Time flies.
[Invitation to the Krewe of Nereus Carnival Ball via wikimedia]

We ask students to do a lot in 15 minutes, so time management skills are crucial. When I have students who have a hard time completing the encounter, I frequently give feedback about time management skills. Much of this feedback centers around asking questions & giving directions in clear, concise ways.

This is a living list. Last updated March 21, 2015

• Practice: Students who need more practice asking questions often ask an unfamiliar question in several different ways all as one sentence, which takes up time. For instance: "How can I help you today, what's wrong, what seems to be the trouble?"

• Only ask one question at a time: Don't stack questions. For instance, "Do you drink, smoke or do drugs?" or "What makes it better or worse?" It seems like it might save time, but as a patient, it's difficult to track multiple questions and it may take me time to formulate a comprehensive answer. I may even forget to answer one of them if one of the questions is more important to me than the others. This is especially important if multiple questions have different answers, if there are three or more questions, or if I am in a lot of pain. Plus, as an SP I may have been instructed only to answer the last question, which requires the student to go back and ask the other question(s), anyway. Sometimes one open-ended question can be better than a series of closed questions. For example, "How much do you drink in a week?" gets more information in one question than "Do you drink?" which often needs to be followed up with "How much would you say you drink in a week?" anyway.

• Shifting questions: Similarly, If I don't interrupt a student, I have often found one question can transform into a different question before the student finishes speaking. For instance: "Can you tell me about the quality of the pain, like does it radiate or can you tell me how long you've had it?" If I had interrupted as soon as I heard "quality," the student would have received a much different answer.

• Trailing off: If I don't interrupt a student at the end of a question that is mostly done but the student hasn't actually stopped talking, a student may look at me expectantly and then trail off. For instance: "Have you noticed X or Y... or...." As a patient, I am highly unlikely to interrupt my doctor, so I ask them to finish the sentence; "Or...."? Usually students repeat the question more concisely.

• Repeated questions: In addition to making me feel unheard as a patient, repeating a question uses up unnecessary time.

• Using jargon: If a student uses a word I don't understand as a patient, I may have to ask them to repeat it so I know how to answer. Or I may use other techniques to answer, all of which take more time than necessary.

• Mumbling: Similarly, if I don't understand what the student is saying, I may have to ask them to repeat the word or the question.

• Taking notes: If students don't have good personal shorthand, they may use a lot of time writing out entire sentences with my answers. Even writing "high blood pressure" takes a lot more time than "HBP". The notes students take during the encounter shouldn't be the same ones they will submit as documentation or as part of a SOAP note. Using more abbreviations and symbols will save students time during the encounter.

• Clear directions during physical exams: Clear, simple instructions during physical exams are an easy way for students to save time. Any confusion or misdirection takes time to correct. I find this to be especially true for musculoskeletal & neuro exams.

• Expectations management: As a patient, knowing what to expect is a huge relief and gives me a lot of confidence & trust in the student doctor. Why are you asking this question? What are we doing next? Why is this exam being done? Students often skip this step because it seems to take up precious time -- but I think it's crucial. As above, anything that causes friction and confusion often eats time, so good expectations management usually makes things run more smoothly and quickly.

• Ungowning and draping instructions: similarly, when a student is not clear about ungowning and draping instructions, it can take a lot of time to clarify. If I am uncertain, I may move more slowly. If the student's instructions are unclear, I may not do what the student doctor expects me to do, which requires more explanation. Best practice (ungowning): "Would you please untie your gown and lower it to your waist?" Best practice (draping): "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." 

If students save even just 30 seconds to a minute using these techniques, it may be just enough for them to close the encounter and leave the room before time is called. As a patient, attention to these details also gives me a lot more confidence in them and I will probably feel more comfortable during the encounter.

Extra credit:
During encounters I listen for students who explain a question or exam with more detail after I've expressed uncertainty verbally or nonverbally -- that is almost always a sure sign the student could have saved time by explaining it first more clearly.

1 year!

Happy birthday, blog!
[Strawberries and cakes via wikimedia]

It's now been a year since I began Setting the Standard. One of my very favorite things to do is to create pattern from chaos, so I have loved writing about this job in very detailed ways. I am very pleased to write concretely about the largely invisible and intangible relationship skills which have such a large impact on patients, like empathy, power differential, consent, physical autonomy, etc. Compiling the differences between institutions feels like I have a particularly unique view on something that initially seems simple. It is also very satisfying to get internal checklists standards and jargon out of my head and onto the "page" to use as a reference when called for.

In my second year I hope to find other SPs engaged in the online community: writing, thinking, feeling, training, and discussing this strange and wonderful work. As I wrote on my "About" page: "The only thing that would make this work more fulfilling is a stronger SP culture... I want to raise our standards. I want an SP culture that is both curious and dedicated to self-improvement." Student and SP management opinions are also welcomed! SP work shouldn't be lonely work, especially if we are in the business of analyzing and addressing communication skills. We're in this together.

I still have so much more to write about, and many more scenarios to perform with many different kinds of institutions. I am terribly glad to be an SP, so grateful for these brief windows into the lives of others who are also ever myself. So as long as I am an SP, I will continue learning, playing, and writing.

Extra credit
I wish I felt comfortable writing about scenarios in the way Tom does, because I appreciate their perspective and poetry. But my thin veneer of anonymity is more important to me. So thanks for writing what needs to be written, Tom! Have a cupcake.

Acting like the moon

After a particularly moving SP performance.
[One Hundred Aspects of the Moon via wikimedia]

Sometimes a student or an observing faculty member will thank me after a scenario, saying "You're a really good actor!" And I appreciate that. It's flattering and reassuring that they think I've done a good job.

But I also think of a Japanese folktale comparing two actors playing the moon. After the first actor performs, the audience praises him: "You shone so beautifully! So bright! So magnificent in the sky!" The second actor, however, performs so naturally he was barely noticed.

Which actor was better?

SP community site?

An SP looking skeptical but intrigued.
[The Detective via wikimedia]

Well, hello, there! Does anyone know anything about http://www.standardized-patient.org/ ? It's exactly what I've been looking for for years but it doesn't quite feel right and I can't put my finger on why.  Maybe: "All content becomes property of the website"? Maybe: one of the most active members seems to be a spammer? Maybe: I can't tell what school or consortium is behind it? (I'd feel more comfortable if a legitimate organization like ASPE was behind it.) Where did it come from? Why is it here? So many questions, not enough answers -- or activity.

[updated 02/28: most of the members have been removed. Hmmmm. Updated 03/09: many more new members, all of whom seem to be spammers. Dang it!]

Answering open-ended questions

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.