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.

SP encounters are not a substitute for medical care

I hear the GU exams feel sort of like this.
[Opisthotonus in a patient suffering from tetanus via wikimedia]

It's important to recognize satire when you see it:

Standardized Patient Suing Medical School After No One Detected Prostate Cancer

I probably get between 600-800 exams a year from various medical students. One of my favorite things about encounters that include physical exams is seeing the large range of findings between student doctors. My blood pressure is excellent but every student comes up with a different number. I have incredible reflexes if student doctors hit the right spot, but less than half of them do. Very few guess my age or weight correctly. I remember one group of students was once very concerned about something that turns out to be very normal in women.

One of the unanticipated side effects of this job is the constant battle against hypochondria: is it fatigue or is it CANCER? But because I have so many exams, I feel lured into a false sense of security. Even though I know these exams are cursory at best, I also haven't been to an actual doctor in... years. I need to change that.

Feedback hierarchy

Rising to the challenge.
[Monte Cristallo via wikimedia]

SP events have very different methods for student feedback. In places where I can give written or verbal feedback, I have developed a feedback hierarchy to prioritize the limited time I have. Developing a hierarchy allows me to succinctly provide feedback that is both individualized for that particular student and yet consistently reflects my most important values.

This list is ordered in a way which increasingly incorporates more awareness of patient needs at each level. Beginning students are most likely to hear the feedback at the first levels, while advanced students can discuss the higher-level items. If I find a student is defensive in feedback, I often find those students respond better to items lower in the hierarchy.

This is a living list. Last updated January 14, 2015.

Level 1: Domain knowledge
Some schools want you to talk to students about items on the checklist, but some don't. I prefer to spend limited feedback time on communication skills further on in the hierarchy. But if student doctors make mistakes in the history or physical exam to a degree which would be noticeable to a patient, it dramatically affects patient trust and confidence. For instance, if a student doctor hurts me during a physical exam, this is the most important feedback to give. If I feel nervous about how a student doctor handles vulnerable areas like my ears, eyes, or nose, it doesn't matter how empathetic they are. If a student doctor is very disorganized or hesitant when gathering history, as a patient I will feel dubious about their competence. If a student doctor touches me in what a patient could interpret as inappropriate, that's the most important feedback to give (e.g.: a student's knees between my legs, a coat cuff brushing against my breast, etc.).

Level 2: Rapport
Many checklists have a "rapport" item, but nobody ever really talks about what that means. For most SPs, it seems to be a catchall category for "I liked the student doctor" or "The student doctor seemed friendly." But I need more specific guidelines for myself so I can give specific feedback to students. So for me, rapport is about establishing a personal connection with the patient. So when I give feedback about rapport, I comment on posture, tone, eye contact, active listening skills, the use of open-ended questions, using my name, matching my energy, jargon, and communicating sincerity. These things help me feel as if the student doctor is paying attention to me and my nonverbal cues. In addition, if a student attempts to learn/respond to anything about me that isn't medically necessary for them to know (or if they tell me something about themselves), I count that as rapport.

Level 3: Empathy
I always say "empathy first" in encounters, but if students have serious deficiencies in the first two levels, I usually address them in feedback first. To be honest, so few people use empathy regularly that many patients/SPs don't even know it's missing. So empathy is the first of the nuanced skills -- those skills which begin to sort the excellent students from the less adept students. For me, responding to a patient's emotional state is the key to empathy. So when I am looking for empathy, I am looking for student doctors to:

• acknowledge the patient's pain: during the chief complaint, when the patient describes the quality of the pain, when the patient rates the pain, or during a physical exam.
• acknowledge sensitivity for awkward or sensitive questions.
• acknowledge loss or grief: for instance, if family members have died while taking the family health history; if the patient or someone close to the patient has lost a job, etc.
• acknowledge fear or confusion: for instance, during a diagnosis or when the student uses overly technical language.

Level 4: Respect
Respect and rapport are often conflated, but I think you can have rapport without respect and vice versa. Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. The power differential really comes into play here. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race.

Level 5: Autonomy
This is one of the things I value most highly. Student doctors who promote patient autonomy prove themselves as trustworthy and make me feel safe. Unfortunately, this is the hardest category for most students because almost everything in medical school (and society at large) rewards the exact opposite of autonomy. I am especially interested in how to facilitate true consent, one where patients feel they have the understanding to make the right decision for themselves and the ability to safely refuse without compromising care. This can be as simple as asking permission to touch a patient and as complex as signing surgical consent forms. So when I give feedback about autonomy, I often comment on the basic tools of summarization and expectations management. In addition, I especially esteem student doctors who go so far as to ask my opinion or invite collaboration. But influencing the way student doctors ask questions is one of my most effective ways to improve autonomy: I want them to ask questions in ways that don't inherently limit the acceptable answers, wait for consent, and keep inviting questions until I am satisfied. Checklists don't usually have a category that would apply to this, so I often lump it into Respect. But I think it is so much bigger than that. You can respect someone but not support their autonomy.

Playing Doctor

A first-year medical student examines an SP.
[The Young Doctor via wikimedia]

"Setting the Standard" might not exist if writing about the SP experience was more common. There are very few academic articles and even fewer personal essays. The few that do exist are single stories that generally approach the SP world from a outsider perspective, almost astounded: can you believe a job like this actually exists at your local medical school?

So I was delighted when I discovered the McSweeney's series "Playing Doctor" a few years ago. Robert Isenberg was the first author I found to write about the strange and wonderful complexities of being an SP in ways I recognized in my own life. I felt validated and inspired.

The Joys of Sickness & The Curious Case Of Trebor Grebnesi are the most spot-on at communicating the day-to-day experiences of SPs. As the series progressed I was looking forward to reading more. But my delight changed to sorrow when half the posts were suddenly removed and the series ended far too quickly.

Writing about your job on the internet carries inherent risks, and writing about students is twice as tricky. I'm a strong believer in boundaries. I believe in HIPAA and FERPA. But despite the care Robert apparently took ("all names, and many details, have been changed to protect student privacy") it wasn't enough.

So I am writing the blog I want to read. I hope to balance what is true for me with what is safe to write. But I also hope to find more voices and more experiences. I want to encourage SPs to write about what they know. I want to make a safe place for SPs to express themselves. If one of our primary skills is interpersonal communication, we need more of it, not less.

Core value: Physical Autonomy

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.