"What do you think I should do?"
[Question to the Card via wikimedia]

Too many choices makes me feel overwhelmed. As a patient, when I ask a student doctor "What do you think I should do?" there are two good options:

1. Tell me what you think I should do based on your best understanding of my needs and yours. This will make me feel as if my request was heard and I can use this information as input into the decision I will eventually need to make. 

2. Ask me more questions to help me differentiate between the options so I can more clearly choose the right one for me. This will keep me engaged in the conversation and will give me confidence and clarity when I finally make my decision.

But sometimes learners who are really trying to maintain a patient-focused interview will say something like: "Well, I can't decide for you. Only you can do that. Everyone is different." And then stop.

The intent is good, but a statement like this should be the beginning of change talk, not the end! If the conversation ends here, I will feel unsupported, guilty for asking, and less confident in the student doctor. I will likely delay the decision until meeting with members of my support network, or I will defer the decision indefinitely. So use this phrase only as a preface before moving onto one of the other two options.

Homework assignment:
How do informed consent and the power differential contribute to this dynamic? Please write your answers in the space provided below. ;)

Wrapping up

Ah, I see we're almost done here.
[A Lady in a Fur Wrap via wikimedia]

We've talked about a proper introduction, but what is a proper conclusion, anyway? As soon as I realize a student doctor is wrapping up, these are the things I am looking for:

Summaries:

• A summarization of HPI
• A summarization of relevant physical exam findings

Answers to these 3 questions in this order using plain language (even if the answer is "I don't think so" or "I don't know yet.")

• How serious is it?
• How long will I feel like this?
• What is the next step?

And finally:

• Teach back
• "What questions do you have?"
• Validation & empathy
• Farewell

How are you today?

"Oh, I'm fine..."
[Allegorical Portrait of Elizabeth I via wikimedia]

One of the questions that makes me cringe is frequently the very first question asked in an SP encounter. The student doctor walks into the room, smiles, and says, "How are you today?"

I cringe because as a patient, I have two choices:

1. "Fine." Which is totally not true, because why would I have come to the doctor if I was fine? But as a patient, I know this is the only socially acceptable answer and the one the doctor is expecting to hear. So I assume the student doctor values social courtesies more than the truth, which makes me feel anxious. I may also assume the doctor is not sensitive, empathic or present.

2. Tell something closer to the truth: "Well, not so great. That's why I'm here." A student doctor's response to this will tell me a lot about how safe I will feel for the rest of the encounter. In many cases, this mild challenge really throws them for a loop and the reaction is almost defensive. A better student doctor will acknowledge the bind of that question, which will leave me feeling relieved and safer to challenge the doctor if the need arises again.

"How are you?" is a habitual phrase that is completely unnecessary to communicate rapport or respect. In fact, because of the power differential, it does more harm than good by requiring patients to either lie  to seem like a "good" patient, or to challenge the doctor and deal with the possible stigma of being a difficult patient.

The first few minutes of any encounter are crucial to setting a sense of safety and honesty. Asking questions that only have one acceptable answer trains patients to lie. In this case, a small lie, to be sure. But lies of any kind undermine a patient's trust and may lead to self-censure.

A better opening: A proper introduction followed by either "What brings you in today?" or "I see you're here for X. I'm sorry to hear that. Can you tell me more about what's going on?"

The value of student self-reflection

So, how did that go for you?
[Jeune Femme au Miroir via wikimedia]

It was a terrible encounter. One of the worst I had ever had. And I had no idea how I was going to talk to the student about it when she returned to the room. Too much had gone wrong, so starting with the positive portion of the feedback sandwich would feel hollow to me -- and I wasn't sure if the student was going to be able to receive it well, anyway.

So when she re-entered the room and sat in anticipation of feedback... I punted. "How do you think you did?" I asked, my heart hammering. She visibly collapsed in a mixture of relief and frustration. "Oh, it was TERRIBLE!" she said. And then she proceeded to talk about all the ways she wish she had done better.

Imagine my surprise and delight: I didn't have to tell her she had done badly! She already knew! So instead of making her feel worse, I could focus my energy on addressing her concerns. What had been a terrible encounter became a very productive one and we both left the encounter feeling better.

That's what cemented my use of self-reflection as the first tool I use in feedback. Some schools probably teach this as a standard approach, but at that point nobody had told me to do it. Engaging students in a healthy dose of self-analysis has served me well for years, even in encounters that have not been as dramatically terrible.

Here's what makes it work:

• Self-reflection helps students take responsibility for their own education. When SPs immediately start with feedback, it's easy for the student to remain passive. Students who are passive in feedback are often more passive in the encounter, as well. I want students to work on their self-analysis during the encounter so that they will be in the habit when SPs are no longer there to provide feedback.
• Starting students with self-reflection allows SPs to begin with a point of agreement -- regardless of whether the student says something positive or negative, the SP can use that as a way of reinforcing or redirecting the resulting feedback. For example: "Yes, I thought you did that well, too." Or: "Yes, I also thought that was one of the weakest moments in the encounter." This helps set a tone of mentorship and respect.
• For me, this is the most important part of using self-reflection: be genuinely interested in the student's response. When I ask, "How did that go for you?" I am not waiting for a perfunctory answer so that I can launch into my own feedback. I am waiting to see where (or if) our needs overlap. If you use self-reflection but don't address what concerns the student, s/he is likely to feel unheard, discouraged and resistant to the whole concept. My motto: "Seek first to understand, then to be understood."
• Hearing specifics from students is crucial. Those specifics are what will allow you to make natural transitions into the feedback you want to give. Some students have a hard time getting beyond, "I thought it was fine!" Some are so uncomfortable they move very quickly into "But how do you think I did?" So if a student answers "fine," I follow up with a different open-ended question: "What's something you thought went really well?" or "What's something you wish you had done differently?" I will choose which one to use first depending on the student and how the encounter went. For instance, I might ask what went well if the student seems prone to respond negatively or vice versa. Building your feedback from these specifics is one of the most powerful things you can do as an SP. Students have been most vocally grateful when I have addressed something very specific for that student for that encounter. But pick just one or two things to follow up on. After all, each of us is just one of several SPs they will see. We have limited time and I would rather they feel solid on a couple of things than overwhelmed by several. This is where the feedback hierarchy comes in handy.
• Be willing to lead the feedback. Students lead the encounters, but SPs are in charge of feedback. Without guidance, a genuine self-reflection can lead to rambling. This is not a good use of limited time. If you do self-reflection right, it can look as if the student is leading the feedback, but SPs should know where they want to go while remaining responsive to student concerns and/or questions. Since our time is so limited, that means learning various redirection and transition techniques to help keep the discussion focused and progressing.

I don't think students are often rewarded for self-analysis in med school, but I consider it to be the first step towards skill improvement. So I try to encourage self-reflection in feedback whenever possible, given the constraints of the school, program, time, feedback method, etc.

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"

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.

A proper introduction

Sadly, students never introduce themselves like this.
[The Introduction via wikimedia]

Many, many checklists have an item in the communication skills section worded something like this: "Did the doctor introduce themselves appropriately?"

Well, what does that mean? How do I know whether a student deserves credit for an "appropriate" introduction? Different schools train their students to default to a particular greeting. But this form of greeting is hardly ever required, so it makes it more difficult for me to know if the introduction is "appropriate." So in the face of a non-existent standard, it means this question is almost always answered "yes" if the student says anything at all.

My personal standard for an "appropriate" introduction includes the student's first name, last name, and title: "Hi, I'm Dr. Amy Basil."

Here are some other ways student doctors have introduced themselves that would not pass that standard:

1. "Hi, I'm Amy."
2. "Hi, I'm Amy Basil."
3. "Hi, I'm Dr. Amy."
4. "Hi, I'm Dr. Basil."

It seems like such a small thing, but when you're grading 60 students over the course of a week, having a simple assessment for an "appropriate" introduction reduces cognitive overhead for SPs and makes us all standardized for the event. And without concrete standards, how can you suggest improvements in feedback?

Extra credit!
If a student doctor follows the introduction by describing his/her role in my health care before launching into questions, I feel immediately more trusting and secure in our interaction. E.g.:
"I'm a doctor here at the clinic."
"I'm your husband's doctor."
"I'm a health coach. Your doctor will be here shortly."
"I'm a member of the health care team working with you today."