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."

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!

Tell me about yourself

I don't think you're going to like the answer.
[The Enchantress via wikimedia]

Sometimes innocent questions can come with a lot of built-in assumptions. That's why it's so important to establish trust and safety first. If a patient has a hard time answering what you think should be an easy question, there's probably a good reason.

"Tell me about yourself," they say as we begin. 

"Tell me about yourself," they say, and lean forward in their chairs, smiling. 

"Tell me about yourself," they say, as if we could have anything in common.

"Tell me about yourself," they say, not hearing the cracking of the earth, not seeing the way the light has been suddenly swallowed by the deep canyon that appears between us. 

"I don't know. What do you want to know?" I say, stalling for time, feeling my heart pound, feeling distant and alone, not knowing when they'll be ready to hear that my alcoholic father beat me and kicked me out of the house in high school. Not wanting to remember the first time I traded heroin for sex. Wishing I didn't have be on guard every second of every day and especially here when I just came in to fix my headache and I have no idea where my doctor is or who they are or what they're doing here and how long I have before they show pity or disgust, both of which will destroy me. 

"Oh, tell me anything." 

Like, how I sleep on the streets at night? How much I drink? How I almost went to prison for stealing a car one night? How every cell in my body felt like it was vomiting for three months straight when I tried to come clean two years ago? How I still miss my 9th grade girlfriend who was sweet and clean? How I feel I'm living on borrowed time since I turned 30 and I dream of making something good in the world that people will like, even if it's just cookies in a bakery? 

"I don't know. I'm pretty boring I guess."

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.

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.