An SP attempts to answer an open-ended question.
[The Open Door via wikimedia]

Ideally, student doctors should ask SPs open-ended questions at the beginning of the encounter and then move to more focused ones. For instance, after introductions, a student doctor should ask something like, "So what brings you in today?" to elicit the patient's chief complaint.

In real life, a patient is very likely to spend the next 18 seconds describing their chief complaint. However, SPs are usually given a pretty simple opening line, like "My eye hurts" or "I passed out" or even something like "I haven't felt like myself lately" for psych cases. This opening line is meant to minimize and standardize the amount of information SPs initially give to students. It usually prompts students to move into close-ended HPI questions like "When did that start?" or "Can you show me exactly where it hurts?"

Sometimes, though, a particularly astute student will ask another open-ended question: "What's been going on?" or "Can you tell me more about that?" I have rarely received a script that includes how to answer that question. It seems simple, but there are two tricky parts:

• At programs that use a checklist for evaluation, as an SP you can't use any of the checklist items to answer that question! A real patient might say, "Well, I'm having really sharp pain behind my right eye that's been going on for four days now." Which means a student wouldn't need to ask about Onset, Quality and Location then. You can't evaluate a student on questions they already have information about, so the student would receive credit for those items.

• It is unlikely multiple SPs will answer that question in the same way, meaning some students will get more or less information about the chief complaint at the beginning of the encounter.

This conundrum has followed me for years and I have rarely felt like I have a satisfactory answer that remains vague enough while maintaining the momentum and realism of the scenario.

So instead of answering that second open-ended question by giving away checklist items, my new standardized answer for most cases is a response about my emotional affect and why I finally came to see the doctor today. For instance:

Student: "What brings you in today?"
SP: "My eye hurts."
Student: "Oh, I'm sorry to hear that. Tell me what's been going on."
SP: "Well, I was hoping it would go away but it hasn't, so I came in because I can't stand it anymore. I'm kind of worried."
Student: "Well, I'm glad you came in! When did this start?"

This kind of response works for a wide range of cases and severities. It gives away no checklist items and offers the student another bid for empathy if they haven't already responded empathetically to the chief complaint. It's an answer that doesn't need to be standardized amongst SPs. And because the student hasn't received any HPI info, they are prompted to ask close-ended questions. And then on we go!

Rejection

An SP flees after an unsatisfactory experience with a student-doctor.
[Sita Bhumi Pravesh via wikimedia]

This Atlantic article is written from the perspective of marriage, but it helps crystalize a particular (dis)connection dynamic I experience with some students:

"Throughout the day, partners would make requests for connection, what Gottman calls "bids." For example, say that the husband is a bird enthusiast and notices a goldfinch fly across the yard. He might say to his wife, "Look at that beautiful bird outside!" He's not just commenting on the bird here: he's requesting a response from his wife -- a sign of interest or support -- hoping they’ll connect, however momentarily, over the bird. 

The wife now has a choice. She can respond by either "turning toward" or "turning away" from her husband, as Gottman puts it. Though the bird-bid might seem minor and silly, it can actually reveal a lot about the health of the relationship. The husband thought the bird was important enough to bring it up in conversation and the question is whether his wife recognizes and respects that. 

People who turned toward their partners in the study responded by engaging the bidder, showing interest and support in the bid. Those who didn’t—those who turned away—would not respond or respond minimally and continue doing whatever they were doing, like watching TV or reading the paper. Sometimes they would respond with overt hostility, saying something like, "Stop interrupting me, I’m reading.""

Students rarely respond with hostility, of course. But when they don't engage when I make a "bid," that makes me feel as if the student-doctor doesn't care about me as a patient. For instance, if I talk about my pain and the the student moves onto the next question without acknowledging it, s/he has rejected my bid. If I talk about my kids, my job, or a funny thing that happened to me but the student doesn't engage with it, s/he has rejected my bid.

Ignoring my request for connection (or responding insincerely) is very likely to affect the student's empathy and/or rapport scores.

HEENT checklist

An SP after a HEENT exam.
[Bartholin head transect via wikimedia]

The Head, Eyes, Ears, Nose & Throat exam is one of the most vulnerable exams for a patient because it uses pointy objects and bright lights near sensitive orifices. I don't know how SPs get used to this. I am pretty strict & consistent in my reactions during this exam because I want to remind students be especially considerate and careful in this region.

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

This is a living list. Last updated October 29, 2015.

Head

• Palpation: Careful of earrings and glasses when present. Use the word "touch" instead of palpation.

• Inspection: Verbalize inspection. When you do, don't use alarming words like "lesions."

 Eyes

• Reaching for my eyes is scary! Warn me before touching near them, ideally demonstrating on yourself.

• Conjunctiva: if you can, allow me to pull my own lower lids down and look up instead of doing it for me. This gives me more control in a vulnerable situation.

• Checking for pupillary reflex: tell me where to look. Otherwise, as a patient I am primed to look directly at the thing in front of my face, and when a bright light is suddenly flashed in my eye I may wince or blink or jerk in a way that gives you an incorrect finding.

• Ophthalmoscope/fundoscopic exam: tell me what you're doing before you do it. Tell me where to look. If you don't have to use the brightest light, I would appreciate it. If you're going to brace against me, warn me before you do. Don't, under any circumstances, brace yourself by placing your finger on my lip (I am surprised this happens as often as it does).

• Using a Snellen chart: if you ask me to "read the smallest line," I read the text on the bottom of the card. Be specific if it matters! 

• Checking visual fields: If you ask "Do you see my fingers?" I will turn my head to look at them. Yep, I see them. Tell me where to look if it matters! Also, sometimes students don't start far enough back (so I can always see the fingers) or come far enough forward (so I can never see the fingers despite that I can see the student shaking with the effort of trying to wiggle them). 

• Accommodation/convergence: tell me to keep my head still, or I am likely to move my head when I see a pen get too close too my face. Best practice: "I want to see how your eyes are moving. Please keep your eyes on this pen and your head still as I move it towards you."

• If I am wearing glasses and you ask me to take them off, especially for the ophthalmoscope exam, I will readily agree -- and then leave them on the table until you remember to tell me I can put them back on. Patients without their glasses can feel even more vulnerable while they aren't wearing them, so the sooner you tell me the better I feel about your awareness and consideration. Unfortunately, it is not unusual for me to have my glasses off for the rest of the encounter.

Ears

• Pointy things in my ears is one of the worst parts of being an SP. I've only had a handful of students cause pain, though. To achieve the highest standard, you must break the plane of my ears and use a cone.

Nose

• But pointy things in my nose is actually worse than pointy things in my ears. How you treat my ears is similar to the way you will treat my nose. To achieve the highest standard, you must break the plane of my nostrils and use a cone (it can be the same cone as my ear, but not vice versa!). 

• Sinus percussion: For heaven's sake, warn me before you start tapping on my face. It can be a very startling sensation if a patient doesn't know it's coming, and even more so in such a vulnerable area. Many patients don't understand what areas are involved when you invoke the word "sinus": if I think you're only going to examine my nose, reaching for my eyes will be a surprise. A better explanation: "I'm going to tap above and below your eyes; please tell me if it's tender." Demonstrate on yourself as your explain it. Always use the word "tap" instead of "percuss." 

• Ask me to tilt my head back rather than pushing it back yourself. I've had students push me back with a hand on my forehead or a finger under my nose, and both ways feel less respectful than asking me to move myself. 

•  SP Pro Tip: when the student inserts the speculum into your nose, hold your breath so the moisture doesn't fog the lens. The exam is quicker that way. 

 Throat

• If you ask me to open my mouth, I will, but I won't stick my tongue out until asked. If asked to say "Ah," I will try to do it without breathing directly into your faces if possible.

• Lymph node palpation: I prefer firm deliberate pressure as opposed to tiny tickling fingers underneath my chin.

• Thyroid palpation: Describe the exam before you put your hands around my neck. Since this exam is frequently done from behind and with a fairly firm pressure, it can otherwise feel alarming. 

• SP Pro Tip: If you are an SP in a school that includes a thyroid exam, I highly recommend beginning saliva production after the oral exam and only swallowing half of it when asked, in case the student requests another swallow.

Quote of the Day

[Portrait of Robert Louis Stevenson via wikimedia]

"Our business in life is not to succeed, 
but to continue to fail in good spirits."

Robert Louis Stevenson

This was obviously not written about the concept of SP work, but it could have been. On the best of days, our job is to allow students to fail in good spirits. That's where the learning happens.

Overstepping one's bounds

An SP about to demonstrate her medical knowledge.
[Queen Victoria via wikimedia]

One of the things I keep reminding myself is that SPs are not medical professionals. For instance, no matter how many times we do a gall bladder case, we are not qualified to diagnose cholecystitis.

In fact, I think it's dangerous for SPs to give advice to medical students about anything beyond what they experienced in the encounter unless expressly directed to do so at the event. I cringe when I hear SPs discuss medical feedback they've given students because "I've had a lot of experience with nurses and I know how they do things" or because the SP has experience with the condition s/he is portraying.

This is especially true given our inconsistent training. But it is also in large part because during feedback the power differential is flipped: SPs become the authority, and our words carry a lot of weight, especially with students earlier in the program. But that balance is fragile. If what the SP says conflicts with what students are being taught, all SPs become untrustworthy. We are part of their education but rarely have any actual insight into what they are being taught beyond what we know about our case. Standards and procedures differ at each school, program, hospital, clinic, specialty, etc. And teaching changes all the time, so there is real risk of delivering outdated information.

I also think this attitude is disrespectful to students. Even though SPs should be respected and appreciated for what we have to offer medical students, it's ridiculous to think we are medical experts when the amount students have to learn -- and have already learned -- is so stupendous. Many first-year medical students probably know more about general medicine than most SPs, even those who work several cases a month. Medical students, by and large, are dedicated and bright. We need to make sure we are honoring their educational journey by refraining from the need to prove what we think we know. Of course, some SPs have been or are medical professionals. But I still feel just as strongly that they should not be speaking to students in that role for all the same reasons.

I feel the strength of SPs lies within our ability to focus our comments on the communication skills of the students, not the medical skills. With limited feedback time, I would hope SPs would choose to focus on the details of the interaction rather than medical feedback.

Setting the standard:
At the very least, SPs must identify when they are offering feedback based on their personal medical knowledge, never giving the impression they are speaking on behalf of the program.

Better schools ask SPs to refer students to their lead instructor if there is a conflict between the way the SP thinks a PE should be done or if an HPI question should be asked that isn't on our checklist.

The best schools reinforce this standard and review to make sure SPs are staying within good feedback guidelines.

Alphabet soup

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."