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

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

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

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

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

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

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

Homework assignment:

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

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

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

The Name Game

Banana fana fo-fatient, mi mi mo-matient
[Detail from the Babenberg Family Tree via wikimedia]

One of the hardest things about the first case in a series of SP encounters is during the introduction. "Hi, I'm Student Doctor Soandso, and you are...?" as they extend a hand.

For someone who can memorize 60-80 different checklist items for a character, when I am asked that question the first time, sometimes my mind just goes blank. And it's terrible because it's right at the beginning of the encounter: if I make an obvious mistake on MY NAME, something any real patient knows by heart, the student will have a much harder time engaging fully with the scenario.

Sometimes I play for time: "I'm sorry, what did you say? Oh, I thought you said 'your car'! Ha ha!" while thinking furiously. If I really can't remember, I make up a name and resolve to look up the real name between students. Getting the name right can be important because many cases are known not by the symptoms but by the character name, e.g. the "Andrea" case.

Some cases don't include names at all, so you get to make them up. I have a series of names I remember based on age bracket, which is especially useful if I have multiple cases in a day. (I finally have a use for all the mistaken names people have called me over the years!) Then I use an historic family surname. So if I'm stuck, one of these names readily pops to mind. I also have a consistent series of names and ages for a combination of up to 5 children, grandchildren, spouses, and pets. I think it is distasteful when SPs (or even faculty members) create names that are punny or based on celebrity/character names. It makes it harder for the student to take the case seriously.

One school I work with has a policy of introducing the patient by both first and last name so that the student is prompted to ask what the patient prefers to be called. But otherwise I just introduce myself by whatever I think the patient would use, which is usually the first name unless the patient in this case would be older or more formal for some reason. However, if a students enters and asks if I am "Mrs. Smith" when the case has not specified I am married (or has specifically specified I am divorced), then I call them on that gendered/social assumption.

I prefer case names when they are gender neutral. Even so there are some names that students assume are a particular gender and they are surprised when they open the door to find I am not the expected gender. Once, a student was so flustered by that he said he was going to complain! "They'll be hearing from me about THAT!" he declared.

Extra credit #1:
I always feel better when students use my name in a scenario: it gives them a boost in the "rapport" category. Transitions are great places to use a patient's name: between the history and the physical exam, between the physical and the conclusion, or during a summary statement.

Extra credit #2:
If a case doesn't include a birthdate, just an age, it's always a good idea to create one because many times student doctors will ask (and I can't do that calculation on the fly). That's also something patients know by heart, so any hesitation grinds the scenario to a halt. That can require tricky math depending on the current month vs the birthmonth, so I almost always pick a birthdate in early January so simply subtracting the age from the current year works out.

Really quick

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

Role reversal

Who is the student and who is the master?
[A Teacher and his Pupil via wikimedia]

Adam Bitterman proposes a "reverse" SP scenario where actors pretend to be doctors and students pretend to be patients as a way to enhance student empathy and etiquette. How fun would that be? I would start by creating five encounters with different types of doctors and a very simple history for students, so that the student experiences the way different doctors can affect the same patient with the same case.

I can imagine many ways it could be enlightening. I also see some ways that medical students would still have trouble empathizing with the experience of most patients. For instance, technical jargon wouldn't make students feel stupid. Students would still likely anticipate the exams being performed, and so never experience the frustration of unclear instructions. Students are unlikely to feel as nervous or ashamed of their bodies as patients do when being exposed or asked personal questions.

Still, it seems like a worthwhile experiment to reinforce good habits, especially paired with some self-analysis exercises. In what ways do the students resemble or respect the Standardized Doctor in the scenario? What did the SD do that caused them to be uncomfortable? I would love to see a checklist of SD communication skills that the student "patients" fill out.

Pain scales

Ideally, when I am portraying a patient in pain, my portrayal will give student doctors a clue as to how much pain I am in. But students are also trained to ask the classic question: "Can you rate your pain for me?"

Classic universal pain scale via nshealth.ca.
[click to embiggen]

Above is the classic pain scale. However, instead of saying "zero being no pain and 10 being the worst pain possible" students often say, "where 0 is no pain at all and 10 is the worst pain you've ever felt." I always think this is a little limiting, because the scale could change for each patient depending on how much pain a patient has experienced in a lifetime. For instance, a patient who has given birth may rate an ankle sprain at a 6, whereas someone who has sprained an ankle may rate it a 10 if nothing else worse has happened to them. Cases are written so that all patients give the same rating, but when the question is asked this way, as an SP I always have to think about it: what is the worst pain I've ever felt? (Pulmonary embolism, in case you're wondering.)

Sometimes, student doctors will simply ask "Can you rate your pain on a scale of 1-10" and I have learned to ask "Is 10 bad or is 10 good?" to remind them they haven't given the patient a complete scale. Because outside of the simulation, if a doctor doesn't clarify, the patient may give what s/he considered to be a reasonable guess, and the doctor may get incorrect information.

Badly written cases will often only have one pain rating attached even though the pain has changed over time. So if  student doctors ask questions like "What did the pain start at?" or "How long has it been at a 4?" as an SP I always wince and guess. The rule of responding to cases that don't have a definitive answer to a student question is that the answer is either "no," "I don't know," or that the answer won't affect the case. But I certainly feel like a better SP and more standardized when I know the answers to good questions.

I say our affect should be an indicator to the patient's pain level, but only one school I work with attempts to standardize SPs to portray pain based on the case rating -- and then usually only for the really important cases that could affect a student continuing with the program. This can make it more difficult for student doctors to interpret my pain, because other SPs may portray a 6 less seriously than I do. Some students may feel I am "overacting" if I portray a 6 with a "wrinkled nose, raised upper lip, rapid breathing," even though that's the official pain scale.

However, my favorite pain scale is from Hyperbole and a Half:

0:  Hi.  I am not experiencing any pain at all.  I don't know why I'm even here.
1:  I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.
2:  I probably just need a Band Aid.
3:  This is distressing.  I don't want this to be happening to me at all.
4:  My pain is not fucking around.
5:  Why is this happening to me??
6:  Ow.  Okay, my pain is super legit now.

7:  I see Jesus coming for me and I'm scared.
8:  I am experiencing a disturbing amount of pain.  I might actually be dying.  Please help.
9:  I am almost definitely dying.
10:  I am actively being mauled by a bear.
11: Blood is going to explode out of my face at any moment.
Too Serious For Numbers:  You probably have ebola.  It appears that you may also be suffering from Stigmata and/or pinkeye.

This scale is the one that most closely matches how I actually feel about pain in my own life. Honestly, if I rate something as a 9, I want the doctor to know I feel I am almost definitely dying. Few people go to the doctor unless the pain is at least a 3 or more. So even though a 3 is considered "mild" pain in the classic scale, it's significant enough to drive the patient to see a doctor. In other words, the pain is bad enough for someone to miss work and/or pay a lot of money to address it. At that point, no pain is "mild" pain, in my opinion. As a patient, one of my biggest fears is that the doctor won't take my pain seriously. I worry they may think a 6 is mild, even though, as the Better Pain Chart shows, I feel like "my pain is super legit now."

Sometimes, students describe the pain scale "where 0 is no pain at all and 10 is the worst pain imaginable." When they do, I smile to myself and think of this xkcd comic:

[click to embiggen]

I can imagine a LOT of pain. Cases always have pain ratings attached to them that won't fluctuate based on how students ask this question, but when the scale is described to me this way I think, if I were a real patient, I would drastically revise my estimate downward.

Extra credit!
If students ask about the ADL scale right after the pain scale, it can be very confusing for patients because the scale is reversed. When that happens, I think it's better to ask about it as a percentage than a single number.

Further reading:
McSweeny's has a delightful article about SPs being trained to simulate pain. Wish more schools did this!

Postscript (Jun01.2020): 

When the coronavirus devastated the profession, this pain scale felt especially appropriate:

Neuro exam checklist

Looks pretty simple, doesn't it?
[from Bell's Explaining the Course of the Nerves via wikimedia]

In the "classic" SP encounter, I am tasked to memorize a case, act it with the students, keep track of what the student is or isn't doing while in the encounter, complete a checklist after the student leaves, and then give feedback to the student after the checklist is complete. Wash, rinse, repeat up to 20 times a day.

Of those types of cases, the hardest one is the neuro case, because the neuro exam has so many things to remember. Most physical exams have a limited number of discrete actions on a small segment of the body. The neuro exam, however, is literally head to toe. A complete neuro exam can include as many as 40 items -- on top of memorizing the history and communication checklists!

And for patients, the neuro exam is often the most obtuse exam. The other exams are generally pretty obvious: if I come with stomach pain, I expect the student to do an abdominal exam. But neuro exams can be used for several cases, including headaches, seizures, palsy, strokes, hypertentions, stress, cardio, confusion, etc.

So when students don't explain what they are looking for, parts of the neuro exam can feel like complete nonsense. My doctor wants me to do what? And what does it have to do with the problem I came in for? Without appropriate expectations management, this can erode my trust and confidence in the student doctor. Plus, since students primarily practice on each other, they anticipate the next step in the process and forget the patient doesn't know it. So when I give feedback after neuro exams, it's primarily focused on expectations management, autonomy and consent.

Here are some of the things I am looking for during a neuro encounter:

This is a living list. Last updated Apr09, 2014.

• Associated symptoms: When students ask only about associated symptoms, I have learned to say "Like what?" so that I don't inadvertently give something away. When students ask about "auras" without explanation, as a patient I find that really confusing, and I may suddenly wonder if I am visiting a New Age doctor instead of an MD. When students ask about "visual changes" I don't know how to answer unless they give examples.
• Eye movement: students almost always forget to tell me to follow the movement of the pen with my eyes only. If they tell me to follow the pen, I move my whole head and wait to see if they notice. Some don't -- which means I can't give them credit for doing an H exam. Most do, and when they stop to give me clearer instructions without apologizing, as a patient I often feel both embarrassed and annoyed.
• Checking visual fields: If a student asks "Do you see my fingers?" I turn my head to look at them. Yep, I see them. Tell me where to look if it matters!
• Shining a light in my eyes: tell me where to look. If you don't have to use the very brightest setting, please don't.
• Examining eyes with ophthalmoscope: tell me where to look. Also, tell me you're going to get so close to me before you do, or I might start backing away. Never touch my lips with your finger to brace yourself. If you're going to use my forehead to brace yourself, warn or ask me before you do it. If you're going to lift my eyelid up, definitely warn me -- but I recommend checking without lifting first to see if you can get what you need in the most minimally invasive way.
• Using a Snellen chart: if a student asks me to "read the smallest line" I read the text on the bottom of the card. Be specific if it matters!
• Checking hearing: I feel more comfortable if I am able to cover my ear rather than the student doctor doing it. If I can see the student doctor's hands while they rub their fingers together, that can affect the outcome of the exam. If a student doctor rubs their fingers together but doesn't ask me if I hear it, I do not respond. I really appreciate when students use words like "taco" or "raspberry" during the whisper tests rather than "ABC" or "123." I feel more comfortable during the Weber or Rinne tests when the student doctor clearly explains why and how they are using the tuning fork.
• Facial expressions: This is the part of the exam where I feel like I'm on Candid Camera. Tell me why you want me to make funny faces for you. Do not use the words "innervate" when you do. Some variation of this is fine: "I'd like to test some nerves in your face, so I'm going to ask you to make a few funny expressions. Can you [smiles/frown/etc]?" If the student-doctor does it with me, I don't feel quite as ridiculous. If the student-doctor asks me to puff out my cheeks but does not tell me to keep them puffed as they push them, I will let them collapse -- which sometimes leads students to believe there is a finding when there isn't.
• Opening eyes against resistance: Quite often, students ask me to close my eyes and then try to open them without warning me. As a patient this Freaks. Me. Out. Feeling fingers against my closed eyes is very alarming because eyes are so vulnerable. But here's what's worse: opening my eyes as the student is reaching for them because as a patient I didn't know there was more to the test beyond closing my eyes. Either way, as a patient I WILL flinch. If done inadequately, this test can make me feel extremely vulnerable and unsafe with the student doctor. If it has been prefaced by other tests that have affected my trust, this one has an even bigger impact.
• Checking for sensation: "Can you feel this?" is not the same as "Does this feel the same on both sides?" And if you just ask "Does this feel the same?" I am likely to say, "The same as what?" unless you've specified comparison on both sides. When student doctors don't warn me before checking for sensation on my arms/legs, it can feel a little creepy, especially when the person is of the opposite gender. When checking for facial sensation, if a student reached towards my eyes before telling me about the facial sensation test, I will often move my head because as a patient I have no idea why they are reaching for a vulnerable area.
• Tongue deviation: "Stick your tongue out" can feel weird unless the student explains why (hopefully as part of the facial expressions). If you want me to open my mouth, tell me. Also, "Wiggle your tongue around" is not the same as "Move your tongue from side to side."
• Gag reflex: Schools have a lot of different policies on this. Some specifically ask student not to do it, some ask the SPs to fake a gag reflex as soon as it is clear that's what the student is testing for. And sadly, some actually want their students to actually test the gag reflex. I have a lot of tolerance for internal exams, but when that happens I fake the gag reflex immediately.
• Resistance tests: I feel very strongly that all resistance tests should be framed simply as "Push/pull against me" rather than "So I'm going to try to put your [body part] into [a position]. Don't let me." or "Resist me." The negative instruction makes me spend an extra second or two trying to figure out what the student doctor wants me to do. Additionally, it makes it much harder to when the actual test begins, because students are generally already holding my body in the position they want me to resist before they finish the instruction. It's as complicated to write as it is to work it all out on the table.
• Shoulder/neck resistance: With shoulder resistance, students often start by pushing down on my shoulders and when I don't automatically push up, they then have to explain the test. Sometimes they will tell me to lift my shoulders up and then push down on them -- without telling me to resist, so I let them push me down. Some students interpret this as a positive sign. The easiest way to perform this test is for the student to push down on my shoulder and say, "Please shrug your shoulders." Relatedly, if a student asks me to "Turn your head into my hand," as a patient I don't know whether they want me to rotate my head or tilt it towards my shoulder.
• Leg resistance: Don't ask me to push up both thighs against resistance at same time. Seriously, have you ever tried that? Do one at a time.
• Sharp/dull testing: For goodness sake, demonstrate sharp/dull testing once on my arm before going through the whole thing so I know what to expect. This is a million times more important if you're going to do it on my face. Also, do not be surprised when different parts of my body are more sensitive than others. That does not indicate a positive finding -- it just means jabbing me on the top of my foot with the same force as the outside of my thigh hurts more because the nerves are closer to the surface of the skin. If you are too tentative with your sharps, though, you may get false dull patches -- as an SP I am dying to tell you when that happens, but as a patient I just assume that's part of the test. If, as a patient, I have findings during a sharp/dull test, I often act surprised unless the patient has already observed it in the case history. That often prompts students to check again -- and if I give them an answer they expect, they cannot resist saying "yes, that's right." If the school has the student use a safety pin (?!!!) and the student has not shown it to me but I see it after the test, as a patient I will feel alarmed and betrayed. If my hand is not in the right position and a student moves it into position without asking while my eyes are closed, I will feel especially vulnerable.
• Reflexes: The thing I hate most about reflex testing is that almost every student grabs my arm without asking me or telling me why -- and I hate it even more so when they grab my hands (thumbs up). Moving a patient without their consent violates bodily autonomy, and as a patient it teaches me you do not value my consent. It is SO EASY and vastly more respectful to ask "Could you please place your arm here [indicating their own arm and waiting]? Okay, now relax your arm." Also, as an SP I have excellent reflexes (in both upper & lower extremities), so it is disheartening to discover lots of students are not able to elicit my reflexes correctly.
• Point-to-point and Rapid alternating movement: When students don't explain rapid alternating movement, I feel like I'm playing a child's game. This is especially true for the finger-to-nose test: as a patient, I wonder if the student doctor think I'm drunk.
• Orientation questions: When students ask me orientation questions without explanation, it seems unnecessarily ominous and obscure. Some are at least aware enough to say, "I'm going to ask you some silly questions." But rarely do they say why. Try "...to rule out anything serious." Afterwards, I would feel relieved if I was jokingly congratulated for passing this most obvious of exams.
• Gait and balance: "Hop off the table" seems a bit too informal for my tastes. Clear instructions about how to walk and how far to walk and why make me feel more comfortable.

Extra credit!
Because the neuro exam has so many items, students often feel rushed. That makes me feel anxious. As the exam progresses, the accumulation of abrupt and opaque exams can foster distrust -- which makes me feel even more anxious and cautious. And the more time student have to spend explaining or re-explaining the tests, the more rushed they feel. So the more students can pre-invest in finding simple ways to explain and manage the neuro exam for SPs, the faster and easier it will be for everyone, including the patients they see later in their careers.

The power of the power differential

Everything looks so... small from up here.
[Jupiter Weighing the Fate of Man via wikimedia]

When we go to the doctor we are at our most vulnerable. We are vulnerable because we are sick and we are vulnerable because we are at a loss for medical domain knowledge. This gap between knowledge and helplessness is the power differential between doctors and patients. The more pain a patient is in, the larger the gap.

The emotional heart of power differential is fear. As a patient, I have a huge incentive to say things which make the doctor think well of me for fear I might jeopardize the care I need otherwise. If I worry about being judged, I won't feel safe. Some patients will respond to the power differential with deference, while others will be defensive. Either way, doctors who are willing to examine their own power dynamics will enhance security, honesty and shared understanding with their patients. So when I give feedback to students about communication skills, I frequently focus on things that reduce power differential.

This is a living list. Last updated June 29, 2014.

What increases power differential:

• Technical language: As a patient, if I can't understand the student, I will feel ashamed and stupid. In response I can attempt a reasonable guess, let it slide, or ask a question. Because patients often see doctors as authority figures, asking a question can feel confrontational. Comprehension (and the desire for confrontation) fails at a rate directly proportional to pain.
• Body language: Formal body language and sitting far away enhances the power differential between us. A clipboard can sometimes feel like a shield if the student has a death grip on it or spends more time looking at the notes than at me. Some students, in order to demonstrate active listening skills, lean forward too aggressively, making me feel scrutinized instead of supported.
• Taboo topics: when students assume they can ask sensitive questions without appropriate framing, they are taking advantage of the power differential. Topics include sex (cheating, STIs, abortion), alcoholism, depression, etc. For some patients, this can even include topics like urine and bowel movements. The more taboo the topic, the more important it is that the student doctor communicates safety and acceptance.
• Physical exam: The power differential is at its most obvious during the physical exam, especially if any part of my body is ungowned. Bodily autonomy is, in my opinion, a primary and absolute right. When students move me without asking me, or when they don't tell me what they are going to do before they do it, or when they give me unclear instructions (and then show surprise when I don't do what they expect), that makes me feel violated and frustrated. Compassion should not end when the physical exam begins.
• Command language: When students ask if I have been "compliant" with prior instructions during an encounter, I immediately feel judged and unworthy. Even in feedback, when I hear that my character was "non-compliant," I flinch. Compliance has power differential built into the word itself: the doctor gives orders, the patient obeys. Similarly, when a student doctor refers to my "complaint," the word implies a value judgement and I worry the student doctor isn't taking my concern seriously. The same is true if the student doctor at some point mentions "denies [pain, loss of consciousness, past medical history]." To hear that I have "denied" something sounds as if the student doctor doesn't believe me.
• Unbalanced speaking ratio: when the provider speaks much more than the patient does, that's a reflection of the power differential.
  
  
  

What decreases power differential:

• Empathy: When a student offers empathy at the pain I am currently experiencing, I can stop worrying about whether the student thinks my issue is serious enough to merit attention.
• Validation: When a student validates my choice to come in, I feel recognized and empowered.
• Normalization: When a student normalizes my concerns, I feel less alone and more accepted. Without empathy first, though, it can feel dismissive.
• Body language: open and relaxed postures help decrease the power differential, but being too familiar can have the opposite effect. A good rule of thumb is to sit close enough so that if we both reached out an arm we could touch.
• Rapport: when a student wants to know something about me that isn't medically necessary, that makes me feel like more of a person. When a student remarks on something we have in common, then I feel more connected. Being too familiar with a patient too quickly it can have the opposite effect, but a good rule of thumb is 1-2 remarks per case in which the patient is a new patient.
• Autonomy: When a student gives me a choice, I feel respected. Whenever a student specifically acknowledges that I am a person who might have her own needs, expectations and feelings, I am relieved and feel more in control.
• Manners: using "please" and "thank you," especially during the physical exam, makes me feel respected.
• Reflective language: When a student uses the same words and terms I use, I feel we are sharing the same reality.
• Summarization: When a student summarizes what s/he has heard at the end of the history and asks me to verify it, I feels as if my opinion about my own history matters. This sounds obvious, but as a patient it can too often feel as if my words fall into a black box and I have no idea if what I'm saying is actually what's being heard. Being specifically invited to correct the doctor is a very simple and elegant way for a doctor to redistribute power. Transparency also helps even the power dynamic, and summarization is one of the best ways to demonstrate it within the context of the encounter.
• Accommodation: whether the student doctor asks my preferred name or whether I want the lights dimmed when I have a headache, accommodation demonstrates a willingness to adapt to the patient's needs. Accommodation also means physical self-awareness: if it hurts to turn my neck, the student doctor should sit where I can see him or her comfortably. If I have to adjust myself to accommodate the doctor, that reinforces the power differential.
• Ownership: when I am allowed or expected to contribute to the treatment plan, I am able to more fully integrate it to fit my actual life, making it more likely I will follow the recommendations.
• Asking permission: when I am asked permission to be touched, especially in painful, vulnerable or private areas, I feel more respected and safe.

Basically, reducing power differential is a way to reduce vulnerability, fear and shame in patients. Reducing power differential enhances trust, confidence and respect.

Extra credit! 
Power is different than authority: discuss.