Open wide!
[Bartholin abdominal anatomy via wikimedia]

When I do a case that requires an abdominal exam, I am simultaneously relieved and apprehensive. I am relieved because the exam is a simple one to evaluate (unlike the neuro exam). I am apprehensive because I never know how I'll feel after a day of belly poking.

Here are some of the things I am looking for during an abdominal exam:

This is a living list. Last updated February 01, 2015.

• Draping technique: Very much like ungowning instructions, draping requires confidence, clear expectations/instructions, and a willingness to give as much control as possible to the patient. Best practice: "I'm going to lay this sheet over your legs. Please lie back and lift your gown to just below your breasts so I can examine your stomach." The drape should cover my pelvic bones (at the very least; I actually prefer my belly button) as I pull my gown up, and then be rolled back later. If the student turns his/her head away after the drape is lowered, it makes me feel like s/he respects my modesty. If a student doctor needs a clearer view of the lower quadrants, the student doctor should ask me to roll down my shorts -- the student should never try to roll it down for me or slip the stethoscope underneath. Both of those things feel very intimate and violating.
• Inspection: Verbalization is crucial for SPs (otherwise, how do we know students are looking for anything?), but I think it's a good idea for patients, too. If a student doctor uses words like "lesions" or "masses," as a patient I start to get nervous even if the findings are negative.
• Auscultation: Listening must happen in all four quadrants. I grade tough on the lower quadrants, so even if student doctors put the stethoscope down four times, if all contacts are above or at the belly button, I don't given them credit. Similarly, listening should happen on the skin, not on the drape. As always, student doctors should announce their intentions before performing auscultation. Use the word "listen" rather than "auscultate."
• Percussion: like auscultation, percussion is only valid in all four quadrants and should be on the skin. Unlike auscultation, it is crucial for the student-doctor to warn me about percussion before it happens because it is such an alarming, unexpected feeling otherwise. When warning me, "tap" is a word that makes more sense to me as a patient than "percuss." This is also true for the liver exam.
• Palpation: like auscultation & percussion, palpation is only valid in all four quadrants and should be on the skin. Like percussion, it is crucial for the student doctor to warn me about palpation, especially that one round will be light and another round will be deep. When warning me, use the word "press" rather than "palpate." Palpation tends to be the most variable aspect of the SP exam: many student are unwilling to press firmly in a scenario. So while my stomach feel less pummeled at the end of the day, I don't feel I can grade as effectively. And those student doctors who do push hard, push haaard. Can't there be something in between?
• Rebound tenderness: make it clear this is a rebound test, not another form of palpation. Push and hold for a couple of seconds, then suddenly release. Be sure to ask if it hurts more pushing down or coming up. If there is pain, be sure to ask where the pain is located: the palpated side or elsewhere?
• Abdominal aorta: the abdominal aorta exam tends to be pretty uncomfortable, even more so than deep palpation. I appreciate student doctors when they tell me that and when they tell me what they're looking for or it just seems like more random pushing on my abdomen.
• Liver/spleen: having someone hook their hands under your ribs can be both uncomfortable and intimate, so it's very important to explain before the exam. When a student doctor percusses the liver, I feel more comfortable when I know how large the area will be beforehand -- many patients have no idea how large their organs are.
• Obturator & Psoas: If I don't know why you're asking me to move my legs, I don't feel as if you understand my abdominal pain.
• Neutral hand positioning: brushing or resting your hand near my pubis or thigh during this exam is very alarming, especially if the student is of the opposite sex.
• Clear instructions & informed consent: "May I palpate your stomach?" How can I consent if I don't know what "palpate" means? How can I consent to a liver, spleen or gall bladder exam if I don't know where they are? As a patient I will say "yes" because I assume the consequences of saying "no" are worse.
• Closing: when a student doctor summarizes the findings, that helps me understand the exam is over. When a student doctor offers to help me up, I feel grateful even if I refuse the help.

Extra credit!
I did not know Saint Erasmus "is venerated as the patron saint of sailors and abdominal pain" until just now. I will think of him at my next abdominal exam.

Beyond the classroom

A medical student in the midst of medical education. SPs are the third wave from the left.
[The South Ledges, Appledore via wikimedia]

I feel bad when I read articles like "5 Simple Habits Can Help Doctors Connect With Patients" because of quotes like this:

"Our medical teachers put a premium on accuracy and efficiency, which became conflated with speed. Everything had to be fast. In 2014, doctors still value speed and technical accuracy, but we also do more to consider the quality of care we give and whether patients are satisfied with it."

As much as I love what I do and how much I value communication skills, when I read this I feel like we ask doctors to do more and more with less and less. In many medical school scenarios we have between 12-15 minutes for each scenario. What sort of meaningful connection can be made in that time? In practice, doctors can't take much more time than that or they risk disrupting an already overbooked schedule.

Also:

"Medical educators should be role models for these common courtesies... Trainees take their cues from us. These behaviors are what constitute 'bedside manner.'"

SPs are only one tiny influence in a medical student's education. What school students pick, what attitudes they arrive with, who their mentors are, their internships, their residencies, the laws they practice under, and the insurance industry all influence the kinds of medical professionals they become. Almost all of these things are outside their control, and certainly outside of mine. So yes, to be effective, medical educators should be role models. I would feel better if I knew the skills SPs teach students were being reinforced at all levels.

Brothers in Arms

The secret SP handshake.
[La Grande Armée de 1812 via wikimedia]

Hooray! I finally found another active SP blog! notmyself2day details his experience as an SP: his cases, encounters, the structure of his school and events. Tom writes with good details and references.

I especially liked this perspective: "This will be like therapy inside out. As a therapist I am usually the one asking the questions. As an SP my goal is similar to that of therapist: to enhance the student’s ability to engage in the world of human relationships successfully."

It makes me wish I had some therapy background! When I first began as an SP I approached it from an acting perspective, but I feel like I've had to develop some therapy skills over time to give effective feedback.

Making a decision

"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.