An SP having a flash of inspiration during feedback.
[Saint Augustin via wikimedia]

My preferred method for feedback includes a lot of questions. I love feedback when it's a conversation and individualized to each student. I stumbled into a question recently that really makes me happy, especially with Y2 students:

Have you seen this before?

Depending on the conversation, it can mean:

• Have you seen this in clinic?
• Have you had experience with this personally?

I don't know why I didn't think about this before, but the answer is usually yes! Students usually have had some experience in the medical profession before being accepted to most programs. The further along in the program they are, the more likely this answer is to be yes.

So then more questions can follow:

• What did you do/see?
• What tools did you pick up that you used in this encounter?

That's the secret: I don't talk about what they did or should have done in another context. Instead, I direct their responses to reflect how they affected me in this encounter. This both focuses their attention and integrates my feedback with experiences they've already had.

One of the primary complaints students have about SP encounters is how they don't reflect the work the students feel they are capable of outside the exam room. I've been thrilled with how this question changes that dynamic. I can honor the students' actual lived experience and together we can refine it within the safety of the event.

Extra credit:
This turns out to be a useful tool when giving difficult feedback, too. "Your eye contact is poor/You ask too many questions at once/You rushed at the end. Have you heard that before? Has anyone told you that before?" Learners often have heard that feedback before, so it helps to notice the bigger picture and come up with a strategy they can attempt in their next encounter.

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.

Quote of the Day

[Portrait of Henry Ford via wikimedia]

"You can't build a reputation on what you are going to do."

Henry Ford

When I give students feedback about empathy or rapport, sometimes they respond by saying, "Oh, I'm so much better in clinic" or "I'm different with real patients" or "I don't do well when I'm being observed." But I can't give feedback on skills I don't observe.

Pelvic anthem

If "8 Miles Wide" isn't the anthem for pelvic models/educators everywhere, it should be! By the way, this song is not at all safe for work, not even a tiny bit.

"It's not my vagina! It's our vagina!" Godspeed, you brave and valiant vaginas.

Feedback models: When you did X, I felt Y

Let X=X.
[De divina proportione via wikimedia]

Another classic SP feedback technique is offering your comments in this format: "When you did X, I felt Y." For example: "When you moved my arm out of your way without saying anything, I felt vulnerable and helpless."

This is the only SP technique I've ever attended a (brief) training on. I know a lot of people hate it because it seems forced and routinized. I resisted it at the beginning, too. But with practice, it's become very natural to me, and now I find it to be one of my most important feedback tools. Here's why:

• I value it for the way it really forces me to truly examine what I felt and why I felt it. It's an excellent tool for self-awareness. The more I know about what makes me comfortable or anxious, the better feedback I can give students.

• Because it focuses on my emotions and observable behavior, rather than the student's motive, it's much harder for a student to argue or dismiss my feedback. This reason alone makes it worth becoming comfortable with the X/Y technique. It keeps the discussion patient-centered.

• I love how it expands my range of expression and allows for more nuanced feedback. Otherwise a lot of feedback is often binary: either good or bad.

• It works for positive and negative feedback equally well. When I tell a student something s/he did made me feel safe and supported, I can visibly see the relief on the student's face. A concrete expression of something that worked well for a patient is as valuable as a comment about something that could be improved.

• It's individual to the SP: different SPs often interpret the same behavior different ways, but express it the same way: "I liked it" or "I didn't like it." Using the X/Y format gives students more information about how their actions are being perceived, which makes the full range of patient reactions more visible.

Though I didn't learn it this way, I also often add: "If you had done A, I would have felt B" like so: "If you had asked me to move my arm, I would have felt like I had some control in a vulnerable situation." This gives students a concrete way to adjust their behavior in response, which I think is critical for good feedback.

However, it can be easy to slip into blame or projection, twisting the format into "When you did X, I felt you were being Y." For instance: "When you asked me the same question again, I felt you weren't listening to me." Assigning motive to a student often leads to a more defensive reaction. Better: "When you asked me the same question again, I felt unheard." When I want to comment on motive, I find it more effective to ask about it directly: "Why did you ask me the same question again?" After the student answers, I can almost always use the agreement technique to redirect and align our goals together without defensiveness.

Homework:
To help me practice this technique in the beginning, I created my own list of Y emotions. I also added a Z category when I needed to shape the conversation around my general values as a patient. I don't use it much anymore, but whenever I work at a new school/event I review it since something unexpected is likely to come up.

Extra credit:
Discovering the concept of non-violent communication a couple of years ago really went a long way towards helping develop the X/Y feedback skill and giving better feedback in general. I really like how it centers itself around empathy. I'm not 100% sold on the whole system, but as a feedback lens I have found it to be very useful.

Case preparation

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

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

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

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

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

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

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

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

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

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

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

The gendering of imaginary medical professionals

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

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

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

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

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

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

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

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

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

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

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

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

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

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