Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

History lesson

A senior faculty member observing an SP encounter.
[Man Holding a Caduceus via wikimedia]

Happy New Year! For Christmas this year I got several SP books, so expect to see quotes/reviews in the future from such thrillers as "Coaching Standardized Patients, "Training Standardized Patients To Have Physical Findings," "Objective Structured Clinical Exams," as well as the new SP classic "The Empathy Exams."

But first I wanted to direct your attention to an article by the esteemed Peggy Wallace: "Following The Threads Of An Innovation: The History Of Standardized Patients In Medical Education" published in 1997. How delightful! I appreciate having an authoritative source to refer to. Here's a brief summary:

"Today, as we enter the new millennium, the standardized patient has become one of the most pervasive and highly talented of the new methodologies in medical education. It was certainly not always so. The standardized patient was anything but welcome and readily excepted educational tool, especially in the early days." Though the use of SPs began in 1963, it was not until 1985 that the traditional OSCE begin to integrate SPs, and even then its dissemination was slow. National boards (USMLE Step2) didn't incorporate SPs until after the article was published!

There were 3 primary contributors to the standardized patient field:

* Howard S. Barrows was the first to use SPs at USC. "Almost never was there a student whose clinical skills were evaluated as unsatisfactory because the faculty almost never directly observed the student with patients. In fact until the advent of standardized patients, there was no objective clinical measure by which to evaluate students." It's fascinating to learn that Barrows went on to teach at McMaster University, which has similarly transformed medical applicant interviews through the MMI. While at McMaster he developed the small group format and the use of USPs. He developed ways of simulating difficult findings on SPs like bruits and pneumothorax. He was the first to develop encounters with difficult patients: seductive, angry, inquisitive, etc. 

* Paula Stillman created specific checklists at the University of Arizona. For instance, what does "examine the eye" mean, really? Stillman could tell you 20 things a student should do to examine an eye that nobody had bothered to standardize before. In addition to using SPs as a body and an evaluator, she also used SPs to teach those skills: "They knew nothing about medicine. They were strictly process people." And yet still effective, I imagine, with the appropriate training! She was the first to begin working with patients with actual physical findings (only one school here does that). 

* Robert Kretzschmar began using SP models as "gynecological teaching associates" in 1968. At first they were just bodies with a sheet obscuring their face and without commentary or feedback, but Kretzschmar expanded the teaching & communication roles for GTAs in 1972.

Things which did not come to pass:

* "The 'patient instructor' might become a necessity rather than a luxury --  and Standardized Patients might be even more extensively needed for clinical learning and self-assessment as the pool of teaching faculty dwindles." (Not without better training!) 

* "And what about the practicing physician, or the one who has lost his license to practice? Might not the standardized patient be able to support the physician in new learning... [making] it possible for the physicians-in-trouble to relearn?" (While I would love to see more of this, I only know of one program that works with physicians-in-trouble and it's a very small, closed group.) 

* One of the interesting skills that seems to have been lost over the years is the use of "stimulated recall" after the encounter. SP feedback can be great, but I imagine reviewing a video of the encounter with an expert guide to ask you questions at specific points would be incredibly effective. (I try to do something similar in my feedback -- e.g. "What were you thinking when X happened or when you asked X?" -- but I'd like it to be a standard tool for schools to use when appropriate.)

Thank you, Peggy Wallace, and thank you, Barrows, Stillman & Kretzschmar! As Wallace concludes, "May that golden rod, now firmly planted, continue to inspire winged ideals in the midst of the inevitable conflict of the opinons that will create the fertile soil for sustaining educational efforts as the search goes on for a better way to support the healers of today – and nurture those of tomorrow."

Awkward handwashing techniques

An SP waits for the student doctor to finish washing her hands.
[The Sisters via wikimedia]

The introduction sets the tone for the rest of the encounter. When a school requires hand washing for credit, there are two potential moments of awkwardness depending on how the student chooses to wash their hands:

1. If the student uses sanitizing gel, they almost always use too much. Then they either spend a lot of time trying to rub it in, or they shake my hand with their slimy hand. With the first, I lose confidence in the student in the same way as I do when a student uses a tool incorrectly. With the second, I lose trust because shaking a slimy hand is disgusting and it makes me feel that either the student doesn't know that -- or doesn't care about my discomfort. 

2. If the student washes their hands in the sink, there is frequently a long pause while the student says nothing and has their back turned away from me. That makes me feel disengaged. If the student attempts to fill that gap with rapport building, an overview of the encounter, or a review of the doorway information/chief complaint, I feel that time is being put to better use and I have more confidence in the student.

Setting the standard:
To limit awkwardness at the beginning of the encounter, I highly recommend students practice how much hand gel to use to be both clean and efficient. If washing hands in the sink, I highly recommend students practice the ability to talk and wash at the same time.

Joyeux Noël

An SP singing at the holiday party.
[A Christmas Carol via wikimedia]

Whatever you celebrate, may your holidays be both merry and bright.

Communicating sincerity

A student-doctor demonstrating sincerity during an encounter.
[Sterne and Grisette via wikimedia]

I feel strongly that feedback is most effective when it rests on a foundation of observable behavior and offers a concrete way for the student to attempt to fix it.

This can be especially difficult for vague skills like empathy, rapport and respect. Because even if a student doctor knows to say the right thing -- "I'm sorry to hear that" to express empathy, for example -- sometimes it doesn't sound sincere.

So what does that mean? Without concrete observations and recommendations, it's not very helpful to say to a student, "When you said 'I'm sorry to hear that,' it didn't seem sincere" and leave it at that. But it's taken me a long time to really feel like I can describe what sincerity looks like in a helpful way.

So for me, sincerity is when verbal and nonverbal cues match. There are several cues I look for when gaging sincerity:

Eye contact: Does the student maintain or engage eye contact when speaking? If the student is looking away while speaking, or abruptly looks down right after or even while speaking, I will feel as if the student doctor is not sincere. However, if the student looks up and engages eye contact with me while speaking, I am more likely to feel they are sincere. 

Tone: When speaking, did the student's tone change? If the student offers an empathetic statement with the same tone as they use to ask about past medical history, I will feel as if the student doctor is not sincere. 

Expression: Did the student's expression change? Did they raise/lower their eyebrows, blink, tilt their head? Are they smiling or frowning? If the student's expression doesn't change when delivering bad news, expressing empathy, or attempting rapport, I will feel the student doctor is not sincere. For instance, if the student-doctor smiles widely while saying "That's terrible!" I will not feel s/he is sincere.

Rate: Does the student doctor pause for a moment after expressing empathy, or barrel right onto the next question without a breath? Does s/he rattle off "I'm-sorry-to-hear-that" all as one word? If so, that will feel less sincere.

Non-verbal vocal expression: Does the student add a non-verbal vocal expression like "ohhhh", a tongue ticking against teeth, or a sharp inhalation when offering empathy? Do they say "mmm-hmmmm" when attempting rapport or engaging in active listening skills? Those are signals that indicate sincerity.

Posture & Movements: Does the student's posture & movements match what they are trying to communicate? For instance, if we are having a personal discussion, is s/he all the way across the room? Checking their watch? Did they shake their head or nod appropriately? If the student is trying to communicate something serious but is slouching on the stool or leaning against the wall, I will feel the student doctor is not sincere. 

Energy: Is the student matching the patient's level of concern? Are they using a similar rate, volume, emphasis as I am? If the student seems much more upset than I am at a parent's passing, for instance, I will feel the student doctor is not sincere.

Setting the standard:
If the checklist asks me to grade a student on skills like empathy, rapport or respect, I prefer to give them full credit only when they seem sincere.

Empathy vs. sympathy: an animation

I loved this animation about empathy (one of my core values!). Student doctors are often so uncomfortable with my emotional discomfort that they want to fix or minimize those feelings. As a patient that often makes me feel worse, as if I am not allowed to be emotionally honest with my doctor. Then I feel like I have to take care of the doctor rather than the other way around.

According to the video, empathy includes:

• perspective taking
• staying out of judgment
• recognizing emotion in other people
• communicating that emotion

I like how this expands my view of empathy and gives me more ways to talk about it with students. I especially love when the video points out the use of "At least..." as an empathic terminator.

Homework:

Listen for ways your emotions are being received or deflected over the course of a week, even (especially?) by people you are close to. How does that make you feel? What would make you feel better?

Feedback models: Feedback Sandwich

The Earl of Sandwich has something to share with SPs.
[First Earl of Sandwich via wikimedia]

Some schools have defined formats for feedback. Many offer open feedback, though: several minutes of wide open time after an encounter to give feedback however the SP sees fit. This can be an incredibly powerful tool -- and completely overwhelming to new SPs.

One easy method to follow for SPs without a lot of experience, or ones who are just starting to refine their technique, is the Feedback Sandwich. It looks like this:

Layer 1: Something the student did well. Save your really good feedback for Layer 3. This is an excellent time to comment on basic skills like active listening, empathy, rapport, pacing, etc. 

Layer 2: Something the student can improve. It is important that this layer is not the largest layer! This layer is most effective when each item contains a recommendation for how to improve. If this is the sort of event that includes multiple encounters for the student, they should be encouraged to practice improving this skill in the very next encounter. 

Layer 3: Something else the student did well. Since this will be the last thing they hear, make it count. Encourage them to keep doing whatever it is they're doing well. Students are often so overwhelmed that SPs can do good in the world just by reminding them they are, in fact, doing well. Sometimes the skills that come most naturally to students can diminish over time because nobody remembers to notice them.

Each layer of the Feedback Sandwich should include concrete examples of observed behaviour during that encounter to illustrate the SP's feedback.

The strength of this format, especially for new SPs, is that it helps focus the feedback rather than jumping around to whatever random thing the SP thinks of next. It creates a basic structure to habitualize observing concrete behavior and balancing the ratio of positive to "negative" feedback. In addition, this can be an especially useful format in scenarios with a very limited amount of time (3 minutes or less): just adjust the number of feedback items per layer to the amount of time you have.

Some people hate the Feedback Sandwich (it's definitely not my favorite). That's okay. It's still a good place to begin. As the SP becomes more comfortable with the Feedback Sandwich, the SP can begin to deviate from this to other models.

Extra credit:
I had no idea Hawaii used to be called the "Sandwich Islands!" I imagine feedback sandwiches on a tropical island would be much more conducive to constructive conversations.