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."

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.