Lady Macbeth could teach us a few things about hand washing.
[Ellen Terry as Lady Macbeth via wikimeda]

One of the things I have become more aware of since becoming an SP is how hard it is to stay healthy in the health profession! Students generally can't make up scenario events, and so they enter my room in various stages of illness and fever.

So now I am much more aware of handwashing -- both theirs and mine. Since I shake so many student hands, I try to wash them between students. I am more careful about rubbing my eyes. I use a paper towel to open the bathroom door after I've washed my hands. I use the back of my wrist to shut off the water. When I handle pens or my phone I want to wash my hands. Sometimes I sanitize the keyboard I am using for checklists.  I even use the sanitizing gel more than I used to, though I primarily prefer soap & water.

When we are in flu season, my handwashing urge kicks into overdrive. But it must be working, because it's been a while since I got the flu, despite persistent contact with potentially infected students.

Discussion question
Does your school have a checklist item for "Student washed hands"? If so, what are the criteria for full credit? Can students use hand gel? Do they have to wash their hands in front of you or outside the room? Do they have to wash their hands immediately before beginning a physical exam? Etc.

Extra credit!
I once had a student in a group setting who refused to use hand gel because she claimed to be allergic to it. In this location there was no access to water. So I allowed her do the physical exam but it made me squirm. Only afterwards did I realize I should have asked her to use gloves instead.

Irregular standards: getting paid

Getting paid is always a gamble.
[His Station and Four Aces via wikimedia]

Every time I work in a new place, I feel like I have the same conversation over again, because every place does it differently and can't imagine other places don't do the same:

• Is prep time included?
• Is parking included?
• Does the time begin when the event begins or the time I am asked to arrive?
• Is training paid? Is it paid at the same rate as the event?
• Is a meal included?
• Is break time paid?
• Is the time paid between multiple events on the same day?
• Are there any additional discounts or benefits? (i.e., medical care, services, library access, network access, food?)

I keep a list of every place I work sorted by pay rate & perks so I know how to prioritize events.

Once that's been settled, every place has a different way of hiring and classifying SPs, which affects how I am paid, taxed & benefited:

• Am I considered a "real" employee? A temporary employee? A contract employee? 
• Am I paid through HR or the department? 
• Does someone track my time? Do I have to fill out a timesheet? Do I have to submit an invoice?
• Am I paid via check, direct deposit, gift card or cash? Many schools push direct deposit, but it's not always a requirement. 
• If I'm paid by check, is my check sent to me? Do I have to pick the check up? Am I sent a pay stub?
• Are taxes taken from my paycheck?
• Many places don't bother to tell SPs they have benefits, even if they do. I poke around on the school's HR site to see what's available to me based on the type of employee I am.

Every place has a different pay schedule, so keeping track of when I will be paid is a feat of mental gymnastics:

• Immediately after the event
• Two weeks after the event
• Once a month
• Twice a month
• An incomprehensible but supposedly regular schedule
• Whenever

Finally, if you're the kind of person who keeps track of your hours (and I am), it can be difficult to compare the hours per event with the hours actually paid. If you get a pay stub, some places combine your hours into one lump sum, making it harder to know whether you have been paid accurately for events that span multiple pay periods. I really love the places that pay per event because it's far easier to catch a discrepancy. I also like places that combine the events into one check but break out the hours per event on the paystub.

If I do discover a discrepancy, following up is never fun. It has to be at least a 2-3 hour discrepancy before I say anything, because nobody likes to look it up and track down the error. Anyway, it makes it interesting to do my taxes every year. Despite my best attempts, very few of the tax documents match my final totals.

Setting the standard:
An adequate standard would be one where SPs know ahead of time the answers to these sorts of questions without asking.

A better standard would make sure SPs are paid for prep time. Parking and an appropriate meal would be provided. SPs should be paid for the time they are scheduled, even if the event ends early. If the event runs over, the SP should be paid for the extra time. Break times should be paid, even if there is an awkward gap between events. Training should be paid at the same rate as the event.

A better standard would also inform SPs of the benefits they have as an employee, which means they need to be told what kind of employees they are being classified as. When possible, I would choose SPs to have as many benefits as other workers used in similar ways or with similar hours to other employees on campus.

Payment is a trickier standard because I know few programs have a lot of ability to control a process owned by HR. If the department does the payment, I would prefer to see SPs paid not more than two weeks from the event with an option for a mailed check or direct deposit. I would also prefer the department to track the time but to receive a paystub broken down by date or event to check against my own records.

If the SP program refers SPs for events to other departments, programs or institutions, there should be a clear way to be paid that does not require the SP to be responsible for figuring it out.

Would you see this doctor again?

Just one glass of wine won't affect the SP's rating, right?
[The Doctor's Visit via wikimedia]

Many checklists contain a question like this: Would you see this doctor again? No pressure!

This question works best when the evaluation is more than a Yes/No question. With a binary scale I feel compelled to mark "Yes" in all but the most egregious encounters.

But honestly, the answer is usually a little more nuanced. As a patient, I am likely to see a doctor again even if I had a pretty mediocre experience. The trouble of finding a new doctor doesn't seem worth it unless it was truly a terrible experience. So "Yes, but..." would probably be a more realistic answer for most of my patients.

Some schools offer a scale that looks more like Definitely Yes, Probably, Maybe/Not Sure, Probably Not, and Definitely Not. That feels a bit easier to pick an option that feels true for that encounter. When I use that scale, most of my students are rated Probably or Maybe. Exceptional students rise to Definitely Yes and difficult encounters, mercifully few, sink to Probably Not. Have I ever used a Definitely Not? If I'm not sure, I probably haven't, because the encounter would be undoubtably seared into my brain.

The big question is: who sees the results of this question? Would you see this doctor again is a much trickier question to answer if you know the student will see the rating directly, because who wants to be rated "No" or even "Maybe"? Fortunately, most schools I work with spare the students this ego-crushing rating. Instead, they filter it through the faculty, who can see the ratings in aggregate and compare other SP ratings for that student to see if there are any red flags they should be watching for. But I didn't know that when I was first starting out, so it seemed like the student's delicate sense of self hung in the balance between my keyboard and mouse.

Extra credit!
Some SPs mark this from the perspective of an SP, which I think is unfair. Given the SP's understanding of the case, they may mark a student down for not having done a particular medical procedure or asked a particular question they consider crucial to the case -- but I feel that the student has already been marked down elsewhere on the checklist, if so. So I only respond based on how I feel the patient I am playing would have answered the question.

Setting the standard:
If this question is asked, it should be at least a 3-point scale: Yes, Maybe, No. It should include a place for comments. Students should probably not see these directly. SPs should be aware of the outcome of this evaluative statement.

Yes, yes: using agreement in feedback

A disappointed student about to begin feedback.
[Yes or No via wikimedia]

When asking a student for self-reflection during feedback, I find agreeing with the student immediately afterwards sets a tone of mentorship and collaboration right from the start.

Whether the self-reflection was positive or negative, I can still find something to agree with: "Yes, I thought you did that well" or  "Yes, I agree that was the weakest part."

I can agree with a student even if I think they're wrong! If a student says something like "I thought I listened well" and I don't share that assessment, I say something like, "Yes, I'm glad you're paying attention to that! As a patient that's very important to me, too." And then we talk about how they could have done it better.

I have also found agreement is a useful tool when faced with students feeling quite negatively about themselves or the encounter. A natural reaction is to minimize their feelings or try to comfort/console them, but hypercritical students won't be able to hear good feedback until their perspective is acknowledged. So rather than saying "Don't be so hard on yourself!" or "No, you did fine!" instead I try to take a step back: "I understand you're disappointed" or "You seem disappointed" followed by "I know you want to [do the right thing, whatever it is]. As a patient I didn't notice that, though. What I saw was [x]." When I acknowledge the student's disappointment, they noticeably relax and we can continue with constructive feedback.

Core value: Consent

Drink this. You don't need to know what it is.
[Self-Portrait with Dr Arrieta via wikimedia]

I have written about physical autonomy as a core value before. As an SP, feedback about treating patients with physical respect seems like the very least I can do. But full autonomy is about respecting the whole patient. Either way, consent is a requirement.

Consent is only consent if it is informed consent. But informed consent is not a ham-handed attempt to shock and awe. No, informed consent is a delicate and nuanced thing. Rather than an intimidating stack of papers as thick as a brick, informed consent is a beautiful waltz of informer and informed. Rather than a mad chaos of anxiety and pressure, informed consent can be a quiet and deliberate Sunday morning. Informed consent invites inquiry and empathy rather than blame and scrutiny. Informed consent should relieve ambiguity and bolster confidence. Informed consent should ideally take as long as it damn well needs to. That's why asking "Do you have any questions?" or "Is that OK?" isn't enough.

Of course, all of that's often not possible in the constraints of an SP encounter, even the long-form scenarios. But when a student genuinely tries to include consent in an encounter, I am relieved and delighted.

A student who excels in consent:

• Identifies procedures before they happen
• Asks permission
• Waits for recognition/response
• Uses simple language to describe complex topics (e.g. AGUS, screening vs. diagnostic)
• Keeps inviting questions until I don't have any more. Consent without comprehension isn't consent. 
• Asks questions that have more than one possible answer: how can I say truly say yes if i don't know what no will mean? As a patient I will say "yes" because I assume the consequences of saying "no" are worse.
• Does not ask leading questions (e.g.: "You don’t mind if I’m touching you like this, do you?")
• Tells me the range of options, not just the worst or best one
• Confirms my understanding using "teach back" or other concrete methods

Extra credit!
I was recently asked to sign things in a hospital. I was asked to sign them without having read them first or know what I was signing for. One was for HIPAA. When I asked to read it, I was told, "It's the same thing you sign everywhere. You've been signing it since 1996 or something." In other words, "You give me permission to do everything on this piece of paper that I’m not going to let you read, right?" This is a poor, but appallingly common, example of respecting patient autonomy.

Discussion question: 
Consent can lean towards coercion when a power differential is involved. Why is that?

Getting a clue

An SP giving a clue card to a student after a heart & lung exam.
[Detail from Card Players via wikimedia]

Obviously, most SPs do not match the physical findings of the cases they portray. There aren't enough of us to specially cast in cases which include findings like heart murmurs, abdominal masses, retinopathy, swollen lymph nodes, clubbing, etc. And despite the fascinating and helpful tips in "Training Standardized Patients To Have Physical Findings," it is almost impossible to simulate these findings, either.

So I usually give student doctors a card that explains the finding after they've finished an exam which might reveal it. Each school has a different method for doing this. Students are usually visibly triumphant when they receive a card, as if they have won a prize.

However, student doctors almost never share that finding with me as a patient. Once they get a card that describes the abnormal results of a tactile fremitus exam, for instance, they continue with the rest of the exam as if nothing had happened!

I find this tremendously frustrating as an SP because they lose out on the chance to practice giving findings that are not within normal limits without alarming patients. I want them to practice offering contextualization, risk or reassurance in these situations, to help me understand why the finding relates to my chief complaint. Without that practice, they will be behind the curve when it happens to them later.

Abdominal exam checklist

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.