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Wednesday, April 19, 2006

Blame Others

The standardized patient experience in medical school is an odd one. I have a lot of criticisms of it, and I'll list those in their time, but the more and more I think about it, I the more and more I feel like such thoughts and displeasure on my part are really hiding my own faults and what I can do to make the situation better.

A standardized patient is usually a retired individual who is paid to come in and have physical exams performed on them by preclinical medical students (first and second years).

After some labs where you practice on them, you then have exams. I've already described the horrors of my first OSCE (Objective Standard Clinical Exam). The OSCE works such that you have stations and you are told before you enter what you're suppose to do with the standardized patient in that exam room. It is typically a focused exam. For example, it may say perform a respiratory exam.

Today, I had another type of exam which my school calls a CAST. It is a head to toe physical, although the time allotted is too short for such and real goal is to get as far as you can. I tried so hard not to be nervous leading up to the test, because I felt that was the most damning thing during my OSCE. I got flustered and I couldn't think and it turned into a deer in the headlights situation.

I walk into my CAST and the standardized patient there is one I had during my OSCE. One who was very critical of my performance after my OSCE (which he had a complete right to be). One who had a very, very low opinion of me.

I could not have had a worse standardized patient for my CAST lab. My jaw nearly dropped.

The man had only criticism for me at the end of the exam, and I think it is an accurate self assessment to say that all but one of them were invalid.

  • Need to study more to know what valve I'm listening to in the heart
    • I started off wrong, told him I was listening to the pulmonic first and then without prompting immediately corrected myself and described correctly what I was listening for in all four locations (Aortic, Pulmonic, Tricupsid, Mitral)
  • Need to compare sides when percussing the lungs
    • Just inaccurate on his part. I did. Granted I forgot to when I examined him for my OSCE but I certainly remembered this time.
  • Need to learn to drape better as he was exposed briefly when I tried to cover him
    • Well he had shorts on but this is the single valid criticism. If I'm going to pretend to use the drape even when he has shorts I should use it appropriately.
  • Need to practice with the blood pressure cuff so I don't get flustered
    • Please, the damn thing got tangled up. It is attached to the wall and he insisted on sitting so I had to stretch it all the way to him.
  • Inappropriately felt the radial pulse with my thumb
    • Just inaccurate. When I was counting his pulse I used the pads of my fingers. I was feeling with my thumb only to check for when the radial pulse disappeared when I expanded the blood pressure cuff, which is appropriate considering I don't HAVE to even do that.
  • Moved on without actually feeling the pulse in inguinal area
    • This is an odd one. I never told him I was trying to feel a pulse down there, I told him I was feeling for lymph nodes. Even if I had, I don't know what this type of complaint is...he doesn't think I actually found it? Actually he doesn't think I found something I wasn't looking for.
There were plenty of things, while he was evaluating, that I knew I missed. If he thinks he knows so much he can criticize me for using my thumb on his radial artery then maybe he should've mentioned my failure to palpate the thyroid gland or to percuss his costovertebral angle when I was at the back. I also forgot to palpate his tongue and floor of his mouth or to test his hypoglossal nerve (stick out your tongue and move it side to side). I was flustered, I apologized too often and asked his permission to do just about everything which probably would've been a valid criticism as well.

All he can make are inappropriate criticisms and not one encouraging thing. That is all I could think about as I left the clinical skills building.

I miss half of what I do because of nerves. Having this particular standardized patient for my CAST obviously didn't help.

That being said, nerves around standardized patients and nerves around real patients don't originate from the same source, at least in my experience. Judging me on how long it takes to unravel the blood pressure cuff with a standardized patient is a poor measure of how I'll perform in the clinic or hospital. What makes me anxious about seeing standardized patients doesn't translate over to interactions with real patients. This is what makes me upset about the whole standardized patient experience.

I am anxious around standardized patients because they're the authority figures. They're grading me. I want something from them.

When I was working in the ophthalmology clinic taking fundus photos, I screwed up a lot when I started, as might be expected. But I was a lot less nervous every time I had to correct myself because I knew the patients had come in for a reason. They wanted something from me. I was trying to help them.

Being flustered around standardized patients may correlate well to how poorly I'll perform when I'm presenting patients to my attendings or getting pimped or basically dealing with the people who will be judging on the spot during my clinical years. It will not correlate well to my interactions with real patients.

And yet, while I believe everything I've written above really I'm not sure it really matters. I can't do anything about the complaints I've listed above. Why would I put my nervousness and my inadequate (in my eyes) performance on anyone else? Yes, the standardized patient exam lacks in its mimicry of the real thing but it is merely a tool. It certainly has its own unique benefits and if I'm missing out on those it is nothing that can be changed by anyone but myself.

Just take deep breaths, realize the standardized patient OSCE for what it is, open the door, introduce yourself and get to work.


Anonymous Moof said...

From a "real" patient's perspective, this was very interesting to read. Frankly, I can't imagine second guessing my physician as he performs a physical.

I think that once you're working with people who see you as "Dr. PostMedSkool" ... it will be completely different. They will not be the "authority" figures, but will be coming to you, looking for solutions for their medical problems ... which you will be trained to address.

If a physician 1) really listens 2) never takes a superior attitude 3) truly tries to understand the patient's concern from a physical and emotional perspective and 4) is forthcoming about why he recommends a particular procedure/medication/course of action (or inaction) ... it's almost guaranteed that he will gain the patient's trust, and perhaps even a bit more.

Hang in there. It's all worth it.

4:04 PM  

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