaviorally-anchored checklists. They also have the benefit of exposure to a wide variety of levels of performance and training in expectations and standards of quality, experiences most 'real' patients do not have... Such reliability and validity, combined with the standardization of clinical cases and patient portrayal, is particularly useful for comparing performance over time or across clinical units."

One of the concerns, of course, is what the study endearingly calls "the ethics of deception." As someone who very much values transparency, I think this is a valid concern. Unlike medical school, where students are aware that SPs are playing a role, USPs are "unannounced" and so have the potential to contribute to a sense of paranoia and mistrust -- both of which contribute to a toxic environment for employees and patients. Transparency, in this case, should mean that everyone involved knows the use of SPs is a regular part of the quality improvement process -- and that everyone involved gets to see the outcomes in a reasonably timely way.

Phone services would be another excellent use of SPs. For instance, I had a recent disappointing encounter while setting up an appointment. I had to call three times before finding someone who could help me. Thanks to my SP experience, I was able to offer concrete, non-inflammatory feedback -- and I was pleased to be able to end with positive feedback for the one helpful representative (feedback sandwich, yo!). But what really would felt satisfying is knowing my experiences could lead to improved outcomes for other patients calling the service.

Extra credit!
I learned a new name for an old concept: The "Hawthorne effect" describes how the awareness of being assessed influences the care provided.

Assigned reading:
Also, see this article: "Why we need 'mystery shoppers' directly observing health care"

Costume party

A typical selection of outfits for an SP encounter.
[Preparing for the Costume Ball via wikimedia]

I wish SPs had costumers. Granted, most SP events are done while wearing hospital gowns. We usually wear undergarments: bras and shorts/pants. We are often on camera, after all! And students have a hard enough time without the shock of fully visible breasts and groins.

But sometimes we are in "street clothes" for encounters that don't require a physical exam. And when that happens, I have to start making assumptions about the presentation of class and gender. This is both highly interesting and a little uncomfortable for me.

For instance: what outward signs most clearly signal an office manager, stay-at-home mom, car salesperson, maid, music mogul, golfer, homeless person, teacher, lawyer, Target salesperson, accountant, Catholic, artist, landscaper, factory worker, party girl, pharmaceutical salesperson, restaurant manager, cook, hippie, construction worker, banker, social worker, delivery driver, cattle rancher, travel agent, hairdresser, jazz musician, bartender... or a fellow medical student?

I have two competing thoughts:

1. Students should not be surprised by SP presentation so that they are more able to respond to the scenario.
2. Students should be exposed to SP presentations that defy their expectations and limit their assumptions.

So depending on the role, this leads to questions like: Should I wear makeup? Should I put my hair up? What sort of shoes does this character wear (if any)? Should I wear a fragrance? Should I wear my glasses? Does this character wear tight-fitting clothing? What colors are typical for this character range/class? What jewelry does this character wear (if any)? What about a wedding ring? What do I wear while giving birth? Do alternative medicine clients dress differently than Western medicine clients? Etc. In any case, I know I am either playing to stereotype or I am causing the students to question my authenticity.

Extra credit!
Worst case scenario: I sometimes have a repeating event in which I know I will be one of four different cases, but I don't know which until I arrive at the event. So I've had to create an outfit that will work for any of the four characters. That's tough! I guess the alternative is to bring several different outfits -- but I don't think even I am that dedicated.

Extra credit #2!
When I have to create a costume from my closet, I will sometimes find a surprising lack of a common item. For instance, I recently discovered I don't have a plain pair of black pants when trying to create a business manager outfit. Apparently I haven't needed a pair for at least 10 years!

Setting the standard:
I can worry less about what to wear if the manner of dress is included in the case. Please do that!

Irregular standards: working at multiple schools

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

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

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

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

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

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

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

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

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

Herding cats: scheduling SP jobs

How can you choose just one?
[Playing Kittens via wikimedia]

SP work is not full-time, even though I work for almost a dozen different places. Even so, scheduling conflicts are not uncommon. So when multiple schools request availability for the same block of time, the scheduling involves an enormous calculus of various factors:

• Rate of pay and the number of hours/days the job runs: How much will this case be worth? Is this a school that pays more than others? Is it a case that runs over several days or weeks?
• Enjoyment of the particular case: When I know what the cases are, how much I enjoy one of the particular cases can influence which job I choose. Or is it a new case? Most schools want to schedule you for a case you've already done. However, I lean towards new cases when possible because it makes me more available for a wider range of cases. And it's more interesting for me: I like to see how communication needs change for different patients in different cases.
• Travel time and/or hassle: I'm willing to travel quite a ways for SP jobs. If there is a potential scheduling conflict, however, I am more likely to choose a job that is closer if all other factors are similar. The same is true if I have to pay for parking.
• Relationship with the school/department: Is it a prestigious school? Is the school/department well-managed? Will accepting this job strengthen the relationship I have with this school or department? For instance, am I still establishing myself at that institution? Conversely: will refusing that job leave me vulnerable to seeming unavailable and therefore uninvited in the future? 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. Another factor: will they be able to find another SP easily? For some jobs, I am the only SP they have, which can make scheduling more complicated.
• Juggle & bundle: Can I cancel or reschedule another commitment to accommodate everyone? I hate to choose this option, but it's been useful from time to time. Can I schedule multiple jobs from different schools for the same day? Those days are the best days. Can the role be split so I can accept the one-day job from another school? Some schools expect that, but some schools hate it.

Extra Credit!

I have learned to say I am "currently" available when responding to an event. Sometimes when one school requests availability, another will offer a job within the same time before the first one has committed. So I also have to keep track of what stage all the offers are in so I can amend my availability for the other school(s). I have learned that if I try to wait for the first school to get back to me, sometimes I don't get any of the jobs. *sad trombone*

The value of SPs

Core values.
[Apples and chestnuts, via wikimedia]

I remember with great clarity a conversation I had with a faculty member who was unconvinced of the value of SPs. As a teacher at a school that has a reputation for being patient-centered, he felt non-empathic applicants self-selected out, which meant they could focus on teaching the physical skills to the students who were accepted.

But (said I) even with the best students in the world, skills decay over time unless they are reinforced and rewarded. Medical school is almost deliberately overwhelming. Faced with competing priorities, it makes sense for students to focus on the priorities that are rewarded by the system. If grades, clinical experience, and service are what the institution rewards, then patient communication skills become less visible and important. Starting with good students just means the slide is less precipitous.

So for all their other virtues, at the most fundamental level SP encounters help remind students that patient communications skills matter. They indicate that the institution still values those skills as part of its medical education. I don't think this should be limited to the first two years, though: SPs should be an integral part of a professional medical education at all stages, including after licensure. Practice may not make perfect, but you are significantly more likely to maintain a skill if you practice it than if you don't.