Sure, sure, that makes sense.
[La Lecture via wikimedia]

One of the things I hear from learners during encounters that makes me wince is this:

"Does that make sense?"

This question is problematic in part because it often seems like a formality, like How are you today? or Is that OK? As a binary closed question, there is really only one right answer to keep things moving: yes.

Also, admitting uncertainty is a difficult thing for patients to do. "Does that make sense?" places the burden on the listener for understanding rather than on the speaker for clarity.

"Does this make sense?" can also cast doubt on the confidence of the speaker, as if the speaker is asking for validation instead of confirmation.

I hear this phrase a lot in trainings, too, and as an SP or workshop participant I am unlikely to say "no." In a group, "Does that make sense?" is often met with silence, but silence doesn't actually indicate comprehension.

If someone wants to assess my understanding, the use of open questions like "What questions do you have?" or "What do you think?" is a much better method. Teach back is an effective tool, too. If what you've said doesn't make sense, my response will make that clear.

Bonus points
Other phrases which discourage questions:

• "That's pretty self-explanatory, right?"
• "We all know..."/"I'm sure you all know [x], so..."

The Silent Curriculum

Flinching from the silent curriculum.
[Susanna and the Elders via wikimedia]

I love "The Silent Curriculum" so, so, so much. It's powerful and true and brave. Go read it. Go!

I referenced similar issues in my "Beyond the classroom" post:

"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."

I think one of the things Katherine Brooks writes that is particularly important is this: "I allowed myself to participate in the unconsented care of patients and prioritized my learning, evaluations, and reputation over my values."

I know when faced with personal self-preservation, I am not always the advocate I should be. I am sensitive to explicit vs. implicit rules; that's part of what makes me a good SP. But I feel at my most helpless when faced with bureaucracy where the culture does not match the mission and I have no safe way to express it.

It also makes me realize that while I love the traditional 15-minutes-in-a-room-with-a-student-doctor, the scenarios and schools I am really impressed with are the ones that focus on interdisciplinary & team scenarios. How medical professionals treat each other very much affects how they treat patients. Core values like power differential and consent are ten times worse when working within an institutional infrastructure. How can we expect people to treat patients better than they themselves are treated? While some may be able to do so in the short term through sheer force of empathy, it is not sustainable in the long term, and the medical profession suffers for it.

So the first time I was in a scenario which specifically requested students to challenge each other, my heart almost burst with happiness. I hope to see more of these kinds of events as time goes on. As learners are encouraged to practice challenging and accepting challenges to authority, I hope to contribute to a culture that values a spectrum of diverse voices and views.

Setting the Standard:
Create scenarios to help learners make decisions in teams in ways that encourage challenging each other or gracefully accepting criticism. Reinforce these aspects of scenarios even when they are not the primary objectives. These skills can and should be practiced in safe spaces where grades, jobs or professional relationships are not at risk.

Summertime

A lazy June day lying over the educational horizon.
[June Day via wikimedia]

Ah, it's the end of the school year. As an SP it is bittersweet in many ways:

• We see such a small slice of students' lives. I often see students more than once, but if they are Y2 students, they can suddenly be ready to graduate, moving onto other programs and cities. When I think about how much they've had to master in such a short time, I am nostalgic and impressed.

• The end of the year changes my feedback sometimes. For instance, during the last OSCE of Y2, I know the students won't go through another OSCE (except for schools who do occasional 3rd year or resident events). So for schools with open feedback, my tone is more informal and summative, more broadly applicable: Congratulations! What have you learned? What are you still struggling with? What specialty are you planning? These skills will help you with that [in a specific way]!

• Summer is when my income plunges. Very few schools have summer events. So I watch my monthly average drop with trepidation and am almost giddy when a random summer job comes my way. When the regular fall schedules start up in August, I'll be ready to jump back in.

• Conversely, summer is when I have the most free time. So I plan my major travels & adventures around this time when possible to reduce the opportunity cost of missing a job during the school year. I'll get to write more, think more. Maybe I'll even get around to reading the Empathy Exams like I said I'd do in January! Yes, I'm looking forward to reading on the porch, drinking homemade iced chai.

Discussion question:
What are your summer plans?

Using students in invasive exams

A student on her way to a transvaginal probe.
[Captives via wikimedia]

This situation at Valencia State College makes me extremely angry: Students sue Florida college for alleged forced vaginal probes. "Two female college students said they were forced to endure almost weekly vaginal probes as part of a medical diagnostic sonography class at a Florida community college, according to a civil rights lawsuit filed in federal court."

This violates at least three values that are very important to me as an SP:

• Power differential: Students should not even be in a position to refuse something like this. It's ridiculous. "The complaint states that the clinical and laboratory co-ordinator initially told the students that the probes were voluntary." Even if that is true, when someone has control over your grades and future, the power differential makes it very difficult to refuse. In addition, this communicates to students that the institution values cooperation over modesty/comfort. When those students graduate, I guarantee they will carry that attitude over to patients when they are the ones in power.

• Consent: If a student refuses a transvaginal probe, that's it. Full stop. No coercion, no harassment, no threats. But based on my experiences as an SP, I don't doubt this claim:"When the women protested they were told they could find a different school, would be blacklisted from local hospital jobs and their grades would be reduced."

• Respect: This? Is the opposite of respect: “Plaintiffs endured these invasive probes without a modicum of privacy. Plaintiffs would disrobe in a restroom, drape themselves in towels, and traverse the sonography classroom in full view of instructors and other students.” So is this: "It also claims Ball made inappropriate comments during the procedures. According to the lawsuit, Ball told a student undergoing the procedure that she was “sexy” and that she should be an “escort girl”." Honestly, even colleges that do hire SPs for these exams are sometimes not as respectful as I'd like them to be. To subject students to this is infuriating.

So yeah, students used to practice invasive exams on each other. As an old-time faculty member once told me, "You never knew whether to pick a partner you liked -- or one you didn't."

But very few schools still practice this for reasons that should be extremely obvious. In fact, schools have used SP models as "gynecological teaching associates" since 1968. The VCA spokesperson states "using volunteers, including students, for medical sonography training [is] a nationally accepted practice." If true, then apparently sonography programs need to get their act together and adopt the more rigorous and respectful standard that the medical community has been using for aeons. If not, then the college is being deliberately disingenuous. Neither of these things gives me confidence in the strength of their educational program.

I suspect the college uses students because GTAs are expensive, and rightfully so. But they are worth every penny, not the least because it avoids this outrageous and uncomfortable tangle between students, peers & faculty.

Extra credit
Relatedly, I cringed when I recently read this from The Naturopathic Diaries: "It was not uncommon for students to perform prostate and gynecological exams on each other in order to complete the required examination for competency. And in fact, the instructor of our advanced gynecology class (an elective course) asked the female students taking the course to act as standardized patients. When I learned this, I was happy that I did not register for the weekend elective course. The lack of actual patients to practice examinations significantly hinders naturopathic clinical training." I know this is not true for all naturopathic colleges, but I imagine it's true for many. Argh!

Setting the Standard:

Students should never have to be put in a position to refuse an invasive exam. Instead, schools should always hire male and female models for those exams. When they do, they should be paid well and treated respectfully.

Using Google Glass

Earliest known depiction of a student using Google Glass.
[The "Glasses Apostle" via wikimedia]

I was going to scoff when I ran across this report preview:

Recording Medical Students’ Encounters with Standardized Patients Using Google Glass: Providing End-of-Life Clinical Education

Until I read "traditional wall-mounted cameras...provide a limited view of key nonverbal communication behaviors during clinical encounters."

Ah! Yes! That is totally true. When I review video encounters, without a good look at the student's face, grading things like eye contact & sincerity becomes much more difficult.

"Next steps include a larger, more rigorous comparison of Google Glass versus traditional videos and expanded use of this technology in other aspects of the clinical skills training program."

Indeed. I am thinking of the cost-benefit ratio, though. The results have higher fidelity, but do they justify the cost and cognitive dissonance during their use? I guess that depends on what the program uses the resulting videos for. Data without analysis is a waste of resources.

Bonus points (added August 2015)

• I've now been in an event that includes these glasses! I don't know what happens with the video, but the glasses just looked like safety goggles, the kind you might wear to protect your eyes from bodily fluids. In the context of this particular event, it wasn't that incongruous, though it probably would have been in a traditional patient room.

• I've also been at events that use Go Pro cameras attached to the learner, which also seems like an interesting strategy.

Have you seen something like this before?

An SP having a flash of inspiration during feedback.
[Saint Augustin via wikimedia]

My preferred method for feedback includes a lot of questions. I love feedback when it's a conversation and individualized to each student. I stumbled into a question recently that really makes me happy, especially with Y2 students:

Have you seen this before?

Depending on the conversation, it can mean:

• Have you seen this in clinic?
• Have you had experience with this personally?

I don't know why I didn't think about this before, but the answer is usually yes! Students usually have had some experience in the medical profession before being accepted to most programs. The further along in the program they are, the more likely this answer is to be yes.

So then more questions can follow:

• What did you do/see?
• What tools did you pick up that you used in this encounter?

That's the secret: I don't talk about what they did or should have done in another context. Instead, I direct their responses to reflect how they affected me in this encounter. This both focuses their attention and integrates my feedback with experiences they've already had.

One of the primary complaints students have about SP encounters is how they don't reflect the work the students feel they are capable of outside the exam room. I've been thrilled with how this question changes that dynamic. I can honor the students' actual lived experience and together we can refine it within the safety of the event.

Extra credit:
This turns out to be a useful tool when giving difficult feedback, too. "Your eye contact is poor/You ask too many questions at once/You rushed at the end. Have you heard that before? Has anyone told you that before?" Learners often have heard that feedback before, so it helps to notice the bigger picture and come up with a strategy they can attempt in their next encounter.

Modesty & invasiveness in SP encounters

An SP tries to remain covered during an invasive exam.
[The Invasion via wikimedia]

Acting (or at the very least, memorization) is an important component to being an SP. But also important is self-awareness and comfort for varying levels of exposure & contact during an encounter. Generally speaking, if you want to be an SP, there are three kinds of exams you could be a part of:

• Interview: the student doctor asks history questions, counseling, etc. but does not perform a physical exam.

• Physical: the student doctor examines one or more body systems using hands and/or tools. This may or may not involve wearing a gown.

• Invasive: primarily breasts, pelvic & rectal exams. These are paid at a higher rate than the first two categories (though the rate widely varies across the US).

Some schools are explicit in these designations, while others do not bother to distinguish between the first two categories.

But these categories are pretty broad. For true ethical transparency, I think the categories should be even more nuanced. For instance, some of the physical scenarios can be invasive and uncomfortably intimate for some SPs who are modest, rightfully nervous of pointy things in their ears, or easily triggered.

Here's how I would categorize SP jobs:

• History Interview: student doctors ask questions about the patient's chief compliant, medical history, family medical history and/or social history. Relatively straightforward, without major revelations.

• Psych interview: Any interview that includes a major social or emotional component, as these require such different affects, reactions and feedback. Different SPs find different kinds of psych encounters draining. Some find depression exhausting, while others find mania exhausting.

• Basic physical exam: the student doctor examines one or more visible body systems using hands, eyes and tools. Neuro exams and mental status exams would qualify, too.

• Mildly invasive physical exam: anything that involves ungowning instructions would probably qualify for this category. Exposing the abdomen or chest is a modesty issue for some SPs, so heart and lung exams can be uncomfortable for them. Exams that require the SP (or the student) to move breast tissue would be part of this category, as would attaching leads. 

• Moderately invasive physical exam: I don't understand why there isn't more consideration and expectations management around HEENT exams, which involve sharp pointy cones in sensitive orifices like noses and ears. I know SPs who have been harmed in these exams. Eye exams, too, can qualify here, especially ones that involve students pulling on an SP's eyelids or pushing on the eyes in some way (neuro exams, looking for conjunctivitis, etc.). Checking for the liver and spleen can be pretty invasive & intimate depending on the school, as the student hooks his/her hands under an SP's ribs. And if a school wants students to check the inguinal nodes, SPs had better be aware of that and consent to it beforehand. Nobody wants a surprise inguinal exam.

• Majorly invasive physical exam: In addition to breast, pelvic, and rectal exams, I would include blood draws & biopsies in this category.

Additional components that may affect SP modesty during encounters:

• What is the level of undress required for each role even if the SP is in a gown? For instance: can the SP wear pants, or bike shorts? Can the SP wear tank tops or bras? 

• Who will be observing? SPs may feel more or less comfortable in group encounters, with peer observers, with faculty observers in the room, with faculty observers outside the room, with staff observation, or with video review after the event.

Extra credit:
I once worked for a school that wanted women to remove their bras for the event since students would be performing heart/lung exams. The school didn't think it was fair for the students who had female SPs to have to struggle with this complication when students who had male SPs did not. This is generally not acceptable, but even worse is that this was mentioned on the day of the exam. What SP was going to refuse at that point? That felt disrespectful (and frankly, sexist).

Setting the standard:
I think having knowledge of these categories is an important tool for SPs to choose the kinds of jobs they are comfortable with, especially when first starting out. For every event, make it clear what is expected of the SP before the SP accepts the job. Do not penalize SPs for refusing jobs outside their comfort level.